.Ill il'^fiill llll!!!' iiiii'; ': ! i! r 'i SURGICAL OPERATIONS ''^jQ^^^Shf*^^' Surgical Operations of the ^ead ILLUSTRATED BT CLIHICAL OBSERVATIONS, FOR PHYSICIANS AND SURGEONS BY Prof. FEDOR KRAUSE Privy Medical Councillor Directing Physician Augusta Hospital, Berlin, m associatuni it'ith EMIL HEYMANN, M.D. chief Physician, Augusta Hospital TRANSLATED INTO ENGLISH AND EDITED FOR AMERICAN READERS BY ALBERT EHRENFRIED, A.B., M.D., F.A.C.S. first Assistant Visiting Surgeon, Boston City Hospital; Junior Assistant Surgeon, Children'.? Hospital; Surgeon, Boston Consumptives' Hospital. 2 VOLlJMES—983 PAGES 1 1 1 PLATES HAVING 606 COLOR ILLUSTRATIONS and 155 FIGURES IN THE TEXT NEW YORK ALLIED BOOK COMPANY 17-25 WEST 60th STREET ■ft5eration 171 The Plastic Procedure of Panse-Korner 172 Phlebitis and Thrombosis of the Sigmoid Sinus, and Ligature of the Jugular ^'ein 174 CHAPTER 11 Surgery of the Nose and the Accessory Sinuses 179 Injuries of the Nose 179 Inflannnatorv Diseases of the Accessory Sinuses 181 Operations on the Antrum 183 Opening Up Both Antra After the Method of Partsch 185 xii TABLE OF CONTENTS PAGE Opening Up the Frontal Sinus 187 Trephining the Anterior Wall of the Frontal Sinus 187 The Uatiical Operation of Killian 188 Exj)osure of and Radical Operation on the Ethmoid 190 Exposure of the Sphenoidal Sinus 191 Exposure of the Sphenoidal Sinus and the Hypophysis After the Method of SchlofFer 191 Killian's Septum Resection and the Approach to the Hypophysis After the Method of Hirsch 195 CHAPTER 12 Surgery of the Trifacial Nerve 197 Neuralgic Pains 197 Painful Points 197 Irradiation 198 Determination of the Affected Branch 199 Accompanying Manifestations 202 The Termination of Neuralgia and Relapses 202 Neuralgia 203 Diagnosis 203 Prognosis 203 Etiology 204 Central or Peripheral Seat 205 General Treatment 206 Alcohol Injections 207 Peripheral Operations ' 208 General Anesthesia and Local Anesthesia 208 Indications 208 Extraction of Nerves 209 Result and Prognosis of Peripheral Operation 212 First or Ophthalmic Division of the Trifacial 213 Resection of the Frontal Nerve 213 Other Branches of the Oplithalmic Division 215 Second or Inferior Maxillary Division of the Trifacial 217 Resection of the Infraorhital Nerve 217 Resection of the Orbital Nen-e 220 Resection of the Second Division at tlie Foramen Rotundum . . . 221 A'ariations in Technique 224 Third or Inferior Maxillary Division 227 Resection of the Lingual Nerve 227 Resection of the Auriculo-Temporal Nerve 228 Resection of the Inferior Dental and Lingual Nerve 229 Modifications in Technique 233 Resection on the Third Division of the Foramen Ovale 234 Remarks on the Resection of the Second and Third Divisions at the Base of the Skull 236 The Simultaneous Resection of the Three Divisions 238 TABLE OF CONTENTS xiii PAGE Extirpation of the Gasserian Ganglion 2ii9 l'ri|)arati<)ii H-l^ Keratitis Neuroparalvtica 24S Remarks on Technique 2-15 Lifjation of tlie Middle Meninnfeal Artery 2-i6 Wiious Ileiiiorrliaire S-i? ^lanipiilation of" tlie (iasscrian Ganglion 247 Care of the Wound and After-Treatmenl 250 Other Methods of I^xtirpatinnf the Gasserian Ganglion .... 251 Coni{)arison of the A'arious Methods 25-t Indications 255 Intracranial Resection of the Tiiiid Division 256 Resection of the Trifaci.il Root 258 LIST OF ILLUSTRATIONS IN THE TEXT FIGURE PAGE 1 Local Anesthesia for Extirpation of the Gasserian Ganglion . . -iii 13 Tension Incisions 98 1-1. Mobilization of the Flaps <)8 15 & 16 A Small, Kectanfrnlar Surface Is Coveredhy a Mobilized Flap . !)8 17 & 18 Large Rectangular Defects Are Covered bv Several Flaps . . 99 19 & 20 Three-Cornered Defects Are Covered by a Flap Whicii Is I'oniRd by a Crescentic Incision 99 21 it 522 Large Triangular Defects Are Covered by a Mobilization of the Wound Edges upon Both Sides 99 Burrow's Modification for Covering Rectangular Defects . 99 Burrow's Modification for Covering Rectangular Defects 99 F'orniation of Flap 101 Turning in the Flap 101 Method of Taking Reverdin (irafts from Front of Thigh (Ehrenfried) 108 Reverdin Grafts Planted on Raw Surface (Two-thirds Natural Size) (Ehrenfried) 109 Extensive Third Degree Burn of Neck, (lust and Axilla (l-'.hren- fried) 109 Same Case as Fig. 54 : Photo Takin Twelve Days I^ater . . 110 Upper Lip Restored by Transplantation of a Free Flap from the Flexor Surfaces of the Upper Arm ll^ Photograph Before Operation, Showing Extensive Lupus . .115 Intermediate Stage ll(i Ajjpearancc Nine ^lonths After TraTisjjlantation .... 117 Nclaton's Method in Incomplete Harelip 128 Graefe's Method 128 Malgaigne's Method 128 Sutures Used in This Method 128 Mirault's Method 129 Dieffenbach's Undulating Incision 130 Wolfe's Zigzag Incision 130 Stitches Introduced in Plastic of Palate . . 13() Knots in the Threads 137 Stab Needle with a Curve Like a Fi>hhook 138 Langenbeck's Lower Lid Technique 151 Szynianowski's ^Modification of Diefl'; iibach's 'l'echnir|ue . . 151 Plastic Operation in Ectr()|)ion 153 The lodges of the Conjunctiva United with Interru|)t('d Sutures 155 Outer Wall of the Orbit Chiseled Through Kit Area of Cortical Bone Chiseled Away in Exposure of the Tym- panic Antrum 170 233 Trifacial Nerve. Schematic Drawing of IN Bi-anches and Their More Important Anastomoses (After Toldt ) . . . . 200 XV 23 & 24 25 it 26 27 28 52 53 54 55 56 57 58 59 74&75 76 77 78 79 & 80 81 82 X: 83 1 05 106 107 158 159 160.Vlfil H)6 184 195 xvi LIST OF ILLUSTRATIONS IN TUE TEXT FIGURE PAGE 23-i Scheme of tlie Distrihiitioii of the Sensory Nerves of the Head, After Fritz Frohse .....' 201 235 I Frontal Nerve; II Infraorbital Nerve 210 236 Inferior ]\Iaxillarv Nerve Exposed by Dividing the Ramus of the Jaw, and Twi'sted After the Method of Thiersch . . . .211 24^1 The First or 0})iitiialmic Division of the Trifacial Nerve, with the Superior Brancii of the Oculomotor, and the Trochlear, as They Appear After Removal of the Orbit .... 21-t 2-i2 The Second or Superior Maxillary Division of the Trifacial, with Its Anastomosis by Two Sphenopalatine Nerves with the Sphenopalatine Ganglion, the Superior Dental Nerves . . 216 2-16 The Dental Branches of the Superior Maxillary Nerve . . .220 255 Incisions Through Lvgoma 223 256 The Third or InfcrioV Maxillary Division of the Trifacial . . 226 263 The Inferior Dental Nerve, Its Course Through the Canal of the Lower Jaw, Its Branches, with the Inferior Dental Plexus and Its Terminal Branch, the ^Mental Nerve, the Buccinator Nerve 230 268 Incisions Through Zygoma and Coronoid Process of the Jaw . 235 282 Operative Field for Removal of the Gasserian Ganglion After F. Krause 249 283 Doyen's Older Tcchnic— Incision 251 284 Doyen'sOlderTechnic— Bony Incision, from the Side . . . 252 285 Doyen's Older Technic — Bony Incision, from Below .... 252 286 Doyen's Older Technic — Exposure of the Ganglion and Its 'Branches 253 LIST OF PLATES PLATK PAGE 1 Excision of a Carbuncle (Figs. 2 to 4) 88 2 Excision of a Cystic Endothelioma (Figs. 5 to 8) 91 3 Angioma Cavernosum of the Cheek I (Fig. 9) 92 4 Extirpation of an Angioma of the Cheek II (Figs. 10 to 12) . 92 5 Cutting and Implantation of a IVdiculated Flap I (Figs. 29 to 32) . 102 6 Cutting and Implantation of a Pediculated Flap II (Figs. 33 to 35). 102 7 Pediculated Flap in the Region of Shoulder and Neck (Figs. 36 to 39) 104 8 Italian Method of Rhinoplasty I (Figs. 40 to 43) 105 9 Italian Method of Rhinoplasty II (Figs. 44 to 46) 107 10 Italian .Method of Rhinoplasty III (Figs. 47 to 51) 107 11 Transplantation of a Free Flap to the Chin (Figs. 60 to 63) . . 119 12 Wedge Excision of Cancer of the Lip (Figs. 64 to 68) . . . . 122 13 Plastic Restoration of Lip from the Cheek (Dieffenbach) (Figs. 69 to 73) 125 14 Operation for Double Harelip (Figs. 84 to 93) 131 15 Operation for Cleft Palate After B. von Langenbeck I (Figs. 94 to 96) 135 16 Operation for Cleft Palate After B. von Langenbeck II (Figs. 97 to 104) 136 17 Plastic Closure of a Cleft Ala Nasi (Figs. 108 to 111) . . . .139 18 Rhinoplasty: Restoration of the Ridge of the Nose by Means of a Tibial" Transplant (Lexer) (Figs. 112 to 118) .' . . . .142 19 Plastic Restoration of Sunken Cheek by Free Transplantation of Fat (Figs. 119 to 122) . . . ". 143 20 Formationof aColumnaof the Nose (Figs. 123 tol28) . . . .144 21 Plastic Repair of Cheek After James Israel (Figs. 129 to 130) . . 146 22 PlasticRepairof Large Defect of Face I (Figs. 131 to 135). . . 146 23 PlasticRepairof Large Defect of Face II (Figs. 136 to 140) . . 148 24 PlasticRepairof Large Defect of B'ace III (Figs. 141 to 144) . . 149 25 PlasticRepairof Large Defect of Face IV (Figs. 145 to 148) . . 149 26 PlasticRepairof Large Defect of Face V (Figs. 149 to 154) . . 150 27 Plastic Re{)air from Forehead to Correct Contraction of Eyelid and Formation of Eyebrow (Figs. 155 to 157) 152 28 Enucleation of the Bulb (Figs. 162 to 165) 153 29 Exenteration of the Orbit, Retaining the Lids (Figs. 167 to 171) . 156 30 Exenteration of the Orbit, with Removal of Lids I (Figs. 172 to 175) 158 31 Exenteration and Resection of Orbit II (Figs. 176 to 179) . . .158 32 Plastic Covering of Exenterated Ori)it After Kiister III (Figs. 180 to 183) 159 33 Kroenlein's Osteoplastic Resection of the Temj)oral Wall of the Orbit (Figs. 185 to 188) 160 34 Wedge-shaped Resection of a Portion of the Shell of the Ear (Figs. 189 to 192) 164 35 Exposure of the Mastoid Cells (Figs. 193 to 194) 168 xvii xvlii LIST OF PLATES PLATE PAGE 36 Exposure of the Tympanic Antrum (Figs. 196 to 198) . . .169 37 Radical Operation in Chronic Purulent Middle Ear Disease (Hgs. 199 to 203) ITl 38 Radical Mastoid: The Panse-Korner ]\iethod of Plastic Closure (Figs. 204. to 209) 172 39 Thrombophlebitis of the Lateral Sinus, and Ligature of the Internal Jugular Vein (Figs. 210 to 212) 177 iO Opening of the Antrum of Highmore (Figs. 213 to 216) .... 184- 41 Radical Operation for Double Empyema of the Antrum, After the Method of Partsch (Figs. 217 "to 222) 185 42 Radical Operation for Infection of the Frontal Sinus, After Killian (Figs. 223 to 227) 188 43 Exposure of Sphenoidal Cells and Nasal Approach to Hypophysis, After Schloffer (Figs. 228 to 232) 192 44 Resection of the Frontal Nci-ve (Figs. 237 to 240) . . . .• .213 45 Resection of the Infraorbital Nerve (Figs. 243 to 245) . . . 217 46 Resection of the Orbital Nerve (Figs. 247 to 250) 221 47 Resection of the Superior Maxillary Nerve at the Foramen Rotundum (Figs. 251 to 254) 222 48 Resection of the Lingual Nerve (Figs. 257 to 258) 227 49 Resection of the Auriculo-temporal Nerve (Figs. 259 to 262) . . 228 50 Resection of the Dental and Lingual Nerves (Figs. 264 to 267 ) . 231 51 Resection of the Inferior INIaxillary Nerve at the Foramen Ovale (Figs. 269 to 272) 234 52 Extirpation of the Ga.sserian Ganglion (Figs. 273 to 275) . . . 239 53 Extirpation of the Gasserian Ganglion (Figs. 276 to 281) . . .241 54 Intracranial Resection of the Third Division (Figs. 287 to 290) . . 257 55 Removal of the Trifacial Root (Figs. 291 to 294) 258 PART I. GENERAL SURGICAL TECHNIQUE CHAPTER 1— PREPARATION FOR OPERATION EXAMINATION" OF THE PATIENT Preceding' the operation a routine physical examination of tlie patient should he made, in order to anticipate the effects of the anesthetic upon the organism, to take measures to prevent operative shock, and to institute any necessary drug treatment. Particular attention should he paid to an investigation of the functional ahility of tile heart and vascular system, the kidneys and the lungs. Exam- ination of the urine for sugar and all)umen should never he omitted. GENERAL PREPARATION On the evening hefore oj)eration, the patient should receive a warm hath in which the skin is scruhhed with soap and hrush, and the finger and toe-nails cleaned. This precaution is omitted only when the patient's physical condition contra-indicates it. After this cleansing bath, the field of operation is shaved. In preparation for a celiotomy the shaven area should extend from the nipples to the groins; upon the limbs to the joint above and l)elow. In operations upon the brain and other procedures on the skull, the scalp shoidd as a rule be competely shaven. In women, however, a certain amount of hair may be allowed to remain in order to prevent mental depression. For instance, in operations upon the cerebellum, the front hair may be pi-eserved. Also in opera- tions upon one side of the skull, for instance upon the Gasserian ganglion, the otiier half of the skull may go unshaven. But under no circumstances should asepsis be endangered out of regard for the wishes of the patient. On account of the inmimera])le bacteria which reside in tlie scalp, after shaving it sliould be washed with ether and a dressing of 1/. per cent, foiiualin applied, to be removed at the beginning of the operation. DIET On general principles a diet should be selected which will increase the strength and well-being of the patient as far as possible in the days preceding the operation, and prevent physical weakness after the 1 2 PREPARATION FOR OPERATION operation. The food should, therefore, be nourishing and easily digest- ible, and of a sort to which the patient is accustomed. A sudden change in diet, and starvation, even in affections of the intestinal track, is useless and may be harmful. Tobacco and liquor should not be suddenly withdrawn in persons who have been long accustomed to smoking and drinking, for sudden abstinence may, in conjimction with operative shock, entail a dangerous and under certain circum- stances fatal breakdown in the strength of the patient. Undernourished and fluid-starved patients should receive in the days preceding the operation, twice daily, a subcutaneous injection of about one quart of physiological salt solution, with, if indicated, an intramuscular injection of one or two c.c. digalen. Fluids may be introduced into the body also by means of enemata; to a rectal injection of eight ounces of salt solution, it may be well to add a glass of red wine, or in the presence of diarrhoea, from 10 to 20 drops of tincture of opium. Rectal injections may be less conveniently given by the drop method, and in certain cases nutritive enemata may be used. The administration of fluids is particularly indicated in patients with stenosis of the pylorus and dilated stomach. The tetany which occurs as the result of inanition and the drying out of the tissues in these cases disappears, as a rule, as the fluid balance is restored. Occa- sionally patients with severe trigeminal neuralgia must receive salt solution or nutritive enemata during the preparatory period, in case they have almost completely stopped eating or drinking on account of pain, as not infrequently happens, and as a result have reached a low grade of vitality; at the same time they should receive morphine to overcome the pain. Ordinarily the administration of fluids in weak patients exerts a favorable influence upon the action of the heart, powerfully increases diuresis, and thus promotes elimination of the toxic agents which have assembled in the bod}^ including the anfBsthetic. On the day of the operation, as a rule, the patient should receive nothing by mouth, except perhaps water or some other drink. If the operation comes late in the day, it will be of no harm for children to receive a glass of milk, or for adults to take a little tea, a cup of broth, or a glass of wine, if they only get it early. NARCOTICS In order to help a nervous patient meet the sm-gical procedure with as much vigor and equanimity as possible, he should receive on the SPECIAL TREPARATIOX S evening before the operation 10 grains of veronal in hot wine or tea. Morphine should be given if on account of severe pain the milder nar- cotic docs not work. If veronal is not well borne, any one of the many sleep-inducing agents, such as sulphonal, trional, or adalin, may be given in its place. In children a narcotic before the operation is given under exceptional circumstances only. SPECIAL PREPARATION MEDICATION' In emergency operations and in the majority of other operations special preparation of the system by means of drugs is unnecessary. The administration by mouth or subcutaneous injection of drugs for the disinfection of the tissues, of the gastro-intestinal track or other organs in order to increase their resistance to infection is ordinarily useless. ^Vhen physical examination shows the necessity thereof, the patient should be given a course of drug treatment for several days or longer, preceding the operation. Patients with cardiac insufficiency should be given some digitalis preparation, and those with nervous disturbances, such as epileptics and persons with exophthahnic goiter, should receive potassium bromide or some other sedative. Patients with bronchitis should be assisted in the solution and riddance of the secretion by the administration of expectorants. In dry catarrh the irritative cough should be controlled by means of codein and similar drugs. Patients with jaundice are given for several days 4.5 grains of calcium chlorate per day in order to increase the coagulability of the cholemic blood. PREPARATION IX niABETICS Careful attention should be given to the preparation of patients with diabetes. It is recognized that in diabetics even slight wounds on the extremities easily lead to infection and j)ossibly gangrene of tlie entire limb. Tlie cause of this is the sugar and allied acids contained in the tissues, in conjunction with the arteriosclerosis which always co-exists in a greater or less degree. The presence of these elements will be recognized by examination of the in"ine. and whether sugar is present alone or with acetone, precautions should always be taken. In emergency operations, to be sure, such as acute api)endicitis, time does not allow, but in any case, before or immediately after the opera- 4 PREPARATION FOR OPERATION' tion attempts should be made to bi'ing about at least a diminution in the sugar or acid saturation of the tissues. If a low grade of diabetes is present, with little sugar and without acetone or diacetic acid in tlie urine, the patient should be carried along on a diet free of carbohydrates until the last traces of sugar have disappeared before the operation is inidertaken. If the patient presents a severe grade of diabetes, therapeutic measures will depend upon the results of the antidiabetic diet, and the lu-inary findings. Either a large amount of sugar is being eliminated and the quantity is not decreased under absolute dietary restrictions, or in addition to sugar acetone is present in the urine. In the first case the limitation of carbohydrates before ojieration is only carried so far as the patient can stand without weakening. A small remnant of glycosuria before operation is less dangerous than an extreme reduc- tion of the body resistance by an otherwise advantageous diet. In the other form of severe diabetes, in which the sugar excretion is combined with the excretion of acetone or diacetic acid, therapeutic measiH'es will depend upon whether the acids appear in the lu-ine only after the withdrawal of carbohydrates from the diet, or if they dimin- ish simultaneously with the sugar, or if they increase in spite of the deprivation of carbohydrates. If the acetone first appears wliile the sugar is decreasing in the lu'ine, the strict diet luust be relieved until the acetone has disajipeared, for the presence of these acids in the tissues will interfere more with wound healing than the presence of sugar. The outlook for wound healing is more favorable if the acetone and the sugar disappear simultaneously, for a severe diabetes may in such cases for a considerable time at least be converted into a mild form, with the help of dietary restrictions. At the same time one should be sin-e in these cases that too great an inroad into the patient's vitality be not allowed. The prognosis is worst when the elimination of acids cannot be influenced in spite of the withdrawal of carbohydrates. In these •cases diabetic coma is a threatening danger. All precautions should be directed to the neutralizing of the acids which are present in the body, and for this purpose the patient should receive large quantities of sodium bicarbonate, in teaspoonfid doses by mouth, and by rectal injection with opium, to the amount of three ounces per day. If coma appears intravenous injections of 5 per cent, soda bicarbonate solution may be given, and it shoidd be continued until tlie lu-ine shows an alkaline reaction. Von Xoorden advises in the case of increasing acid PREPARATinX OF SPECIAL REGIONS 5 elimination and threatening coma in spite of comjjlete abstention from carboliydnitcs, to interrupt tlie diet temporarily by the administration of oat-meal. Umber recommends the simultaneous administration of large doses of morphine or opium, by means of which the distressing thirst is also controlled. PREPARATIOX Ol' SPECIAI, KECIOXS Before anesthesia is started, the mouth should be M'ashed out with 4 per cent, boric acid solution or 2 per cent, hydrogen dioxide, and the teeth should be mechanically cleaned with a tooth brush. In this way the bacterial flora of the mouth is diminished, and the possibiHties of infection of wounds in the mouth and tongue incurred during anes- thetization, and of infection of the respiratory track, are lessened. Irrigation of the bladder is performed preceding operation on the lu'inary organs only in the ])resence of cystitis. A 2 per cent, boric acid solution or a one to two thousand or one thousand solution of corrosive sublimate may be used. In every case it is of advantage to promote diuresis by taking non-carbonated waters, reinforced by urotropine, which may be given vip to seventy-five grains per day. In addition eveiy patient should empty the bladder before operation, for a full bladder may be a source of trouble during a celiotomy, and if it is emptied during the operation, either spontaneously or by means of a catheter, asepsis is disturbed. Before gynecological operations, the vagina should be washed out with alcohol, boric acid solulioTi, or lysol. Evacuation of the stomach followed by lavage is indicated only when it is difficult or impossible for the stomach, on account of narrowing of the pylorus through scar contraction or new growth, to empty itself. In every operation on the stomach or duodenum the retained and par- tially digested food should be washed out through a stomach tube with a solution of warm water, .'3 per cent, boric acid, soda bicarbonate or one to two thousand corrosive. The irrigation must be continued until the water comes back clean. This precaution should never be omitted if it is probable that the stomach contents may be inspired durhig vomiting in the course of or after the an;estliesia, for instance, in the presence of intestinal obstruction, or in emergency operations which are undertaken shortly after a meal. On the day before the operation care must be taken that the intes- tines are well cleaned out. Frequently assistance must be given by means of castor oil, Carlsl)ad salts, or an enema. Only mild laxatives should be used, in order that the patient be not minecessarily weakened 6 PREPARATION FOR OPERATION through diarrhoea. This precaution should be taken before operation not only to increase the comfort of the patient, but in order that it shall not become necessary to take measures soon after the operation, for with the effort necessary to bowel movement a freshly operated case may be placed in some danger. Also after operations upon the jjeritoneal cavity, the belly muscles are weakened from the incision, and normal bowel activity is interfered with; and on accoimt of the intestinal paresis which follows celiotomies, with the resulting danger of toxic absorption, a previous catharsis is necessary. In particidar the lower bowel should be emptied because it frequently has to be employed in the first days after the operation for the administration of drugs and means of nutrition. CONTRA-INDICATIONS TO OPERATION A contra-indication to the carrying out of any necessary operation can only be established on pressing grounds, after a careful investi- gation of the entire system. Neither extreme age nor early infancy is to be considered a hindrance. Weak and exhausted patients are at the present day anesthetised by such gentle and harmless means that the attempt to bring operative assistance should always be given weight against sure death. Obese and very anemic patients, diabetics and leukemics appear to be particularly endangered by major pro- cedures. During menstruation operations upon the genitalia and in their neighborhood shoidd be avoided, unless delay is dangerous. Likewise in pregnancy, unless some special indication exists, the operation should be postponed until after delivery. In the presence of hemophilia only the most urgent operations should be undertaken. Before every operation one should protect himself against error in this respect by a careful history. Preparatory treatment by means of hydrastis or gelatin (by rectal or subcutaneous injection or as an addition to the food) , and by injections of a foreign serum (diphtheria antitoxin) may be of great advantage in increasing the coagulability of blood. THE OPERATING ROOM For an operating room any room with sufficient natural or artificial light may be used on occasion. The one necessary condition is that it should be free of dust. For that reason a room without curtains, hangings, carpets and similar dust retainers should be chosen. In any POSTURE 7 case such furnishings should not be disturbed immediately before the operation. The floor should be carefully wiped with a moist cloth, but not dry swept. For major operations an operating room completely equi])ped and with a good statt" of attendants is preferable to any makeshift. In case of necessity a single flat kitchen table may be used for an operating table. For hospital use special models have been developed in Germany, which are built entirely of metal and stand solid upon a central pedestal; they may be thoroughly cleansed and their various parts readily adjusted. The top of this table may, by means of an oil pump, be raised or lowered on a level or it may be tilted to either side or lowered at either end. The typical American table stands upon four legs and has a sectional top of glass or enameled steel. The leg section may be folded down, or the head section lifted, and the table as a whole may be tilted by means of a crank so that the head is depressed and the foot elevated. POSTURE The patient is to be placed in the position which best facilitates approach to the field of operation. At the same time respiration or cardiac activity should not be interfered with by compression of chest or abdomen. Procedures on the front of the body are customarily carried out with the patient u})on his back, whether they involve the head, trunk or extremities. The head of the patient lies upon the same level as the body, or. better still, is carried slightly backwards in order to make it easier for the anesthetist to lift up the lower jaw and pull forward the tongue in case the airway is obstructed. The arms lie ordinarily at the side of the patient. For celiotomies, involving the lower portion of the abdomen, the forearms may be carried across the thorax, and held rolled uj) in the patient's night-gown; for o])crations in the upper portion of the abdominal cavity the hands are laid flat, palm down- ward, under the buttocks on either side. Care is to be taken that one of the arms does not hang over the edge of the table, as paralysis may result. The anesthetist follows the pulse by palpation of the facial or temporal artery, or In' stethosco])e strapped to the precordium. Trendelenburg's position, which consists of an elevation of the pelvis with the knees bent, is employed in all abdominal gynecological opera- tions, in operative procedures on the bladder, and upon the lower seg- ment of the colon. The legs are tied down, to prevent the patient from slij)i)ing. Its advantage lies in the fact that the small intesthies 8 PREPARATION FOR OPERATION and the omentum are carried by gravity into the upper portion of the peritoneal cavity and do not interfere with the operation. Patients witli arteriosclerosis should not l)e kept too long in this position, because the blood pressure within the cranium may be increased to dangerous proportions. This holds true also for old persons with prostatic hypertrophy. In every case the horizontal position should be restored as early as possible, at any rate before one starts sewing up the abdominal Avail. The stomach and intestines fall at once into their original position, but the omentum is apt to remain in the upper portion of the peritoneal cavity. Accordingly at the end of the operation the omentum should be unfolded and draAATi do\\Ti over the intestines. If this is omitted, serious circulatory disturbances may take place in the omentum, and symptoms of obstruction may appear in the rolled up, and possibly kinked off, transverse colon. In the lithotomy position the patient, placed upon his back, is pulled dowTi until the buttocks project beyond the end of the table. Both legs are held flexed at the hips, either by assistants, or in leg-holders which attach to the lower end of the table. This position is necessary in operations upon the anus and rectum and in gynecological opera- tions through the vagina. Tlie lateral position is employed in operations upon the thorax, the kidneys and ureters, and the hip joint. If possible the patient should be jjlaced upon his right side, as in this position the heart is less re- stricted. As in the Sims position the under arm is drawii through to the back, to prevent pressure paralysis, and the upper leg is sharply flexed at the hip and knee. A pillow or bolster is placed in front of the thorax. In operations upon the cerebellum, the sjiine, cord and the back generally the patient lies flat on his stomach, with tlie head projecting beyond the table to facilitate etherization. The forehead is supported bv the lap of the anesthetist, or by a specially constructed frame. In operations upon the skull and face the patient may advanta- geously be placed in a half sitting posture, as in this way the flow of blood is better controlled. The head is held by an assistant with both hands, by whom it may be moved forward or backward, rotated, or laid on tlie shoulder at will. Pillows, rolls and sand bags of various shapes and sizes may often be used to advantage. With a small sand bag one may raise when necessary certain parts of the body, and it is particularly useful in supporting a limb upon which chisel and mallet are to be used. Hard POSTURE 9 stuffed rolls may be shoved under the shoulders, in operations upon the neck, to allow the head to hang back and thus put the soft parts of the neck on the stretch. In operations upon the lower thorax, to increase the lateral flexure and widen the apertuie between the ribs, a pad may be placed under the side. In operations upon the gall- bladder and bile ducts, a sand-bag or roll is placed under the back in the region of the diaphragm to facilitate exposure. For these purposes as well as for kidney operating the Cunningham elevator is of great convenience. Paralysis may occur in the arm or leg as the residt of pressure during the operation. It is more common in the arm; if the arm hangs to one side the musculo-spiral nerve is pressed between the humerus and the edge of the table, or if it is held high above the head or lies under the body in the lateral posture, the brachial plexus may be squeezed between the clavicle and the first rib. In the leg the peroneal nerve is most apt to be involved, although jicroneal paralysis occurs comparatively infrequently. Insufficient j)adding of the leg holder causes pressure of the nerve against the head of the fibula. In order to avoid serious cooling of the body surfaces of the exposed patient the operating room must be as warm as may conveniently be borne by the operator and his staff'. All i)ortions of the body which lie outside of the operative field should be wrajjped in woolen cover- ings. In celiotomies and perineal operations each leg should be com- pletely encased in a flannel boot, and the chest and shoulders also well covered. It is best to leave the coverings, if they are still dry, upon the body of the patient after the operation, particularly if he has perspired freely, and to remove them oidy after the patient has been transferred to a previously warmed bed. CHAPTER 2— ANESTHESIA In order to carry through major operations without pain we ordi- narily employ inhalation anesthesia, less frequently spinal and local anesthesia. The results with intra-venous and rectal anesthesia have not yet justified their general adoption. For inhalation chloroform, ether and nitrous oxide or some combination of these are used, accord- ing to the indications, and the experience and preference of the surgeon. Inhalation anesthesia is ordinarily without danger Avith any of these agents, if overseen by a careful and experienced anesthetist. But over against its beneficence for the patient and its ad\'antages for the operator have to be placed the possibility of danger to the patient, during the administration, or from the subsequent effects. These depend chiefly on the fact that the patient during the anesthesia is absorbing a poison, and that the loss of sensibility to pain is onlj^ one manifestation of a general intoxication. THE SPECIAL PROPERTIES OF CHLOROFORM AND ETHER The activity of both these agents depends upon the fact that the inhaled vapor, carried by the blood, invades all the tissues and pene- trates to the cells of the cortex. In order to induce narcosis the sensory paths and the cortex must be overcome. For even in comparatively deep anesthesia the motor paths from the cortex are active, as may be shown by electric stimulation of the motor region during an operation for the relief of epilepsy. Also the jieripheral portions of the motor tracks always respond to stimulation in spite of deep narcosis, as may be seen by the contraction of a muscle which results when a motor nerve is touched. The cerebellum is afi'ected earlier than the cerebrum, for at the beginning while consciousness still persists, there appears a high grade of ataxia, similar to that resulting from alcoholic in- toxication. In order to completely overcome the motor tracks large quantities of the anesthetic are necessary. Such a motor paralysis involves con- siderable danger, particularly as paralysis of the nerves in the pons and medulla is synonymous with respiratory and cardiac paralysis. This condition appears only when large quantities of pure vapor are 10 chlorofor:m and ether ii given unmixed with air. The loss of motility of voluntary muscles during anesthesia depends upon the paralysis of the cortex and of the will power, and destruction of the reflexes depends upon the paralysis of the sensory portion of the reflex arc. Since chloroform and ether are toxic the quantity used is of signifi- cance in relation to their injurious effects. Ordinarily a considerable amount of ether may he necessary to induce anesthesia, quantitatively considerably more than chloroform, but as the operation proceeds the amount of ether which is necessarj' decreases, and at the same time the danger of respiratory paralysis. Coincident with the poisoning of the central nervous system injuri- ous efl"ccts are produced upon other tissues and organs. The toxic influence of either agent may become apparent in its most dangerous form at the begimiing of its absorption, as in the cases of sudden death at the beginning of the anesthesia. This sort of toxic effect occurs usually in patients with status thymicus or lymphaticus. In their later toxic symptoms the two agents diff'er from each other. Chloro- form works an injurious effect upon the heart muscle in smaller quan- tities than ether, but the effect upon the kidneys is more prolonged in the case of ether than in the case of chloroform. The small traces of aU)umin in the first few days after chloroform anesthesia usually disaj)i)ear rapidly, while lU'emic symptoms are sometimes met with after a long ether anesthesia. The parenchyma of the liver is more seriously damaged by chloroform, and fatty denegeration and general icterus are not infrequent sequelas. After etherization the coagula- bility of the blood is decreased. The effect of ether upon the mucous membranes is its most serious drawback. While irritation of the nuicous mem})rane of the stomach and intestines seems to be without harmful results, except as it occa- sionally induces prolonged vomitiivg. the effects of this agent iq)on the bronchial mucous membrane may be dangerous. They ])resent them- selves clinically in the well-known evidences of irritation, such as bronchitis and broncho-pneumonia. Whether ether is employed by rectum, intravenously, or by inhalation, it induces an active and imme- diate secretion of mucus. If the nuicus collects in the air passages and is not cared for by lowering the head and clearing out the pharynx with gauze the patient is in danger of choking or of inspiring it. In addition, in long continued anesthesia, the irritation of the mucous membrane may lead to inflammation, out of which ether pneumonia may develop. 12 ANESTHESIA SUDDEN DEATH DURING ANESTHESIA Death through syncope after the first whiffs of chloroform vapor occurs quite infrequently; with ether it is rare. Death during the course of the anesthesia may develop with the employment of ether as well as with chloroform, and Iiere also chloroform exhibits itself as the more dangerous agent, on account of its great toxicity, if reck- lessly applied. This form of anesthetic death with chloroform may be avoided prac- tically without exception if the anesthetist notices in time the warning signals which precede every danger, and immediately removes the mask and starts methods of resuscitation. Thus chloroform death during the course of anesthesia is often to be ascribed not to the toxicity of the agent alone, but to the ignorance or inattention of the anesthetist as an accessory. Death during the com-se of etlierization is less frequent, but it may happen if a deep narcosis with inordinately large quantities of ether is continued for a long time, with a closed or semi-closed inhaler. This danger is reduced to a minimimi if ether is employed judicially, by the drop method. As regards the dangers which develop after the end of the anesthesia, chloroform has some advantage over ether. SEQUELAE OF CHLOROFORM AND ETHER Patients with sound heart muscle, particularly young persons, stand chloroform well, but it exercises a dangerous and sometimes fatal effect upon degenerated and insufficient heart nniscle. This explains the not infrequent cases of death in the days following the operation. Cardiac paralysis may however occur in certain cases after ether anes- thesia, even if limited quantities are used, death being due to nothing but atonicity of the heart nmscle. Other late results of chloroform, such as vomiting, headache and psychic distiu'bances are observed also after ether. The serious danger with ether lies in its injurious effect upon the bronchi and the alveoli of the lungs. Not only is post-operative broncho-pneumonia in the first days after ether anesthesia more frequent than when chloro- form is employed, but the type of inflammation is more severe. It involves larger areas of the limg, and is more difficult to treat. This is the case even when the ether is chemically pure, and is not given in great concentration. Post-anesthetic pneumonia may also be caused by emboli, which are set free from thrombi in the veins, and carried by the general circulation to the lungs. In this regard also ether is CHLOROFORM AND ETHER 13 the more dangerous agent, because it decreases the coaguhibility of the blood. Thrombosis of the extremities, apoplexy, and hematin-iu arc, therefore, more frequently observed after ether than after chloro- form anesthesia. With chloroform, after recovery from the anesthetic the greatest danger is over, while with ether a certain danger of com- plications persists for several days. IVIoreover, with chloroform anes- thesia can always be induced i!i patients who go under ether with dilliculty, and only by the use of large and harmful quantities. SELECTION Ol- THE AXES'J'HETIC The choice of anesthetic will depend on the result of the physical examination. Patients with uncompensated lieart lesions, such as edema, cyanosis, coronary sclerosis and cardiac dilatation should never receive chloroform, particidarly when the insufficiency is the result of myocarditis. Also arythmia of the pulse demands ether. Degen- erated and weak heart nuiscle cannot stand the toxic action of chloro- form, and the patient who survives the operation may go to pieces within a few days after the anesthetic with syni])toms of progressing cardiac weakness. But it must be admitted also that a heart with degenerated muscle fibre usually does not stand ether well. Nor should chloroform be employed in fresh cases of endocarditis; but in compensated heart lesions, on the other hand, it may be used without hesitation in limited quantities. On account of its paralyzing effect upon the heart, chloroform is dangerous in all patients with arterio- sclerosis; to be sure these patients also stand ether poorly and throm- bosis and brain hemorrhage are particularly to be feared as compli- cations. Also the employment of chloroform in diabetes is to be avoided. But the use of ether may not prevent the onset of an attack of diabetic coma. Chloroform is also contra-indicated in status thymicus and lymphatieus as well as in Basedow's and iVddison's dis- ease, and in advanced tuberculosis with amyloid degeneration. On the other hand where a tendenc}'^ to pneumonia and to catarrhal manifestations of the organs of respiration exists, ether should be avoided as an anesthetic, because the particles of ether circulating through the body, whether inhaled as vapor or introduced in any other way, for instance by rectum or intravenously, irritate the mucous membrane of lungs and bronchi and set up a considerable secretion. Through aspiration of mucus and saliva and as a result of the direct toxic effect of ether u])on the alveolar and bronchial epithelium, ])ost- anesthetic pneumonia is apt to occur in the presence of existing disease 14 ANESTHESIA of the respiratory track. In operations upon the chest and the abdomen it is important that the patient should be reheved of the strain of coughing, and particularly of all changes of position which may be necessary for better ventilation of the lungs. Ether is not toxic to the heart, but the heart functions do not always suffice to overcome a pneumonia which is caused by ether, while the small amount of chloroform which is necessary for these cases hardly has any effect upon the heart. Alcoholics and patients with kidney disease stand ether more poorly than they do chloroform. On the other liand ether may be admin- istered by an unskilled person if necessary, in whose hands chloroform anesthesia would be attended bj^ very grave danger. Frequent repeti- tion of either chloroform or ether anesthesia sliould be avoided, especially in the young and the aged, on account of the cumulative effect of their destructive action on liver and kidneys. SCOPOLAMIN AND MORPHINE AS A PRELIMINARY TO ANESTHESIA Half or three-quarters of an hour before the anesthesia is started the patient may be given a subcutaneous injection of 1/120 grain of scopolamin hydrobromate together with 1/6 grain of morphine hydro- chlorate. This injection is given once only and is not repeated. Scopolamin-morphine exerts a quieting influence upon the mental state, and upon humanitarian grounds it maj' be used in all cases where no contra-indication exists. The pertin-bation and anxiety which precede the operation give way to a peaceful imconsciousness and quiet sleep. The patient loses in large measiu'e all memory of the moments preceding the operation, he remembers little or nothing of the transportation to the operating room, and often on awakening several hours after the completion of the ojjeration, is astonished that the operation is already over. As regards the anesthesia, the use of these agents possesses direct advantages, for the anesthesia can be induced with a smaller quantity of ether, and frequently no trace of the stage of excitement appears; moreover the anesthesia is less likely to be disturbed by spasm of the muscles or vomiting. Often for considerable intervals, for instance while intestines are being anastomosed, the anesthetic may be prac- tically withheld without the patient awakening or becoming unquiet. The cumidative toxic effect of the anesthetic is unquestiona])ly de- creased, because when this combination is used a smaller quantity of the anesthetic is required. SCOPOLAMIXE-MOUrHIXE 15 Weak or anemic women and youthful patients may be given an injection of 1 l.)0 yrain of scopolainin. Alcoholics, on the other hand, require a larij^er close in order to <)et the same result. ^lore tlian 1 80 grain of scopolamin should never be given. On account of its toxic properties, ciiildren under the age of fifteen should never be given scopolainin. Among other j)r<)perties of the scopolamin-morphinc injection must be reckoned the fa\()ral)le effect upon llie setjuela' of tlie anesthesia. Post-anesthetic lung affections and particularly vomiting are consid- erably less frequent after the operation M'hen it is employed. This is explained by the effect of the scopolamin in drying the mucous membranes. One drawback of scopolamin consists in the fact that it is a jaoison which is not readily excreted from the body after injection. Its toxic effect is recognizable particularly on the respiration and the blood vessels. Although fatal results are practically never heard of from the small doses described, disturbing concomitants may occur in the way of superficial breathing, collapse, and even a certain grade of cyanosis. The loss of the vessel tone and the paralysis of the arterioles and ca])illaries as the result of the action of scopolamin cause diffuse bleeding, and the wound of a head or face operation, for instance, may bleed like a squeezed sponge without it being possible to seize the small vessels and stop the bleeding by any other means than pressure. On account of the cyanosis, the danger of collapse and the tendency to sujjcrlicial breathing it is advisable in the second stage of cranial operations to avoid scopolamin, for patients with brain tumors are likely to suffer from disturbances of resi)iration as a result of pres- sure. Not infre(]uently tiiis goes so far as to cause a complete cessation of respiration, and in this regard the scoj)olamin simply augments the action of the brain tumor. Attempts to overcome this paralysis by the aid of ordinary resuscitative methods or with antidotes are without result, for scopolanu'n is not readily excreted and its effect lasts for several hours. Its use shoulil be avoided particularly in operations upon the nose, mouth, pharynx and larynx, for after such procedures it is necessary that the patient awake from the anesthetic as soon as possible, in order to cough up any blood which has been aspirated, or has flowed down into the bronchi unnoticed. The substitution of pantopon for the morphine, |)articularly in skull operations, undoubtedly results in a decrease in the venous hyperemia 16 ANESTHESIA of the head during the anesthesia. Also the deep sleep of the patient at the end of the operation is not so prolonged with scopolaniin- pantopon as with scopolaniin-morphine, and the patient may be imme- diately awakened out of his slumber. In the same waj' the patient seems to suffer less from inactivity of the bowels in the first few days after the operation if pantopon is used. But on the other hand on account of the collapse which has been observed with scopolamin- pantopon immediately at the beginning of the anesthesia in celio- tomies, it is wise to continue the use of morphine in all abdominal operations. Either combination should never be used except in the hands of a skilled anesthetist. Its contra-indications as stated by Herb* are as follows: In patients in whom the respiratory centre is depressed or likely to become depressed through operative procedures; obstructive dyspnoea due to growth within or without the trachea, causing pres- sure, or exophthalmic goitre; in operations about mouth or throat; in the case of debilitated or cachetic persons or those suffermg with continued sepsis ; in patients presenting any degree of stupor or those susceptible to morphine; as well as in children and the elderly. TECHNIQUE OF CHLOROFORM ANESTHESIA In administering chloroform particidar care must be taken that too large a quantity is not poured upon the mask at one time, and more- over, since concentration of the poison increases its danger to the heart, a sufficient quantity of air should always accompany the vapor. The mask should never be saturated with chloroform and then applied to the face, but it should at first be held dry some little dis- tance from the face until the patient, after a few inspirations of air, has become accustomed to it. Then the narcosis is begun with a few drops of chloroform, which are dropped upon the mask at intervals. In the beginning the patient thus receives chloroform vapor mixed with considerable air, and with a careful administration suff'ocation, nausea and anxiety do not appear. After a short period the frequency of the drop is increased and at the same time the mask is gradually approached to the face. After the first few inspirations, the danger of syncope beizig over, the depth of the anesthesia is increased, the respiration, pulse and pupillary reaction and the color of the face being carefully noted. Loss of the pupillary reaction denotes the limit which the anesthesia *Jour. Amer. Med. Ass., 1913, Ixi, 834 CHLOROFORM ANESTHESIA 17 should be allowed to reach; for this represents a paralysis of a portion of the brain which is in close relation to the vagus centre and to the centres which exercise an effect upon respiration and cardiac activity. Even slight disturbances of respiration sliuuld induce tiic anesthetist to interrupt the application of chloroform. Disturbances of respiration may be caused mechanically or as the result of paralysis of the centre of respiration. Opening the mouth by means of a mouth gag is not sufficient to clear the entrance to the larynx because not only the epiglottis but also the tongue wliich has dropped back against the posterior wall of the larynx shuts off the passage-way. The tongue must be seized by tongue forceps, if the air way is obstructed, and pulled as far as possible out of the mouth. Paralysis of the centre of respiration in chloroform anesthesia is rare, but with ether it is less so. We have frequently seen cessation of respiration during operation upon brain tumor, but there is no ques- tion in these cases but that intracranial pressure is as much to blame as the anesthetic, for respiration has been seen to stop in tumors in the cerebellum even after the chloroform had been discontinued for some while, and patients have died of respiratory failure imder local anesthesia, while the heart has been kept going by artificial means for several hours. A\'hilc paralysis of respiration may be largely overcome by the insti- tution of artificial respiration, the disturbances of circulation during chloroform anesthesia are fraught with graver danger to the patient. Toxic paralysis of the heart muscle announces itself by a gradual loss in its power. The blood becomes dark in color, the face is cyanotic or white and the pulse becomes more frecpient, as a rule, smaller in volume, and finally quite thready. Cardiac paralysis occurs at the beginning of the anesthesia, as well as with an anesthesia of long diu'a- tion, for which large quantities of ether or cliloroform are necessary. Naturally cardiac difficulties are more likely to arise during opera- tions where there has been a considerable loss of blood, or reflex dis- turbances through irritation of the peritoneum and through changes in pressure within the thorax and abdomen. Tlie careful and experi- enced anesthetist notices the gradually increasing weakness of the heart by the quality of the pulse and the color of the face. Since it never develops suddcidy but always announces itself early by these symp- toms, it can be met with cardiac stimulants, such as stiychnine, camplior, caffeine, infusion of salt solution, and lowering of the head. We should make early and prophylactic use of the rapidly acting 18 ANESTHESIA camphor, because when injected subciitaneoiisly, by its stimulant action upon the vasomotor system it readily overcomes the early signs of cardiac weakness. If the heart has stopped beating all attempts by means of injection of drugs are useless, because they remain at the site of injection and on account of the failing circulation reach neither brain nor heart. In such case attempt must be made to stimulate the heart to action by means of indirect or direct massage. Short powerful thrusts must be made ^\itli the right hand lying upon the chest wall in the region of the heart at the rate of at least 60 times a minute. The heart is shaken through the chest wall and is thereby stimulated to contraction. This procedure usually succeeds. It must be accompanied liy artificial respiration in order to overcome the supersaturation of the blood with carbon dioxide. As soon as the heart begins to beat again, one should inject stimulants in order to support its activity. If the abdomen is open the hand can be pushed through the celiotomy wound and the heart can be directly compressed and massaged against the chest wall through the diaphragm. As a last resort direct massage of the heart may be instituted after resection of the fifth costal cartilage on the left side and opening of the pericardium. Two fingers are shoved under the base of the heart and the heart rhythmically compressed against the chest wall, or carefully kneaded. Care should be taken that chloroform is kept in a cool place and away from light. A fresh container should be opened for each opera- tion, and when the operation is over the remainder in the bottle should be thrown away, and not used for anesthesia. ADMINISTRATION OF ETHER The conduct of ether anesthesia requires less care in the observation of the cardiac activity. Ordinarily the pulse remains full and strong, because ether is a stimulant to the heart nuiscle, while chloroform is depressant. For this reason, in patients who are sick ether is the anesthetic of choice. But after a prolonged administration ether begins to show a toxic action upon the heart muscle, and the same symptoms of cardiac depression appear as with the employment of chloi-oform. On the other hand ether demands a more careful observation of the respiration, and the respiratory track. If the lireathing remains strong, the inspired air being mixed with the richly secreted mucus makes a churning, gurgling noise. ^^Mlile this sonorous respiration ADMINISTRATION OF ETHER 19 during ether anesthesia is to be taken as a sign that there is no obstruc- tion, at the same time there is a certain amount of chinger connected with it. So long as these secretions are hmited to the mouth and the pharynx they are harmless, because they may be removed through lowering the head and M^iping out the pliarynx down to tiie epiglottis. But the secretion is more dangerous in the bronchi and bronchioles of the lung, from Avhicli they are not removed until the end of anes- thesia. They remain there until the patient coughs them out. In this lies the greatest danger of ether anesthesia, for during deep anestliesia mucus and other material from the nose, mouth and pharynx run down into the bronchi or are inspired, and can only be removed through coughing and retching. For this reason preliminary cleansing of the mouth is particularly advisable. Many surgeons limit the otherwise copious secretion by an injection of one one-hundredth grain of atroj)in and one-sixth of morphine before starting anesthesia. "While in young and strong patients this nuicus seldom forms a serious obstruction to respiration, nevertheless in weaker patients, and particularly those with poor hearts, it may threaten, during the course of anesthesia, to lead to suffocation. This is brought about by the fact that the tenacious mucus sticks together in a mass and in that way a narrowing of the respiratory passage results, which if the patient has not the strength to overcome, acts as an obstruction to breathing. The patient then does not become cyanotic, as would occur if the heart were affected, but pale, and the heart weakens simultaneously with res])iration. The respiration and cardiac acti\ ity may be restored if at the right time the tongue is pulled out and the pharynx wijjcd clean. Otherwise ether anesthesia is carried on just as chloroform. The ether is poured out of a drop bottle, at first slowly, and then faster, upon a mask which carries 12 or 10 layers of thick gauze, and the drops are increased rapidly until the stage of excitement is passed. Then when the patient sleeps quietly, as may be inferred from the sonorous respiration, the quantity is again decreased. In alcoholics the excitation is a])t to be particularly severe, and it is sometimes difhcidt to get them under with ether alone. Instead of pouring on excessive (juantities of ether, it may be advisable to start the anesthesia with clilDroform oi- ancsthol. Experiments with the Council anesthetometer* have shown that the inspired air must contain 30 per cent, of ether vapor by weight to *Boothby, Jour. Amer. Med. Ass., 1013, Ixi,.S30. 20 ANESTHESIA saturate the blood sufficiently for the induction of full surgical anes- thesia, and that after relaxation a 15 per cent, vapor is strong enough to prevent diffusion outward from the tissues and to maintain the requisite ether content of the blood. In alcoholics, ether apparently exerts greater excitatory power on the respiratory centre than in non- alcoholics. Naturally a greater quantity of ether is required to bring this larger volume of respired air up to the 30 per cent, requisite for induction. But an expert anesthetist using gauze and the drop method will induce an anesthesia rapidly and smoothly without caus- ing excitement or suffocation and the deeper j-espiration which results. The percentage of the ether vapor may be raised by holding the hands in turn on the side of the mask, so as to increase the vaporization by their warmth. ETHER IN MINOR SURGERY In order to carry out minor j^rocedures, ether may be employed in any one of a number of ways. The best knoAvn is the suffocation method, with a closed mask. A Blake cone with a close-fitting face- piece is stuffed tightly with gauze, or the outside of a Juillard mask is covered with an impermeable material, and inside is placed a tight wad of gauze the size of the fist. Upon the gauze about 2 ounces of ether is poured, the excess which is not absorbed by the material is shaken out, and the cone filled with ether vapor is set upon the face. At first the patient feels as if he must suffocate, particularly when a towel is wrapped about the edge of the cone to aid in preventing the access of air. Immediately there results a violent struggling and a sudden powerfid excitation, wliich is increased as the irritation of the ether upon the mucous membranes causes a reflex closure of the glottis. In addition to the ether we then have the narcotic effect of the supersaturation of the carbon dioxid in the blood. This condition, which is dangerous to the heart and respiration, disappears as soon as the cone is lifted to allow a single inspiration of fresh air. The spasm of the glottis and sense of suffocation disappear, and inspiration of the ether vapor follows without further trouble until deep anesthesia is induced. For the setting of fractures and the reduction of dislocations, for small amputations, and the incision of abscesses, this method works rapidly and gives a satisfactory anesthesia. It has been completely discarded, however, by most surgeons on account of the danger to the heart, from the sudden crowding of the ether, and the suffocation. PRIMARY ETHERIZATION 21 Naturally, it should never be used iu old or weak patients or when the heart or the vessels are diseased. A less dangerous modification of this method consists in pouring about an ounce of ether upon a cone and gradually approaching it to the face, until the irritative symptoms and the sense of suffocation have been overcome, when a large quantity of ether is poured on and the cone is placed u])on the face. ^lore ether is poured into the cone from time to time as recjuired. This method takes longer than the suffocation method, and it demands a larger amount of ether, because it is diluted with air. Eut on account of the inspiration of concen- trated ether vapor for a considerable time it is not harmless to the lungs and it in no way possesses the advantages of the drop method. The method best suited for short minor procedures depends upon the employment of the analgesia which accompanies the stage of excitation at the beginning of anesthesia. This is similar to the methods of pre-anesthesia days, when the sensibility was deadened by alcohol and other exciting agents. In the ether "rausch," so called, the patient maintains consciousness, hears and answers questions, losing oidy the sense of pain. The conduct of a primary etherization is carried on according to Sudck* in the following way: A mask such as is used for the drop method is laid ui)on the face dry, and when the patient has become accustomed to its presence a few drops of ether are applied, at first at long intervals and then more rapidly. There is no unpleasant sense of suffocation because the quantity at first is small and the dilution of the vapor with air is great. The i)atient may be directed to hold the arm up in the air, or to coimt out loud. At the end of about fifteen full inspirations, the anesthesia is tried by a needle prick. The right moment of loss of sensibility to pain is reached when the arm sinks, the counting is interrupted or the prick of the needle no longer felt. This primary etherization is not true anesthesia, for during its course the patient can answer questions and may talk in lively fashion, and sometimes even cries out, without later, at the end of the operation, being able to recall anv sensation of pain. ITe is conscious, however, of the noise of the instruments; he hears, sees, and is physically aware of what is happening to him, but he appreciates no painful .sensation. There is no danger of harmful results connected with this foiin of etherization; the patient may get up as soon as the o])eration is over. This method is ajjplicable j^articularly for the removal of stitches, *Verhanci. tier d. Ges. f. Cliir., 1909, p. 414. 22 ANESTHESIA the extraction of the roots of teeth, the incision of furuncles and the evacuation of abscesses and similar minor but painful procedures. Since reflex activity and muscle spasm are decreased but not entirelv overcome, the application of this method to more extensive operations, such as the reduction of dislocations and the setting of fractures, is impracticable. The analgesia is at its height at the beginning of the "rausch," but it disappears rapidly as the administration is continued. NITROUS OXIDE (gas) Nitrous oxide or laughing gas has been very generally used in America for minor surgical and dental work since its introduction in 1844. It was first applied to major surgery, in combination with oxygen, by Andrews of Chicago, in 1868. Recently, under the leader- ship of Crile, its use in major surgery has extended. In Europe nitrous oxide has not been adopted to any great extent, largely be- cause the gas cannot be obtained generally at a reasonable cost and in portable form. For minor surgical procedures it is probably the most effective agent at our disposal. It should not be given to the very yoimg, or the aged, or those with heart or lung complications. It is not un- pleasant, there is no troublesome preliminary stage of excitement, anesthesia is complete after 10 or 12 full inhalations, and recovery is immediate, without after-effects. Naturally its use must ordinarily be limited to procedures requiring not more than a minute to carry out. However, with an experienced anesthetist, watching the color and the respiration, the patient may be kept under for as long as ten minutes, by alternating gas and air as required. It is not particularly good for setting fractures, on account of the necessary hurry, the spasm, and sometimes the involuntary movements of the patient. It is excellent for incision of abscesses, excision of carbuncles, and other rapid minor jirocedures, and for painful post-operative dressings. It has been generally applied in polite practice for some years as an agreeable agent for the induction of anesthesia as a preliminary to ether, using a gas-ether sequence apparatus, such as that of Gwathmey or Bennett. The anesthesia under nitrous oxide depends upon a diminution of the oxygen supply to the brain, as part of a general pseudo-asphyxia- tion. Cyanosis is one of the accompanying phenomena. The zone of harndess anesthesia, however, is narrowly limited, and the pressure of the gas and the proportion of air must be regulated with watchful NITROUS OXIDE 23 care. "With an over-dose the cyanosis increases, the resj^iration be- comes stertorous and sometimes crowing, muscular twitchings appear, which develop into clonic contractions and possibly a general con- vulsive seizure, and the patient if neglected dies. Deaths under gas, however, are practically unheard of, as there is ample warning, and fresh air relieves the symptoms. Gas can be purchased in containers of various sizes at the cost of a few cents per anestliesia, from makers throughout the country. Some hospitals make their own gas, and pipe it under low pressure to the operating rooms. The apparatus for its administration should be the simplest j)ossible. It consists of a yoke, to make connection with the tank, which has a handle to control the flow. A large size rubber tube goes from the yoke to a rubber balloon, holding when inflated about two gallons. A short tube, about one inch in diameter, runs to the face piece. This should be made with an inflated rubber pad to fit the hollows of the face, or a rubber sleeve, to strap behind the head. It should entirely exclude all outside air. There should be a large expiratory valve, which may be closed, and a valve on the intake, Avhich should allow of all gradations from pure air to pure gas, and for rebreathing into the bag. For mnjor operative rcnrk oxygen must be su])plied Avith the gas, in varying projjortions. The best a])])aratus, of which the Boothby machine is an example, are equipped with a device for turning ether vapor into the circuit also as needed. Crile has used gas-oxygen in over 4.000 general svirgical cases, and he states that it reduces mor- tality and lessens suffering. Shock occui-s less than one-half as fre- quently as with ether, and "apparently the worse the risk the better it acts." It is not unpleasant to take, the nausea is trifling, and com- plications rare. The cellular degeneration in brain, kidney and liver is j)robably much less than after the use of any other anesthetic agent. The post-operative impairment of vitality is distinctly less, and if occasion arises, the patient shows no hesitation about returning for another operation. On the other hand it nnist be said that the apparatus for its admin- istration is costly and com])licated, and that the gas and oxygen are items of IK) inconsiderable expense, standing the occasional adnn'nis- trator in private ])ractice $1.5 or more for a long anesthetization. No one but a skilled person should be trusted with the method, and he must give his undivided and intelligent attention to the patient. A j)reliminary injection of scopolumin-morphine is usually considered 2-i ANESTHESIA necessary. On account of the persistence of muscle spasm ether vapor must frequently be employed, or novocain or some other local anes- thetic injected into the muscles along the line of incision. The unac- customed surgeon is hampered and the operating time is considerablv lengthened by the increased venous hemorrhage, the spasm, and the time necessary for the local injections to take effect. At the present stage of its development the method is distinctly one for hospitals where particular interest can be given, trained anesthetists developed, and the surgeon re-educated. According to Crile, the results well repay the effort. ETHYL CHLORIDE To obtain in the office or out-patient clinic a reasonably safe ephemeral anesthesia, ethyl chloride, such as maj^ be obtained in glass tubes with a spring stopper, has been used for some years. The best mask is an ordinary chloroform mask covered with gauze, but over the gauze a piece of rubber tissue should be fitted, with a hole at the middle the size of a five cent piece. Upon this the spray of ethyl chloride is played; tlie warmth of the hand suffices after the stopper is open to vaporize the ethyl chloride and drive it out under pressure through the capillary canal in the neck of the tulie. In children the spray is unnecessary, and the ethyl chloride may be given in smaller quantity drop by drop, by partially opening the stopper. One hundred drops or a spray which is played for about twenty seconds induces a com- plete loss of sensibility to pain. Patients may be Ij'ing do^vn or in a sitting posture. They are not unconscious, but ca^^ open or shut the mouth and may grip the arms of the chair. A short period of reaction usually follows, during which the patient laughs and talks unrestrain- edly or acts as if partially intoxicated. Ktliyl chloride is economical because the tube alloAvs its being used in small quantities. Ethyl chloride should not be used for complete anesthesia on account of its dangerous possibilities. SPINAL ANESTHESIA In old persons with degenerated heart muscle, arteriosclerosis, ajid chronic bronchitis, we have at times in operations in the lower abdom- inal region or on the lower extremities made use of spinal anesthesia after the method of Bier. At first we used stovain, but more recently we have employed the older and less dangerous drug, tropacocain hydrochlorate. It is less powerful as an anesthetic, but it is easilj^ sol- SPINAL ANESTHESIA 25 uble in water and may be freshly sterilized before use. Many surgeons use the drug in powder form, placing it in the barrel of the syringe and allowing it to dissolve in the aspirated meningeal fluid. A dose of 9 10 grain in a half dram (2 c.c.) of the fluid serves to induce anesthesia in five to ten minutes from the navel downwards. The tropacocain may be bought dissolved ready for use in glass ampullae. Xovocain has no advantage over tropacocain even when its effects are heightened by the addition of adrenalin. The successful employment of spinal anesthesia depends chiefly upon the technique of injection. If when the needle has penetrated into the dural canal and the anesthetic has been injected, the expected effect does not appear, the fault lies either in incomi)lete solution of the powdered drug in the spinal fluid, or its mixture with blood, a leaking out of the fluid through the site of injection, or in the posture of the jDatient. With skilled technique these difficulties diminish so that with surgeons practised in the method bad sequelte and death rarely occur. In our own limited expei'ience we have seen neither death nor persistent disturbances of any sort, but at the beginning we had several failures. The harmful results depend upon the toxic effects of the drug upon the nerve tissues. Particularly commonly observed are fainting and collapse, nausea and vomiting, and ])artieularly the almost regularly occurring headache. The most dangerous is the disturbance of res- piration, which in certain cases has proceeded to fatal paralysis of the respiratory centre. Some authors refer this to the use of the Trcn- delenberg position after injection, but this does not coincide with the experience of gynecologists. If the o])eration necessitates the Tren- delenberg position, it should not be assumed until anesthesia has begun, in other words vintil the drug has gone into chemical com- bination with the nerve cells. Others lay the blame upon too large a dose. Jonnescu believes that he can avoid respiratory paralysis as well as other disturbances by adding 1/640 grain of strychnine nitrate to the injection. A small addition of suprarenin to this mixture will lessen its toxic action. In addition to respiratory ])aralysis many authors descril)e a form of muscular j)aresis, most comiiioiily affecting the eye muscles. They appear for the most jjart after the lapse of a week, .ukI disappear again after a short time. Disturbances in motility of the lower limbs and in control of the bladder and rectum seem to be only temporary, although they have, in certain cases, persisted for some time. Finally 26 ANESTHESIA among the deleterious results appears a group of meningeal irritative sj'mptoms, such as neuralgia, paresthesise, and persisting head and back-aclie. They are the least dangerous of the sequelje, but they are the most pernicious and agonizing for the patient, and often resist large doses of morphine. Spinal anesthesia is on the whole very well borne by old patients. Bier* recommends it in particular for the excision of carcinoma of the rectum and for extensive resection of the bony pelvis, and states that such jiatients after its use feel much better than those who have had general anesthesia. It may be employed also for the larger gyneco- logical procedures, for instance, the Wertheim extirpation of the uterus. The method should not be used in children, anemic and septic patients, and all those with affections of the brain, spinal cord, and nerves, particularly when the same residt can be obtained with local anesthesia. The preparation corresponds to that for general anesthesia. The patients would stand the effects better, undoubtedly, if they were not obliged to fast. But fasting is necessary because it must always be reckoned that the method may fail and that general anesthesia may have to be used. Also care must be taken that the bladder and colon are empty, for we have observed soiling and fatal woimd infection after paralysis of these two organs. Scopolamin-morphine is used just as before inhalation anesthesia. To carry out the injection the patient sits across the operating table with his shoulders bent forward and legs hanging. The region of the lumbar spine and the sacrum is painted with tincture of iodine and the spinous process of the second lumbar vertebra is marked with a fine needle or with the point of a scalpel, by a superficial scratch. Exactly in the middle line, in the second himliar space, a fine trochar carrying a cannula is inserted, pointing slightly upwards, until the patient ex- presses sensitiveness as the spinal dura is penetrated. The spinal canal is successfully reached when upon witlidrawal of the trochar a clear liquor runs out of the cannula. In order to prevent too great a loss of spinal fluid the index finger is placed over the mouth of the cannula. Immediately the syringe in which the drug has been pre- viously placed, either dry or dissolved in sterile water at a moderate temperature, is connected with tlie cannula and several c.c. of the fluid aspirated into it in order to make an even mixtm-e of the liquor and the anesthetic. Then under gradual pressure the contents of the *Verh.in(i. der Deutsch Ges f. Chir, 1909. SPINAL ANESTHESIA 27 syriiio-e is emptied into the dural canal. Then the syringe and the trochar are jjulled ont and the skin puncture is sealed with gauze. Thereupon the patient is laid upon his back and from time to time the progress of tiie anesthesia is tested by means of the jjoint of a needle. It usually takes ten mimites for the motor and sensory paralysis to reach the desired grade. Anesthesia obtained with 4 .5 grain of tropacocain on the average lasts for an hour, while stovain anesthesia lasts longer. First the perineum becomes insensitive, then the leg, and tinally the skin of the abdomen as far up as the navel. The anesthesia disappears in the reverse order. If after an interval of fifteen minutes the anesthesia is absent or incomplete, the injection may be repeated in tlie same 2)lace or in the next intravertebral space, above or below. Anesthesia may be successfully induced to a higher level than the navel if a higher intravertebral space is employed for the injection. There is no question, however, but that the dangers of injury to the cord and paralysis of respiration increase with the height of injection. Jonescu has carried out the stovain-strychnine injeetioti several times without fatality in the cervical cord itself. The danger of injury of the spinal cord is very small in the region of the third lumbar vertebra and below, for from the second lumbar vertebra down the dura con- tains only the cauda equina. In this region the broad cysterna lum- balis of the arachnoideal sac protects the roots. The upper limit of the anesthetic zone may be raised above the navel if after the injection the patient be changed from the horizontal to the Trendelenberg y)osition, and licld in this position for a short time. In this way the higher spinal roots are bathed in a portion of the solution. If this change in position is not made immediately after the injection, the solution will affect only the nerve roots proximate to the point of injection: but there is a certain risk in assuming this position just after the introduction of the solution, as there is danger that fibres of the phremc nerve may be paralyzed. l?ut later on this position has no prejudicial effect oti the length or the danger of spinal anesthesia, as may be imderstood from the experience of gynecologists. The least dangerous method for extending the anesthesia consists in the distribution of the anesthetic over a greater extent of the spinal cord. This may be attained by aspirating more than .5 c.c. of spinal fluid into the syringe and reinjecting it into the dural canal. ]?y mixing 4/.'> grain of tropacocain Avith eight to ten c.c. of spinal fluid the loss of .sensibility as a rule reaches as high as the margin of the 28 ANESTHESIA ribs, so that even a celiotomy may be carried out without pain and without muscle spasm. Suice most failiu'es depend upon faulty technique, the following points must be observed with particular care: It is important tliat a fine needle be employed so that the injected fluid will not run out through the opening in the dura. This will happen if the punctm-e is large, because the pressure of the fluid in the dural canal is rather high, even under normal conditions. Quincke states that the normal pressure varies from 50 to 1.50 mm. of water and the pressure must be over 200 before it can be called abnormal. This exjjlains how, in case the internal pressure is increased, a certain amount of fluid may be forced out through the puncture before it has time to act upon the nerve roots. It is also important that the instruments which are brought in contact with the anesthetic are absolutelv free from rem- nants of soda bicarbonate, for even minor traces of alkali will neutral- ize the solution, which is active only in an acid medium. For this reason the necessary instruments and vessels should be sterilized in plain water or any adhering soda must be washed off" with salt solution from all parts of syringe and cannula. If this is omitted, failures will sometimes result therefrom in spinal and even in local anesthesia. Lack of skill in lumbar pimcture may cause failure. To find the dural canal and inject the solution among the roots without injin-y to the cord, the puncture is made exactly in the middle line in the second or third interlumbar space. At the level of the first lumbar disc the conus medullaris frequently is not completely threaded out into the fibres which make up the Cauda, and its lower end may be exposed to injury from the point of the needle. Such a contingency would prevent the fluid from reaching the surroimding nerve roots. The same thing is to be feared when the needle is inserted from a point to one side of the spinous process, or in the lateral posture. To be sure it is sometimes impossible to reach the dural canal through the middle line on account of a kyphosis of the spinal column : or when the spinous processes of the lumbar vertebrae instead of being horizontal are oblique, and if the intervertebral space is unusually narrow. The attempt is then made to introduce the needle from the side, between the laminje. In this case the position of the point of the needle cannot always be exactly located, and it is possible that the injected fluid comes in contact only with the nerve roots on one side, in which event an irregular hemianesthesia results. Similarly it is unwise to insert the needle with the patient in the lateral posture on account of diffi- SPINAL ANESTHESIA 29 culties which arise in attempting to give the needle the desired direc- tion. Faihn-e from these sources may be avoided if the patient is seate(l, with the upper portion of the body bent forward so that the vertebra? are separated as far as possible. If the counting off and marking of the second lumbar interspace has been omitted before the disinfection, the hem of a sterile towel is stretched between the crests of the ili;e. This will cross the middle line at the spine of the fourth lumbar vertebra and from this point the second space may be easily arrived at. Another source of failure lies in the mixture of the solution with blood. Occasionally a certain amount of l)lceding may not be avoided, particidarly after puncture in the middle line. It spoils the injection, because the solution goes into chemical combination with the blood before it has a chance to come in contact with the nerve roots. For that reason the fluid which flows from the cannula must be as clear as water. Bleeding usually occurs when the needle does not reach the dural canal, but scrapes the surface of the lamina. \Vhen this hapi)ens it nnist be slightly withdrawn, and reinserted in an altered direction. Veins in the ligamentum subflavum may be the source of bleeding, particularly in punctures made from one side of the middle line, and if the needle is introduced too deeply it may meet veins lying along the ojjposite wall of the dural canal. As long as a blood-tinged fluid appears from the cannula the injection must be postponed. To avoid the point of the needle meeting the anterior wall of the dural canal it should not be introduced in thin persons deeper than 5Y2 cm., or in obese persons more than (Jl/) cm. If wlien the mandrin is removed clear fluid does not flow out, it may be obtained sometimes by simply twisting the cannula. Before it is pushed in deeper it should be with- drawn 1 ^ cm. or so in order to be sin-e that it has not already met the front wall of the canal. If it is to be pushed in further the mandrin must always be replaced. I.OCAI, ANESTHESIA While general anesthesia is caused by the influence of a drug upon the cortex, local anesthesia dejjcnds upon tlie paralysis of the sensory nerve endings within the operative Held or upon an interference with the conductivity of the nerve tracks which supply the field of operation. Of the various methods which are employed at the present time for instituting local anesthesia many have been in use for a considcral)le period. For instance, cold has long been known to overcome .sensi- 30 ANESTHESIA hility to pain, and anesthesia by freezing is now induced by chemical means. FREEZING Freezing in superficial operations is now accomplished by the use of ethyl chlorid. This highly volatile fluid may be obtained in glass tubes with a spring stopper. When the stopper is removed the fluid, which is volatilized by the warmth of tlie hand, squirts out through a capillary opening in the neck of the tube. A limited area or a strip of skin may by means of this spray be rendered insensitive to pain. The liquid spray striking the skin abstracts the heat necessary for its volatilization, as is shown by the formation of a layer of stiff frost. When this a])pears, the surface is ready for incision. It will form more rapidly if one blows meanwhile upon the skin. If the spray is long continued, superficial necrosis may result. For the opening of fm'uncles and incisions for the removal of for- eign bodies or the puncture of an aspirating needle this form of local anesthesia sufl^ices. However, one must be careful not to use the Paquelin cautery on a surface frozen with ethyl chlorid, for the prep- aration is inflammable and burns of the skin may result. Freezing fails as soon as deeper layers of the tissues are to be separated. In order to render regions below the skin anesthetic for operative pur- poses the employment of drugs by injection is necessary. INFILTRATION AND CONDUCTION ANESTHESIA COCAIN AND ITS SUBSTITUTES The develojjment of local anesthesia, which is at the present time employed not only for superficial procedures, but for almost all known operations, began with the introduction of cocain into ophthalmology by Roller. Cocain has a strong toxic action wliicli even after the injection of small doses may induce collapse and fainting and in larger doses cramps and paralysis of respiration and of the heart. With a maximum dose of 4/5 grain evidences of toxic action may appear. In no case should the amount used in any given operation exceed ll/> grains. Moreover, cocain diluted to 1 per cent, may cause active symptoms of irritation at the site of injection, but the burning pain disappears as soon as the drug has taken effect upon the nerves. In spite of its toxicity and the irritation which it causes, cocain is still used to-day for superficial anesthesia of the mucous membranes of INFILTRATION AND CONDUCTION ANESTHESIA 31 the nose, pharynx and mouth. Strong sohitions of five to twenty per cent, are used; they are apphed by means of a sterile brush or a pledget of absorbent cotton. In the conjunctiva of the eye a three to ten per cent, solution is instilled. Within a few minutes anesthesia occurs, followed immediately by a strong anemic action, so that super- ficial procedures may be carried out with a clear field and without pain. The infrc(|uency of cocaiii poisoning in s])ite of its use in strong concentrations as a local application depends upon the slow absorp- tion, which residts from the contraction of the vessels, liut toxic symptoms are always possible. They are especially likely to appear if cocain is injected under pressin-e into the meshes of the skin or into closed cavities such as the bladder. On this account its use even in mild solutions is being given up for less dangerous and at the same time less anesthetic preparations such as eucain, alypin, tropococain and particidarly novocain. Novocain has given general satisfaction on account of its freedom from local irritation, so that injections may be made without pain and without later disturbances of the nutrition of the tissue, and on account of its high relative freedom from toxicity; it is much less toxic than cocain and large quantities may be injected into the skin without danger. For the j)roduction of local anesthesia many methods are described. The widely usud ScJiIcic}/ infUtrdtion 7Hc///or/ consists in satin-ating the tissues by layers in considerable quantities of a very weak cocain solu- tion. A wheal appears as the residt of the first subepidermal injection, and a line of these is created across the operating field, corresponding to the line of incision, by inserting the needle each time obliquely at the edge of the wheal just created. Then through this insensitive field the dermis is infiltrated. After the skin is divided, the deeper layers are infiltrated and cut. With this technique the tissues are puffed with fluid, and assume a glassy aspect, so that the normal appearances are considerably disturbed. The lack of sensibility to ])ain depends upon the fact that the nerves are saturated with the solution at the same time as the other tissues. Conduclion ancsflic.sia consists in a pai-alysis of the nerves which go to the operative field. Ilackenbrueh arrives at this result by making a series of injections encircling the field without infiltrating the skin or the subcutaneous tissue of the operative site Itscli'. Since all the nerves going to the operative field must be met in such a ])i()- cedure, anesthesia through infiltration is unnecessary. The method of Oberst in the same way depends upon a paralysis of nerve con- 32 ANESTHESIA ductivit}'. In operating upon fingers and toes tlie nerves wliicli go to the middle and the terminal plialanges are met in the connective tissue close to the periosteum of the first phalanx, as near as possible to the hand or foot, by means of a series of injections completely surround- ing the digit. The effect of the anesthetic is increased by fii'st render- ing the part anemic by means of an Esmarch bandage and turniquet, because in a part which is empty of blood and with the circulation interrupted, absorption is hindered and the local effect is increased. The same effect may be obtained by the use of suprarenin. Braun originated a similar procediu'c for the amputation of limbs. After Esmarch anemia has been obtained, the cocain solution is injected close to or about the nerves which supply the limb so that the solution may diffuse into their substance. ^Nlore advantageous is the endo- neural method of Gushing, INIatas and Crile, by which each separate nerve trunk is freed up by dissection and the injection made directly into its substance. Each of these various methods has its own peculiar disadvantages, with the single exception of the method of Oberst, which prevent their general employment. The painfidness of the wheal formation at the beginning of infiltration anesthesia, and of the application of the Esmarch bandage in regional anesthesia, the unnatural ajipearance of the tissues, which are swollen with fluid from the injection, and finally the danger of poisoning even when a small quantity of cocain is used, added to the difficulties of technique for a long time created a prejudice against local anesthesia, so that frequently, even where it might properly be used, inhalation anesthesia was given the pref- erence. The swing in the pendulum began with the recommendation of Braun that cocain might be replaced liy the non-toxic and unirri- tating novocain, and its present popularity began to develop with his discovery of the advantage of the addition of suprarenin to the solution. braun's procedure The active principle of the extract of the suprarenal gland, first recoo-nized bv Furth and obtained in crvstalline form bv Takamine. possesses the power of inducing strong contraction of the blood vessels, and as a result, of producing an almost bloodless zone in the tissues. This effect appears even if the drug is strongly diluted. When it became possible to produce the drug s\nithetically and chem- ically pure, which could even withstand sterilization by boiling for a BRAUN'S PROCEDURE 33 short period, no further theoretical objection to its use for injection appeared. Ten to fifteen drops of one to a tliousand sokition in 100 c.c. of a 1 o per cent, novocain sohition a(hiiirahly answers all purposes. In a short time after the injection an anemia of hi<^h degree appears at the site of injection, which is equivalent to tlie anemia obtained by the procedure of Ksmarch. As the result of the reduced or practically suspended circulation of the injected limb, an early absorption of the (lru<>' takes ])lace. and at the same time its general toxic action is limited and its local effect increased. For this reason when combined with suprarenal extract only small quantities of novocain are necessary. But on the other hand larger quantities of no\ocain may be used, if the operation is extensive enough to make it necessary, without causing danger of poisoning. By means of this combination of the anesthetic with suprarenin it was first successfully bi-ought about that the slow and often painful infiltration anesthesia of Schleich. limited in its application to the subcutaneous tissues, and conduction anesthesia for the deeper parts, might be c()ml)ined and developed as the basis of a safe and harmless method of wider application. And moreover it became unnecessary to inject directly the nerves which serve the operative field, for as a result of the anemia-inducing action of the suprarenin the anesthetic remains for a longer time at the site of injection, and if this occurs in the neighborhood of a nerve, it diffuses into it sufficiently to over- come its conductivity. ^U) VANTAGES AND DISADVANTAGES OF LOCAL ANESTHESIA While at first local anesthesia was limited in its applicability to minor surgery, with the recognition of the advantage of the com- bination of novocain and sui^rarenin and with the development of the technique of injection, the field has gradually b'oadened, so that to-day it has become possible to employ it for all the ty2)ical operations upon the head, trunk and extremities without pain and without the aid of inhalation anesthesia. For certain operations local anesthesia is practically necessary, because general anesthesia is contra-indicated. This is true of all procedures upon the air j)assages and in their vicinity. It is indicated also in all cases in which tlic danger of general anesthesia is out of proportion to the importance of the operation, and when disease of heart nniscle forbids inhalation anesthesia. The harmlessness of local anesthesia is its greatest advantage. In spite of recent wide extension of its use in major surgery, it m ANESTHESIA would not be advisable to consider that local anesthesia can replace general anesthesia in every case, for there always remains a certain class of patients in whom the procedure for technical reasons cannot readily be carried out, or whose psychic state contra-indicates its use. Even when nervous pertiu'bance and anxiety have been largely over- come by the previous use of scopolamin-niorphine, which we never omit in large operations under local anesthesia, the excitation of such patients, during the operation, may increase to such a stage that it is not without danger to the heart and mind, and the bodily agitation also endangers asepsis. JNIost of the patients who have been trephined under local anesthesia state that they have felt no pain from the in- cision, but the sawinnj and chiseling of the bone brings back frightful memories. And the psychic trauma arising during the preparation and the course of the operation is not to be looked upon lightly, and in order to impress this, it is necessary only to recall the reports from the period before the use of anesthetics, according to which patients have died in shock waiting for a tootli or nail to be extracted. Hysteri- cal and nervous patients and most children are not fit subjects for local anesthesia, and on humanitarian grounds it is onlv right that if a patient desires general anesthesia it should be given, if there is no contra-indication. Certain physical conditions contra-indicate the general employment of local anesthesia more definitely even than mental states. It is to be regretted that the very patients who cannot stand general anesthesia on physical grounds are also poor subjects for local anesthesia. Among these all cases of sepsis which are not definitely localized, and advanced arteriosclerosis, particularly when it is combined with gan- grene or diabetes, are to be reckoned. Also it must be stated as a principle that malignant growths should not be removed under local anesthesia, because the insensitive field of the conduction anesthesia is limited, and the coiu'se of the operation not infrequently makes it necessary to overstep the bounds. With the exception of hernia we can find no advantage in the em- ployment of local anesthesia for celiotomies. The abdominal wall can always be opened without pain, but handling, tying and cutting in all portions of the mesentery cause agony. Fainting with weakening of the pidse. and distiu-bing pallor, may be the accompaniment of a rapidly carried out appendectomy as soon as tying off of the meso- appendix is begun. Also in patients who are reduced by starvation as the result of stricture of the pylorus or at the cardiac end of the INDICATIONS FOR LOCAL ANESTHESIA 35 stomach, the estabhshnient of a gastro-enterostoniy or of a gastric fistula under local anesthesia has no advantage over inhalation anes- thesia. One can readily succeed in reachino- the stomacJi without pain in every case, but the collapse and the reflex shock caused by the handliiig of the viscera of a patient who is not completely anesthetised is at least as dangerous as the small amount of anesthetic necessaiy to put such an emaciated and weak patient to sleep. iVnd the proportion of fatalities during the first week after establishment of a gastrostomy un per cent, solution. If it happens that an injection does not reach the vicinity of the nerve, another attempt must be made. In fat patients it is hard to reckon the depths of the nerve, as this may not be constant. One will succeed much more readily in reach- ing the neighborhood of the nerve if its location is determined by a bony prominence or by some other readily palpable landmark. CIRCUMINJECTION OF THE AT.SSEI.S The proximity of large vessels is not particularly a matter of anxiety so far as the injection goes. One cannot always avoid meeting them. :ni(l in ordir to recogm'ze the injury immediately we use the following scheme: The needle is introduced attached to the syringe, and as soon as the jxiint has reached the desired ])lace the piston is 38 ANESTHESIA slif^htly withdrawn. If blood is sucked into the cyHnder, the needle is drawn back and reinserted in another direction. By the color of the blood one may recognize whether a vein or artery has been injured; in either case the incident should have no result upon the anesthesia. Even when the solution is injected not into the tissues, but into a vessel, no harm results. In order to make as small a wound in the vessel as possible in all deeply penetrating injections, we make use of as fine a needle as possible, which adds some- thing to the difficidty of the injection. If the bleeding from the punctiu'e does not stop immediately, temporary light pressure with a sponge will overcome it. JNIoreover, the tiny wounds of the ves- sel wall close themselves rapidly under the influence of the supra- renin. This vaso-constrictive action is also of significance in other respects in carrying out conduction anesthesia in the deep tissues. To induce anesthesia injection about the nerves is sufficient, but in conjunction with the loss of sensibility to pain one also obtains usually an excel- lently clear field which is not in the least obstructed by bleeding. This residts from the fact that the vessels and nerves run together practically all over the body, and both are equally affected by the influence of the suprarenin. Where this is not the case, for instance in isolated venous plexuses, lying upon muscle or bone, or in the case of arteries running by themselves, one can induce anemia of the operative field by injecting the solution about these vessels, in addition to the perineural injection. This does not always follow, but we have carried it out satisfactorily several times, particularly in procedures upon the skidl. The amount of suprarenin contained in the tablet is sufficient to induce a complete closure of the small vessels and a narrowing of the larger ones, but its influence is not sufficient to stop bleeding from the large vessels. This is of importance as regards the final hemostasis, as all the bleeding points which ajjpear during the operation and which represent vessels which have become anemic under the influence of the suprarenin must be caught and tied, if there is to be no question of secondary bleeding and hematoma formation after the operation. Tying of the vessels will be found very painful if the anesthesia is inadequate, and for that reason it is necessary in order to create a satisfactory anesthesia to carry out the separate injection of the nerves and the vessels, in so far as they are separated from each other. SPECIAT, PROCEnURES 39 CIRCULAR IXJECTIOX OF THE SOFT PARTS AXO BONE All the reiiiaiiiiii<>- soft parts which lie in the deeper layers of the body may be rendered anesthetic in a similar way thr(ni(>h conduction anesthesia. The braui and most of the viscera as well as bone possess themselves a very low grade of sensibility and no jjarticular experi- ence is necessary in order to operate upon them painlessly, but on the other hand the j)arietal layers of the pleura and of the j)eritoneum, tendon sheaths, wide muscle fascia; and aponeuroses, the dura mater and periosteum as well as the perichondrium, are usually sensitive. But since their nerves lie outside of the organs which they protect, to induce anesthesia it is sufficient to inject superficially the sections which fall within the operating field. Peritoneum and transversalis fascia are also so insensitive that for them a circumferential injection of the connective tissue under the deepest layer of abdominal muscle suffices. A special injection of the fascia or even of the peritoneum is unnecessary. In thin belly walls the danger of puncture of the peritoneum is very slight, because if the needle is introduced slowly the resistance of the transversalis fascia can be felt distinctly. In muscular and fatty abdominal walls one cannot always depend upon introducing the needle to the desired level, so as just to feel the resistance of the transversalis fascia. In the same way it is unnecessary to introduce the solution imder the periosteum in order to operate without pain on the periosteum and bone. From the connective tissue between it and the soft parts which surround it the nerves and vessels penetrate to it and likewise to the bone itself, and it is at this point that the conductivity is in- terrupted. ]\Iuscles are the most sensitive at the place where the nutritive vessels and nerves enter, but large sections are so insensitive as to allow themselves to be cut Avithout pain, even without anesthesia. Similarly operations may be performed without pain on the long tendons; they are sensitive and require anesthesia only where they are covered by tendon sheaths. Bone, muscle and tendon are all anesthetized on the same ])rinciple. that is by the saturation with the anesthetic of the connective tissue which surrounds them and which contains the nerves and vessels which go to them, from several points in front and behind, above and below. SPECIAL PROCEniTRES In accordance with these general remarks it is evident that as many methods may be conceived for its accomplishment as there are oj)era- 40 ANESTHESIA tions. Any one who understands the mechanism of anesthesia and is acquainted with the course of the more important nerves can in any ])articular case easily and satisfactorily render the operating field insensitive. For that reason it is unnecessary to explain methods for conducting an operation under local anesthesia which are self-evident. But one must recognize the value of the work of Braun, who first showed the advantage of joining suprarenin with the anesthetic agent, and of combining infiltration and conduction anesthesia, by which cocaine operations are no. longer limited to minor procedures upon the peripheral portions of the body, but are extending rapidly to include complicated cases in the depths and in the large body cavities. LAMINECTOMY Some time ago we did our first laminectomy under novocain-supra- renin anesthesia. The fluid was injected a few finger-breadths above and below the spinous process of each vertebra involved. After a few wheals were formed in the middle line along the planned-out incision, in order to make the skin insensitive to the deep punctures, the needle was next inserted through the wheal to one side of the spinous process down to the lamina, and by elevating and then depressing the point, about .5 c.c. was injected above and below. Then it was drawn nearly out and passed down the other side of the spinous process, where the same procedin-e was repeated. This process was carried out for each of the wheals. Before the needle was completely withdrawn, the skin was rendered insensitive by subcutaneous injection. Incision of the skin and muscle as well as the removal of the periosteum from the spinous processes and laminae were entirely pain- less and there was practically no bleeding. The trephining of the lamina was painless and, following this, the cutting of the lamina with the laminectome was painful as often as the instrument came in con- tact with the dura. If this was avoided, however, the biting off of the remnants of the lamina with the rongeiu's was hardly to be felt. Pain was only experienced during the extradural probing between the dura and the laminae and in sponging the dura, and with every contact with the posterior surface of the cord, and particularly the posterior roots. TREPHINING We have also employed local anesthesia for trephining, in the attempt to avoid the dangers and injurious effects of a general anes- thetic. The technique of this procedure presents no difficulties; it TREPHINING 41 consists of a circumferential infiltration of the field of operation, under the aponeurosis as well as subcutaneousl}^ from various points. It is unnecessary to insert the needle under the periosteum, and this is witiiout any advantage, and causes pain. Anestliesia of the peri- osteum and bone appears in ten to fifteen mimites. Injection renders unnecessary special procedures for hemostasis, for witliin the given time the field which has been encircled by injections becomes so empty of blood that few if any vessels ha\'e to be caught and tied. In tre- phining over the cerebellinii the depth of the occipital fossa makes it necessary to introduce the needle throvigh the entire mass of the muscles of the neck. A separate injection should always be made in the neighboi-hood of the occipital artery, which may be met near the tip of the mastoid process behind the sterno-mastoid muscle. In spite of the fact that the technique of local anesthesia for tre- phining presents no difficulties and that anesthesia may be induced with assurance, it is a question whether the procedure presents uncon- ditional advantages for the patient. For trephine cases the contra- indications which we have noted above hold against a too general em- ployment of local anesthesia. The psychic influence of fear and anxiety are not to be taken lightly, and scopolamin-morphine cannot be employed for brain tvmiors because the cardiac and respiratory centres are usually damaged from increased intracranial pressure and the scopolamin works a similar paralytic effect. The patients are usually considerably stirred up during the cutting of the trap door in the skull and they complain considerably during the process, and for a long time afterward, because they have been deprived of the advantages of general anesthesia. JVIoreover, we have several times had the experience that patients after the injection fall into a deep sleep, out of which they awaken foi- a moment, but do not stay awake long enough to take a deep breath. Particularly we would like to call attention to the fact that one patient with a tumor of the temporal lobe in whom local anesthesia was employed without the prophylactic scopolamin injection succumbed as the tumor, which had grown onto the dura, was lifted out, without it being possil)le to (hffcrentiate the manner of death from such as is sometimes observed in brain cases wliich have had general anesthesia. OPERATIONS ON THE FACE Procedures on the face may as a whole be carried out very satis- factorilv under local anesthesia, because the branches of the trifacial 42 ANESTHESIA nerve are readily accessible to injection outside of the skull. Thus the frontal nerve may be found at the supra-orbital notch, the infra- orbital nerve at the infra-orbital foramen, or, deeper, on the floor of the orbit, the inferior dental nerve inside the mouth just above the lingula, which projects over the inferior dental foramen of the lower jaw, and the lingual nerve at the side of the mouth in the fold of mucous membrane between the tongue and the floor of the mouth. The teeth of the upper jaw may be rendered insensitive by injection at the juncture of the gum with the mucous membrane of the lip, although a considerable time must elapse to allow the fluid to diffuse through the thin shell of bone comprising the outer wall of the antrum of Highmore. H. Braun has shown that in the extraction of upper teeth the gum about them should always be injected. The lower teeth may be readily anesthetized through an injection of 5 c.c. above where the hngula of the lower jaw can be felt with the finger. To carry out extensive operations upon the soft parts of the face such peripheral injection does not suffice to create a satisfactory anes- thesia. On account of the rich anastomosis of the terminal branches of the trifacial it must be supplemented by a circumferential infiltra- tion of the operative field. There is considerable advantage in the fact that such a complementary injection of the field facilitates opera- tion greatly by its eff'ect of limiting the flow of blood. The extraction of branches of the trifacial in the treatment of neu- ralgia can only be carried out painlessly when they are anesthetized as closely as possible to the Gasserian ganglion, either at the base of the skull or in the ganglion itself. For the first branch, on account of its intracranial course and its close relations to the optic nerve and the nerves supplying the muscles of the eye, this is impossible; for the second, which passes through the foramen rotundum in the greater w^ing of the sphenoid we follow the method of injection described by ]\Iatas; the third root is met in the vicinity of the foramen ovale, or the injection is made in its two branches, the inferior dental and the lingual. For the anesthetization of all the roots at once, the following method, which we have now employed for the extirpation of the Gasserian ganglion four times, msiy be used with advantage to replace general anesthesia. In a forty-year-old patient the second branch was first injected at the foramen rotundum. For this purpose a needle 10 cm. long was introduced laterally beneath the bony prominence which marks the junction of the malar bone with the malar process of the upper jaw EXTIRPATION OF THE GASSERIAN GANGLION 43 (Fig. 1) . The needle proceeded inward along the lateral wall of the antrum until its point, at a depth of about 51/. cm., impinged upon the external plate of the pterygoid process. It was then withdrawn about 1 cm., the portion outside the cheek strongly depressed and its point turned further toward the eye until, after repeated attempts, at Fig. 1— local AXESTHESL\ FOI! KX TlUrATIOX OF Till': (iASSERL\N GAXGLIOX. The red lines give tlie direction for the introduction of the needle for injection at the foramen rotunduni and the foramen ovale. The red crosses show the points of insertion of the needle for anesthetization of the temporal fossa and the zygoma. a depth of about (ii .. cm., it was no longer in contact with bone. A skull which was held near at hand clearly showed that the point of the needle lay in the sphenopalatine fossa. Upon withdrawing the ])iston no blood was aspirated, and .5 c.c. of 1 •_> per cent, novocain solution could be injected without danger. Since the patient had previously received scopolaniin-niorphine. he did not feel the i)ain in the teeth of the upper jaw which is taken l)y Schliisscr, liraun and other authors as a criterion for the ])roper |)osition of the lu'cdje. In order to anesthetize the third root hi the foramen ovale the 44 ANESTHESIA mouth was opened wide, to separate the coronoid process of the lower jaw as far as possible from the zygoma. Thereupon the needle was introduced through the skin of the cheek a finger's breadth below the middle of the zygoma just above the tip of the coronoid process, inward toward the base of the skull and forward toward the pterygoid process. When it met this at a depth of 5I/2 cm. it was Avithdrawn 1 cm. or more and its direction altered by lowering the portion outside and carrying it in the direction of the mouth until the point of the needle glided by the posterior edge of the external plate of the pterygoid process and passed in along the base of the skull about 1 cm. further. Although the patient even now had no pain in the teeth of the lower jaw, a comparison with the skull showed that the point of the needle must lie in the vicinity of the foramen ovale. At this point also 5 c.c. were injected. Then a circumferential injection of the temporal fossa was made. Through each of five points of insertion the needle is carried in A^arious directions and the injection made above and below the temporal muscle and its fascia. Finallj" at the anterior and posterior ends of the lower edge of the zygoma a subfascial and subcutaneous injection of about 5 c.c. was made, so that about 110 c.c. of the solution in all was employed. A quarter of an hour after the injection was completed the cutting of the trap door in the bone was begun. Incision of tlie soft parts and bone and even the separation of the dura witli the Braatz separator proceeded without expression of pain. Only when the freeing of the dura from the base of the skull with small sponges began did the patient start to complain. As soon as the second and third roots and the edge of the ganglion were exposed about eight drops were injected directly into the middle of the ganglion with a bent needle, so that it was filled up like a bladder. Immediately thereupon the patient fell into a deep sleep. The removal of the ganglion, the twisting out of the nerve trunks and the sewing down of the trap door of skin and bone could then be carried otit completely without pain. Hartel* has demonstrated a method of anesthetizing one side of the face by a single injection into the ganglion, which makes injection of the various facial roots unnecessary. The anesthesia begins immedi- ately. Through the cheek a long, fine needle is introduced into the third division, and it is passed within its sheath through the foramen ovale and into the ganglion itself. In this way the third branch sei-ves *Zentral, f. Chir. 1912, No. 21. F,X'rKE:\IITIES 45 as a path of conduction for the tieedlr and prevents it from "^lichng off and piincturini>- any nciyhhoring vesseL The introduction is made aI)out '.i cm. external to the aiif^le of tlie mouth. \N'itliout injuring the mucous membrane of the mouth, the needle is introduced between the lowei' jaw and the outer wall of the anlruin as far as the infra- temporal fossa. "Now one feels his way backward, observing the following important points concerning the direction of the needle: Observed exactly from in front, the needle should point to the pupil of the eye of the same side. Seen exactly from the side it shovdd point toward the articular tubercle of the zj'goma."* As soon as the nerve trunk is met by the point of the needle, the patient feels pain in the lower teeth. In this way one recognizes that the needle is in the right jjosition so that the needle may be jjushed along further until pain is felt in the upper teeth, then Hartel injects l/o to 1 c.e. of a 2 per cent, novocain-suprarenin solution. In nine cases in which he has used the method he has obtained complete anesthesia. EXTREMITIES For the various operations on the neck, thorax and abdomen which may be carried out under local anesthesia the special technique Avill be described in their respective chapters. We Avill consider here only local anesthesia of large sections of the body, particularly anesthesia of the entire limbs and extremities. Kulenkampfft found that in oider to break the conductivity of all the sensory tracks of the arm the proper place for the injection is above the clavicle, in the gap between the scalenus anticus and medius, where the brachial plexus runs to the outside of the subclavian artery. The artery may be easily recognized by its pulsation, and the clavicle is likewise readily palpable. The brachial plexus lies here in loo.se tissue, which is particularly suited to take up the solution. Ten c.c. of a 2 per cent, solution arc injected. The danger of injuring the sub- clavian artery with the needle is slight ; on the other hand, the needle may glide by the plexus and come u]) against the first rib. It is, therefore, advisable to inject the solution oidy after the patient has felt a radiating paresthesia in the fingers, which signifies that the needle is in contact with the plexus. An injection wheal having been made in the skin over the place decided upon, a thin needle 4> cm. long is inserted in the direction of •Hiirtel. 1. c. fZentral. f. Chir. 1911, No. 40. 46 ANESTHESIA the second or third thoracic spine, that is to say, somewhat medially and posteriorly. As soon as the fascia is penetrated and sensations arise in the fingers, the syringe is emptied. Since the arm will l)ecome hypereniic in a short time, the application of the Ksmarch method of inducing local anemia is requisite. Loss of sensibility appears in about twenty minutes and lasts for two or three hours. The method of Kulenkampff has been tried out without ill effect in twenty-five cases. In our experience, in the care of cases of accidental wounds of the hand, the procedure has several times proved inadequate, and in o^iher cases the anesthesia did not appear until after a half hour. The anesthetization of large sections in the lower extremities is even less dependable; a complete interruption of conduction such as that in the upper arm is not possible because the sensation is served by four nerve trunks which lie at a considerable distance from each other, the obturator, the anterior crural; the external cutaneous and the great sciatic. Circular subcutaneous injections about the extremities induce an anesthesia of the skin only, which suffices for skin-grafting. Nystriim* states that the external cutaneous nerve Avhich supplies the surface of the outer part of the upper thigh may be anesthetized through a subcutaneous and subfascial injection somewhat below the anterior spine of the ilium, and close to it. Braun anesthetized the whole foot satisfactorily by injecting the subcutaneous tissue around the leg above the ankle, for the terminal filaments of the external popliteal (peroneal) nerve spread subfascially over the anterior sur- face of the tibia and in the interosseous space, and injecting the two branches of the posterior tibial nerve behind under the Achilles tendon and near its medial edge. Anesthesia appeared in twenty-five minutes. In order to carry out resections and amputations on the peripheral portions of the extremities Biert developed a form of anesthesia which differs from the foregoing. The field of operation is limited by two torniquets, which are firmly applied above and below, and novocain, lo per cent, in physiological salt solution without the addition of the suprarenin, is injected with considerable force into the veins. The fluid overcomes the valves and diffuses through the capillaries to the terminal filaments of the nerves. The field of insensibility Avhich is obtained through this direct venous anesthesia spreads as the fluid finds its way into the larger nerve trunks, which Bier has already shown with indirect venous anesthesia. *Zentral. f. Chir. 1901, Nr. 5. fVerhand. li. Dcutsch. Gesselleschft. f. Chir. 190S. DIRECT VENOUS ANESTHESIA 47 The success of this procedure depends upon the particular care which is given to the anemia which is previously induced and to the venous injection. To expel the blood the whole extremity is held up in the air and is bound from toe to groin with a soft elastic bandage, and at the upper end of the operative field a wide tourniquet is laid on to cause conijilete circulatory stasis. The expulsion bandage is then taken off, and at the lower end of the ojjerative field another tourniquet is applied. Since the upper tourniquet cannot be borne for any length of time on account of the pain which it causes, ^lomburg directs that after the anesthesia has begun this one be removed after a second has been applied within the insensitive area just below it. When the anemia and circulatory stasis is complete a vein, which has been marked before the operation, is exposed and tied off prox- imally, and in the peripheral end a cannula with a rib about its end is tied tight enough to stand considerable pressure without leakage of fluid. It is then connected with a strong and tight 100 c.c. syringe containing the novocain-salt solution, without bubl)les. The injection should be made slowly, but under considerable pressiu'e. The anes- thesia appears between the two tom-niquets immediately after the in- jection. The amount necessary for the thigh of an adult is 75 c.c. of the 1^ per cent, solution; for the upper arm. .50 c.c. All visible vessels must be seized and tied at the end of the operation. If the uj^per tom-niquet is loosened a moment so that blood may enter the vessels, and then drawn tight again, it will enable one to find the lumen of the larger vessels as the blood spurts out, it Avill wash ovit the remnaTit of the novocaiji from the veins, and the anesthesia, nevertlie- less, will suffice to finish the operation. The instant tliat the upper tourniquet is completelj'' removed the anesthesia disappears. CHAPTER 3— ASEPSIS Drj' asepsis serves best to promote smooth healing of wounds. By asepsis we mean practically the exercise of the utmost care in de- priving pathogenic bacteria of access to the wound, without injuring the tissues by the chemical agents which are employed for killing bacteria. Antisepsis strove to attain this goal, but with the means which were at its disposal, the way was difficult. The principle of antiseptic wound heahng consisted in overcoming bacteria through the employ- ment of chemical poisons (Lister's carbolic spray) at the point where they were already in contact with the wound or were about to be. Various obsen^ers have demonstrated the inactivity of this method toward bacteria in an infected wound, but on the other hand have established the injurious effects which chemical agents exercise as cell poisons. Xow efforts are made to keep all antiseptic agents from the wound and to free so far as possible from sources of infection before- hand everything which comes into contact directly or indirectly with the wound. The ideal of absolute asepsis has not yet been wholly realized; it is not possible, for instance, to get rid of antiseptic poisons altogether in disinfection of the skin. And even after strong drugs are em- ployed in the preparation, as strong as the skin ^vill stand, it is not in a bacteriological sense absolutely free of bacteria. We can succeed in reaching a state of absolute freedom from bacteria only with instruments, linen and dressing material which have been steril- ized in superheated steam or in boiling water. Although the skin remains, from the purely bacteriological point of view, notwithstanding our efforts, a bacteria carrier, practical ex- perience has taught us that the removal of all bacteria carrying material by one of the many disuifectant methods suffices to overcome the danger of infection from this source. Interference with healing is to be laid more to other faidts. which are the more numerous the more complicated the method of disinfection is. Air-borne infection is responsible for ti-ouble still less frequently than the intelligently disinfected skin. Infection may occm- through bacteria-laden dust, or through drops of water which are exhaled in 48 AIR BORNE INFECTION 49 forced expiration, coughin<>\ sneezinn for hernia, and kangaroo tendon pos- sesses advantages over catgut for this purpose, and is so used by many surgeons. Also linen which has been treated with celloidin (Pagen- stecher), on account of its cheapness, fineness, strength and steriliza- bility, is excellently adapted for these sutures. For sewing up the skin nothing excels the readily sterilizable silkworm gut, or, for the face, horsehair. To unite bones or to close hernial and other openings which are under strong tension, the best service may be procured from the absorbable and safely sterilizable aluminum bronze wire. The un- irritative healing which follows the use of this material practically without exception can almost entirely be referred to the fact that the polislied sin-face of the thread cannot carry bacteria. And no doubt the hands also have less occasion to touch the thread and to wipe off bacteria in holding on to it and while tying the knot, as on account of the smoothness and stiffness of the material this nnist ordinarily be done with instruments or gauze. STERILIZATION OF CATGUT In the preparation of catgut so far as possible a clean, raw product should be j^rovided and the technique carefully followed. Bacterio- logical examinations show that pus organisms, tetanus and anthrax, which in previous experience might be met with in raw catgut, are never found in the raw material prepared according to Kuhn. For use the catgut is sterilized after the method of Claudius in an iodine- potassium iodide solution in the following way: In a sterile vessel the unrolled catgut is covered with the followhig solution: Iodine crystals 2 c.c. Potassium iodide .... 4 c.c. Distilled water 1000 c.c. and is allowed to remain for twenty-four hours. For size No. 3 and all larger sizes, which we personally never use, the treatment must be prolonged for twelve hours more. After this time is over the solution, wliicli is sufficient for twenty-five strands five yards long, is poured off and replaced by SO ])er cent, alcohol, which takes up the excess of iodine from the catgut. ^Vhen the alcohol is colored dark it is renewed, but if the catgut is to be kept for a long time it should be thinned with water. When tlie strands have lain in the alcohol for some time they are removed and placed dry in a sterile glass. Catgut 62 ASEPSIS thus prepared may be used, Xo. 00 for use on the dura, No. for suturing the intestines and for ties, Xo. 1 for larger vessels and for sewing up, and far less frequently Xo. 2 or 3 if the tension of the tissues demands a stronger thread. Surgeons who wish to save the bother of preparing their ovn\ catgut and who appreciate the convenience and cleanliness of using it in glass tubes may obtain catgut as well as other suture material prepared in various ways all ready to use. There are many excellent brands on the market, put up by manufactin-ers who have acquired considerable rejiutation for a sterile product. The better makers have a competent bacteriologist test samples from each batch and apjjrove of it before it is sent out. Recently in the United States the method of preparing catgut originated by Bartlett of St. Louis, or some modification thereof, has been adopted by a considerable number of hospitals. STERILIZATIOX OF SILK AND LINEN While in the sterilization of catgut Ave cannot get along without antiseptics, the use of such agents is unnecessary in the sterilization of silk. Impregnation with salts of mercury should be done away with, because the silk may be sterilized Avith more assurance and with less injury by boiling or in steam under pressure. The opinion that as a result of impregnation with antiseptic the development of bacteria in the suture hole is hindered is negatived by the fact that the antisep- tic, particularly the salts of merciuy, goes immediately into union with the albumen of the cells, and bacteria from the hand may remain on the threads in spite of the antiseptic. The fact that coarse silk is not readily sterilized and may retain bacteria within itself has taught us not to bury thick threads in the tissue, but Avhere a continuovis or interrupted suture is necessary, such as in serous suture of the abdom- inal organs or in closing hernial openings, to use only the finest sizes, Xo. 1 and less frequently Xo. 2. The largest size used for skin sutures is Xo. 5, and only for the Heidenhain hemostatic suture, Avhich will be described later, do we employ as large as 'Ko. 14, since we ahvays re- move it after the skin is sutured. In the chapter on blood-vessel surgery we will take up the question of the paraffin silk specially prepared for this purpose. In order to carry out the sterilization economically, the silk which is needed for an operation is rolled upon a card or glass bobbin and sterilized in a glass vessel in the autoclave. As soon as the glass is cold the silk is covered Avith 80 per cent, alcohol, in Avhich it may remain DRAriNT, THE PATIENT 63 staiuling for any length of time necessai'y. A bobbin which had once been taken out of the vessel is not replaced until resterilized in boiling water (without soda). ^Nlany surgeons sinij)ly boil the silk with the instruments. Silk loses its strength if boiled too long. Linen is sterilized in the same way as silk. It has a smoother sur- face, but is a little less strong than silk and possesses the advantage of greater economy. It is not fitted for impregnation with antiseptic agents. *e>^ FURTHER ASEPTIC REGULATIONS DURING OPERATION DRAPING THE PATIENT When all preparations are ended every one who is concerned in the operation puts on a sterile gown. This should be buttoned in the back and closed in fi-ont, to cover the body. The gown may have sleeves reaching lielow the wrist, the ends of which are gathered in under the gloves, or it may have elbow sleeves only, and the forearm be covered by separate close-fitting half sleeves, which are pinned on by the nurse with sterile safety pins. The operative field is painted with tincture of iodine and its surroundings are covered by four towels. Only enough space is allowed to remain uncovered as suffices for the length of the incision. In order that the towels be not shoved about over the wound, they may I)e pinned together, or fastened to the skin edges, with Backhaus clamps. A large celiotomy sheet with a small slit- like opening may be used to cover everything; its oidy disadvantage is that if an unexpected change becomes necessary during the opera- tion it cannot be removed without some danger to the asepsis. In laying on the towels as well as in draA^'ing on the goA\Tis one must carefully observe that they touch nothing which is not sterile and so become a source of infection to the wound. From the beginning of the operation only the region which is under the eye of the surgeon is to be considered sterile. Places at any dis- tance, even when they are covered with sterile towels, are not to be considered sterile. It cannot l)e completely avoided, liowever. that as the operator or his assistant turns aliout to reach for instruments or for other purposes, the goM7i will come in contact with something which is not completely sterile and thus indirectly become a means of infection. When any break has ha])pened in techm'que, even when it is no more than a suspicion, the whole procedure should be repeated. 64. ASEPSIS otherwise the operating room personnel will become careless of minute detail. Towels and strips which have become soiled during an in- testinal suture, for instance, or in opening up an unsterilized area, are removed before the wound is sewed up or before further clean regions are exposed, and replaced by clean ones, the gloves are removed and the hands are again carefully scrubbed in soap and water and oxy- cyanate solution, and the instruments are newly rinsed and disinfected for the rest of the operation, unless a new kit has previously been prepared. Following the rule that the fewer fingers the less danger of infec- tion, the number of assistants during an operation should be as few as possible. One assistant who renders the field of operation ap- proachable by means of retractors, and a nurse to handle the instru- ments, are sufficient for practically all major operations. Both must wash off their hands in oxycyanate solution from time to time as well as the operator, and in every detail carry out without remission the rules of asepsis. CARE OF THE WOUND Since with all our precautions we cannot succeed with certainty in preventing all access of bacteria, in dressing the wound we attempt to make it as difficult as possible for the bacteria to develop. Accordingly, we spare the wound surface of all contact with antisep- tics. But if antiseptics are present for the purpose of destroying bacteria upon the uninjured surface of the skin, their bactericidal action in an open wound is reversed rather than otherwise. For antiseptic agents work upon fresh wound surfaces as cell poisons, which stimulate the tissues to secrete and lead to inflammatory clianges or to necrosis, effects which prepare a favorable cidture medium for the development of bacteria. For that reason all instruments and materials which are brought into contact with the wound should be dry and aseptic and not moist and covered with some antiseptic agent. DRAINAGE The difficulty of the proliferation of the bacteria will be increased if all the fluid which is secreted in a wound as Avell as the blood which oozes out after the operation can find an unimpeded exit. A wound which glues itself together rapidly ofl^'ers no nutritive material either in the way of retained secretion or hematoma. Drainage of large woimds and the most careful hemostasis are therefore the best means DRAINAGE AND PACKING 65 of protection. A strong transitory compression with gauze frequently suffices for a complete hemostasis. In order to pi-event the formation of hematoma, spurting vessels are seized and tied. Those vessels which come to view in making the incision are best tied off before they are divided. Where blood seejis out from capillary wounds and in places where numerous lymph vessels are cut in sewing up, we leave an opening for a drainage tube, which is laid to the deepest part of the wound. Sometimes a counter-incision must be made for carrying off the secretions, while the wound itself is sewed up tight. An uneven wound floor which cannot be smoothly united in its depths, for in- stance after the removal of a tumor, is always drained. Two or three days later, or as soon as the wound suifaces adhere and give off no more secretion, the tube can be removed. To reinforce hemostasis in oozing surfaces of considerable extent, and to suck up wound secretion, gauze drainage must be left in occasionally. For this purpose we employ, especially in the peritoneal canity, folded gauze strips a yard long, of which one end is conducted out through a hole in the suture line. Such strips have the advantage that they can be lost only through gross carelessness. Plain sterile gauze is used for general purposes and for the drainage of the peri- toneal cavity, and iodoform gauze is used only for the drainage of tuberculous foci. Vioform gauze has the advantage over sterile gauze that it dries out large cavities more effectively without irri- tating the wound or exercising a toxic effect. It may, therefore, be employed in extensive and strongly secreting wound cavities, for in- stance after extirpation of the rectum, and in small but deep wounds where one is not sure of the asepsis. If packing is employed to control venous or parenchymatous oozing, sterile strips are effective. Such oozing ceases from the pressiu'e of the gauze, because this rapidly adheres to the vessel wounds. After five days at the latest the vessels are closed through a ])ermanent thrombosis and the stri]) can then be removed, although it may remain longer if there is urgent need. Arterial bleeding should not be con- trolled by means of packing. Gauze left in the abdomen should always be wrapped in rubber dam where it comes through the wound (cigarette drain), because skin and gauze stick together ra])idly and in that way the secretion is dammed back. For the gauze, whether it is plain or impregnated, is always a source of irritation to the cut surface. Suprarenin is used at times for provisional hemostasis. To allow 66 ASEPSIS one to work in a deep h'ing field undisturbed by bleeding, physio- logical salt solution is employed, to 100 parts of which 20 drops of the one to a thousand suprarenin solution are added. Gauze sponges or strips are soaked in this solution. For hemostasis over deep wounds where the vision is interfered with and in operations upon the skull where it is imijossible to tie off and the field is too narrow to allow of packing Mith gauze strips, sponges soaked with suprarenin maj^ be used to advantage. For the drainage of wounds of the sui^erficies, such as amputation stumps and after removal of the breast, and particularly where the cosmetic result is a factor, narrow strips of rubber dam are very eff'eetive. They do not adhere to the woimd edges, nor do they promote inspissation of the secretions and in that way plug up the incision. For this reason rubber has largely supplanted gauze in septic wounds. In addition to hemostasis and to the carrying off of wound secre- tions, gauze strips serve ijarticularly well also in shutting off a clean field from infected areas. In this way we protect the free peritoneal cavity, the meningeal space, the pleural and other cavities from infec- tion in that we create a dam around about the infected focus. As a result of the irritation which the protective walling off exercises upon the tissues, adhesions form which at first are loose, but later make up an extensive wall against the penetration of infected material. Gavize impregnated with iodoform irritates the tissues more to the formation of adhesions than does sterile gauze. CARE OF THE W^OUND EDGES Next in importance as a preventative against the development of bacteria to the removal of wound fluids is the avoidance of every mechanical injury. A smooth division of the tissues with a sharp knife is better as regards healing than dull tearing apart or bruising of the tissues by blunt dissection. The sharply cut soft parts adhere again rapidly. In irregular wound surfaces with hollows and pockets, foreign bodies and necrotic shreds, this adhesion is hindered and l)ac- teria find opportunity to develop and proliferate in the exudate which immediately fills the dead spaces. The incision which runs in the direction of the fibres is the most advantageous for every tissue. In the depths tearing and bruising of the tissues may be avoided if one does not make too short an incision; a long carefully handled wound heals with more assurance than a short and badly damaged incision. CARE OF THE WOUND 67 In the course of the operation everything should be avoided which might increase the mechanical irritation of the wound. Unnecessary contact should be avoided ])y covering the wound surfaces with gauze sponges. Ties shoidd include when possible only the bleeding vessel, and should avoid neighboring tissues, in order to cause no necrosis in the woimd. jNIass ligatures, if possible, should be done away with altogether. In the same waj' in aseptic operations the thermocautery should never be used for the separation of tissues. Bits of tissue lyhig loose in the wound, such as splinters of bone or little tabs of fat, shoidd be removed before sewing up, as well as tabs of hanging muscle and fascia. CHAPTER 4— AFTER-TREAT:MEXT DRESSING At the close of the operation the skin in the neighborliood of the wound, the hne of suture being protected, is wiped clean of remaining iodine and dried blood with a sponge soaked in ether, benzine or alcohol. The dressing consists of sterile gauze next the skin, covered with absorbent cotton or sheet wadding. The gauze when laid on flat serves as a compress, or if opened it serves to absorb any blood or wound secretions, as well as the moisture of tlie skin. The cotton protects the wound from hai-mful pressure, reinforces the capillary action of the gauze, and, so long as it remains dry, acts as a filter against bacteria entering from without. If the cotton is damp it loses these properties and the wound dressing must be changed. If, as in certain operations, such as those on the brain and spinal cord and on the chest and abdomen, one must reckon upon an early and marked infiltration of the entire dressing, which will offer favorable circum- stances for the development of bacteria, we complete the dressing by adding an outer layer of sterilized iodoform gauze. This forms an efficient protection against the danger of invasion of the moist gauze by foreign bacteria. Even in infected wounds the lower layer of the dressing should con- sist of plain gauze, in order that no irritation of the skin should occur as the result of antiseptic agents. The dressing is fastened on with a gauze bandage or by adhesive straps. Either should be so applied that the dressing material and the wound edges are lightly compressed and that a complete occlusion of the wound is obtained. For wounds which secrete freely, and which have to be covered with a thick layer of dressing material, and in places where the hair grows rapidly, appropriate methods nuist be employed for keeping on the bandage. The dressing when complete must be applied so as to allow no foreign bodies, for instance, rem- nants of food, or even the hands of the patient, to get under it and reach the wound. Wherever the dressing stands away from the skin it should be stuck down by means of a strip of zinc oxide adhesive plaster. 68 THE FIRST DRESSING 69 Generally speakiii<>', wounds on the linil),s should have a dressing applied to include both of the neighboring joints. In wounds of joints, segments of the limb above and below should be included in the bandage. For the head and face the classical methods of bandaging are the best. Celiotomy dressings should include one or both thighs, and extensive chest and shoulder bandages should include the head and neck. In applying the dressing the patient shoidd assume the position which he later will maintain in bed, in order that the edge of the bandage shall not cut in or stand away when he changes his ])osition. AVhere it is available, the best method of holding on dressing material is adhesive plaster, which may be bought in every width. But plaster strips must not be applied overlapping each other clapboard- wise, but between them small spaces must be left in order that the evaporation of the skin moisture be not restricted. Where excessive and ])ersistent secretion is expected, such as after the creation of intestinal or bladder fistuhe, or in extensive infected wounds, the dressing should be held on by means of a swathe or many-tailed bandage, undei- which the dressmg can be renewed without difficulty. To hnmobilize movable portions of the body, it suffices to incor- porate strips of s])lint wood in the dressing, or to apply a splint. Where wood projects and touches the skin it should be carefully padded with cotton, jjarticularly when bony processes lie just under the skin. For the limbs one may use any sort of ready-made splint of wood, wire or tin. For the lower extremity the Volkmann T splint is an advantageous support. When anywhere in the body one wishes to guard against the least possible motion, a Plaster of Paris bandage is applied over the dressing. To facilitate the change of dressing a window is cut in the hardened plaster at the proper place. Fess resistant, but simpler to apply, and lighter in weight than the plaster bandage, are the starch or silicate (water glass) bandages. The impregnated bandage is before use placed in water, wrung out and applied about the dressing. Since these become stiff when they are dry, their edges must be padded to prevent them from cutting into the skin. CHANGINCJ THE DRESSING The healing of an aseptic wound follows, as a rule, under a single dressing. The dressing is first changed when the sutures or the skin clamps are to be removed, usually after a week. A soft sterile pad 70 after-treat:\ie\t or an ointment dressing is then applied for protection over the fresh scar. "\\^herever the Avound is ha])Ie to tension or where sudden pres- sure might open up the hne of suture, some or all of the stitches may remain without danger for fourteen days, three weeks or even longer. An abdominal incision may thus be exposed to danger in attacks of coughing, vomiting or in difficult defecation. The sutures remain throughout this period without arousing any reaction or they grad- ually cut their way through the skin, but usually a strong epithelial scar has formed by this time between the stitch holes. A mild red- dening of the stitch holes does not demand immediate removal of the stitches, since after the passage of the first few days wound infection does not arise from the skin or from the open stitch holes, under aseptic conditions. The appearance of fever and acute pain in the wound in the first few days after the operation signify an interference with healing, which may be caused through infection or through secondary bleeding. If only insignificant swelling or inflammation of the stitch holes is evident, it is sufficient to remove one or another suture and in that way allow the wound edges to gap without danger of complete sepa- ration. If in spite of this the temperature ascends and general symptoms as well as the appearance of the wound leads one to make the diagnosis of retained secretion or infection of the deeper layers of wound, all stitches must be removed, and the open wound must be packed lightly in all of its recesses with rubber dam. The temperature rise from an iminfected hematoma disappears twenty-four hours to forty-eight hours after this operation. The time to dress drained wounds depends upon whether the wound is clean or infected. Packing which serves only to protect a large cavity from hematoma or infection can be allowed to remain for a considerable time, particularly if it is impregnated with iodoform and so protects the absorbed secretion from dissolution. Bleeding from venous vessels occurs, as a rule, immediately, or at the latest not after five days, so that packing to stop the vascidar ooze can then be removed. When a drainage wick of gauze is removed, a small rubber dam wick should be left in the wound a few days longer, in order to anticipate all retention of wound secretion. Persistent adhesions do not occiu' until after a considerable time. Accordingly, in order to protect against the extrusion of coils of intestine, for instance, the packing which is removed at the first dressing must be replaced by a new one. If a strip sticks too tightly to the wound edges, it may be CHANGING THE DRESSING 71 loosened by tlie use of hydrogen dioxid, or by allowing warm boric acid solution to trickle upon it. In infected wounds and those which secrete freely, the dressinarts and the bone for sources of inllanimation to pass from without inward. Purulent meningitis and inflammation of the brain may be the fatal result of a su2:)erficial infection. For this reason fresh accidental M-ounds of the head of any extent should not, as a rule, be immediately sewed up, but should be treated openly. First the surroundings of the wound over a considerable area are dry shaved and painted with benzine followed by tinctiu'e of iodine, or with iodine alone, then the torn tissues are freed of dirt and blood clots with sterile forceps and gauze and every spurting vessel is tied. In order, so far as possible, to transform the whole wound into a smooth-walled cavity, cruslied portions of the wound, edges and tabs of tissue, are removed by knife and scissors, and when necessary tlie external skin womid is eidarged. Bridges of tissue which separate small ])ockets from each other are s])lil. and linally the wound cavity is packed in all of its recesses with sterile iodoform gauze. In the open treatment retention of blood and of wound secretions are diminished, and in that way the danger that bacteria find favor- able conditions for forcing their way into the depths is lessened. If after three days the wound surfaces show no evidences of infection, the packing is removed and the wound sewed uj). Sometimes exception must be made to this i)rinci])lc of the open treatment of wounds of the soft parts on the head. If as the result of 80 TREATMENT OF WOUNDS OF THE HEAD powerful trauma in a tangental direction a considerable flap of skin is torn from the cranium, this must be replaced on account of the danger of necrosis of the exposed bone, and held in its original position by several stitches. In the deepest point of the wound pocket a drain- age tube is placed and sewed in, to carry off wound secretion and blood. A longitudinal incision made at the root of the flap ordinarily does not endanger its nutrition. The drainage lessens the danger of infection since, as a result, tlie wound surfaces remain dry and rapidly adhere to each other. Primary closure of wounds of the face may be requisite if cosmetic results are to be considered, for with secondary suture one never obtains so fine a scar as with primary suture. But freshly sutured wounds contain within their depths hidden sources of infec- tion. Therefore, as soon as signs of inflammation appear in any sutured wound, stitches must be removed and the wound opened up. TREATMENT OF COMPOUND FRACTURES OF THE SKULL The treatment of compound fractures of the skull is carried out on similar jirinciples. No matter what the origin of the wound, one can never determine whether or not it is infected, and even though the majority of compound fractures of the skull heal without difficulty, nevertheless, this always remains an insecin-e probal)ility. The usual treatment is limited to cleaning up and disinfecting tlie surroundings, applying a sterile dressing, and waiting. Without doubt this method of procedure in the majority of cases gives good results, but one should never judge without a close examination of the wound whether matter has been forced in deep which may lead to infection of the wound. For example, a young man of twenty-one years was brought into the hospital foin- days after an apparently slight wound of the scalp, which had been treated in the above manner; he presented definite symptoms of meningitis and after a few days died. Under the edges of the skin woimd, which had already adhered, was found a fissure fracture of the parietal bone, a slight splintering of the lamina vitrea and an extensive tear in the dura; on the surface of the crushed brain substance were found several hairs. Xo symptoms referable to the cortex were aroused by the tramna, which in an injury of the right parietal lobe, a mute region, is not to be wondered at. One such unfavorable result counterbalances a hundred good ones, when one considers that this patient might have been saved by a slight procedure COMPOUND FRACTURE OF THE SKULL 81 carried nut immediately after the injury. If there is the least sus- picion that the scalp wound lias been contaminated by septic material, it should under every circumstance be opened up wide. One should not stop even at trephining. In addition to the danger of infection, one may often look for later disturbances on the part of the brain from a s^jlintering of the internal table, wliich occurs with the fracture. In irrcsjxinsive regions, which taken altogether make up tlie largest part of the superficial area of the brain, such a splinter, even if it perforated the dura mater, might lie for some time without causing irritation, and only arouse symptoms after the course of weeks, months or years. Sucli splinters may, as experi- ence has taught us, heal in and smooth over without causing ej)ilepsy; and moreover, this is not the only cause of this brain atlliction; it may come also as the result of a severe shaking up or local contusion of the brain after uncomplicated fractures. But in open fractures the possibility of its occurring must always be considered in addition to the danger of infection. The following represents our experience in a similar case: A thirty-seven-year-old army officer met with a severe automobile accident at night, so that he had to be carried unconscious to a hospital. There several insignificant wounds from splinters of glass and a wound on the forehead were found, and the patient gradually recov- ered consciousness. After the application of an ase])tic dressing he was sent home alone. In the next few days the dressing was changed several times by a consulting surgeon, but l)eyond that nothing was done. The injured man felt fairly well except on tlie first two days, when he complained of a headache and occasional delirium. The temperature on these two evenings was TOO..). l)ut it tlien fell to normal. According to the report of tiie house jjjiysician, the pulse was always subnormal, but at times it fell as low as 52 beats to the minute. Eight days after the injury, after the patient had eaten a consider- able dinner at three o'clock in the afternoon, he was taken with severe cramps and convulsions, whicli developed into a deep coma ; the cramps lasted at least five mimites and the unconsciousness for half an hour. Examination at the beginning of recovery, when we were called in, showed normal fundus and j)ui)illary reactions and no sen- sory or motor disturbances anywhere over the body, but, on the other hand, there was a severe headache in the frontal region, which lasted until anesthesia was started at 7. -30 that night. The X-ray 82 TREATMENT OF WOUNDS OF THE HEAD showed several depressed splinters in the middle of the frontal bone. In the middle of the forehead there was found an oblique fresh scar 4 cm. long. This scar was excised, whereupon it appeared that to the right side the periosteum was loosened by granulations, so that the bone was exposed and the surface was pallid. After this obser- vation a traji-door of skin and bone with its base to the right was made. The two drill holes were bored in the middle line where the scar had been excised. The lower drill hole opened into the frontal sinus, and after the anterior bony plate was penetrated the posterior plate had to be drilled. From the upper drill hole there appeared a turbid seropiu'ulent fluid followed by blood. The bony incision was made in the ordinary manner with the Dahlgren forceps. Immediately on turning back the flap two large bony splinters and one small one were discovered projecting into the dura. In addition a fissure ran to the right for some distance, and between the dura and the bone was found a thick, somewhat decomposed blood clot. About 1 cm. more of bone had to be removed at the right in order to allow the removal of the clot. In the direction of the root of the nose we found a large and a small splinter of bone projecting. The frontal bone below was cracked over a considerable area; a large splinter of bone, which included the entire glabella, was allowed to remain, because it was attached to the skin. Above, two loose flakes of bone were found between the dura and the lamina vitrea and removed. No fm-ther fragments could be felt. Finally the right temporal lobe and the left in its median fourth were exposed, both naturally covered with dura, as well as the longitudinal sinus in the entire extent of the wound, over 5 cm. There now appeared in the dura near the longitudinal sinus a tear which had already superficially adhered. In order not to meet the sinus a dural flap was made over the right frontal lobe, so that its base was directed toward the sinus, that is to say medial. On opening this flap it was apparent that the tear of the dura had just encountered a large arachnoidal vein, as a result of which the whole visible portion of the brain was saturated with blood. The vein was double tied and divided. Careful palpation of the entire lobe showed nowhere either splinters of bone or other foreign bodies. It was carried out by intro- ducing the index finger near the falx cerebri, while the other index finger palpated correspojidingly on the outer side. Finally the whole subdural space was packed with ^•^oform gauze, as the wound, which COMPOUND FRACTURE OF THE SKULL 8S was eight days old, did not seem to be free of the possibihty of infec- tion, and the skin and bone flap was sewn down. Healing was uninterrupted. Tlie temperature just after the opera- tion rose to IOL'2, pulse UG, but it fell that night to !)8.8, pulse 76, and on the second evening it reached 100.4, pulse 02. When on the sixth day the drainage was removed a few drops of turbid fluid followed. From that on the temperature varied between 07.(5 and 08.8 and the pulse between (!(> and 7<). On the eleventli day the stitclies were taken out, the wound being healed, and on the fifteenth day the patient left liis bed and two days later the hospital. He is now completely well. According to our o])inion, the treatment even of small external wounds should not be limited to the ajjjjlieation of antiseptic or aseptic dressings, but the skin wound should be enlarged, so that no pockets or recesses remain, and all foreign bodies, such as hair, sand, etc., as well as clot sliould be removed, splinters of bone jjulled out and crushed portions of the brain substance and lacerated tissue trimmed away. In order to prevent necrosis of the bone and later injury of the brain, sharp projecting points in the bony edges of the wound should be smoothed off with rongeurs. When the necessitj'- arises, the wound in the dura should be enlarged in order that thei-e sliould be no retention of blood or secretion, and in that way further destruction encouraged. When the bleeding has been carefully controlled, the entire wound cavity cleaned by sponging with sterile gauze and exposed through wide retraction, it should be packed with sterile iodoform gauze to the very bottom. If handled in this manner, even very dirty and com- plicated wounds run a favorable course. It is most advantageous to employ the gauze in the form of strips or tape, as it is more con- veniently removed through the wide apertures which are left in closing the wound, after five or six days, or later, as the ease may be. Through partially sewing up the skin wound one lessens the possibility of prolapse of the brain, which occurs more readily if the pia is also torn over any considerable extent. To be sure, one nnist usually, by means of a plastic flap, with or without periosteum, attempt later to create a covering for a larj^e hernia of the brain. The fin-ther treatment of wounds of the brain as a result of pressure of bony splinters, particularly fresh injuries of the centres which lie in the cortex, will be considered in the chapter dealing with this special region. 84. TREATIMENT OF WOUNDS OF THE HEAD BULLET WOUNDS OF THE SKULL Military practice has taught us that perforating bullet wounds heal best if only the surrounding portions of the skin are cleaned and an aseptic dressing applied. Every attempt to locate the bullet, and par- ticularly early probing, should be rejected entirely, since it increases the danger of infection, which in the first place is slight. The bullets in many cases heal in without irritation, and may remain in situ in soft parts or in the brain itself for the span of a lifetime without causing symptoms. An indication for operative interference, according to these prin- ciples, appears when bleeding, either from a sinus or a large vein in the pia mater, or from the middle meningeal artery or one of its branches, or finally from the carotid canal, gives rise to evidences of brain compression and focal symptoms; and an examination of the course of the bullet must be made, if the l)ullet, which is itself ordinar- ily sterile, has presumably carried with it into the depths septic par- ticles, such as bits of clothing. Fresh bullet wounds of the skull only seldom indicate surgical inter- ference: nevertheless, the removal of a bullet, or at least the opening up of its path so far as this is possible, may be indicated after several years. Difficulties may arise referable to splinters or depressions of bone, to the dura, or to the site of the bullet. Also a number of late complications find their explanation in the property of the bullet to wander. This wandering may take place without symptoms when areas of minor significance or portions of the brain already destroyed by the bullet are encountered, then only repeated X-ray examinations Mill give the necessary information concerning its changes in position. But it is possible, and this is particularly true in those with a neuro- patliic tendency or when an inherited taint is present, for a general epilepsy to develop. In other cases more or less severe symptoms develop from the wandering of the bullet, which may be differentiated according to the sections of the brain which are involved. At times also, infrequently, the basal nerves of the brain are compressed, a circumstance which is apt to give very definite symptoms. The subject of the removal of bullets and other foreign bodies from the ])rain will be taken up later. TREATMENT OF INFECTED AVOUNDS AND SEPTIC PROCESSES. INCISION OF PHLEG.MON Infected wounds, abscesses and all spreading purulent inflamma- INFECTED WOUNDS AND SEPTIC PROCESSES 85 tions on the head demand deep incision of the infiltrated tissue, on account of the danger of extension of infection into the cranium. The incision should he made hcyond the boundaries of the inflammatory infiltration in depth as well as in superficial extent, so that the tissue Avill spread open and the secretions flow off unhindered. Absorption of the wound secretions is promoted by light packing, drainage and moist dressings. One should not hesitate to open wide by counter incisions the deepest pockets of the infected wound. All phlegmonous processes, whether they originate fi-om diseased teeth, glandular abscesses, infected wounds on tlic face, mouth, or from within tiie nose, should be laid wide open in a similar manner. Although in the first place the incision must open up the infiltrated area to its entire extent, at the same time regard must be paid to the facial nerve, since the division of its branches maj' result in permanent paralysis. One may avoid cutting the facial nerve with assurance by kee])ing outside of a triangle, the apex of which lies at a point where the lobe of the ear meets the skin of the cheek and the base lies on a line between the outer end of the eyebrow and the corner of tfie mouth. If an incision has to be made within this triangle, its direction should be in a line radiating from the apex. The supra-maxillary branch for the lower lip is not always easily avoided; as a rule it runs just behind and parallel to the margin of the jaw, but its position is irregular. Kven in deep cellulitis of the face, developing from carious teeth or other foci which lie deep, which creeps forward upon the masseter and spreads out under the strong temporal fascia, the necessary incision may be made so that no injury to the facial nerve results. TRKATMENT OF ruRUNCI.ES The treatment of furuncles on the head and face dej)ends upon their position, the condition of their develoj)ment, whether tlu'y are single or multiple, and particularly whether the symptoms are local or general. Oi-dinarily the treatment of ripe furuncles is simj)le and well under- stood. They are recognized by a complete or nearly comjjlete necrosis of a hair folHcle and a softening down of the neighboiing tissue within the limits of a small reddened and swollen area. At the most a portion of the lymph nodes of the region may be indurated and tender. Such a furuncle heals as soon as the slough and crust which covers it have been removed by forceps and the softened or liquefied tissue has been 86 TREATMENT OF WOUNDS OF THE HEAD allowed exit by a crucial incision. The further the softening has gone, the smaller may be the incision and as a result the less the scar. Heal- ing follows under soothing ointment dressings or, if the skin will stand it, a moist mildly antiseptic dressing. If one is scrupulous about the scar which results from incision in inflamed tissues, the removal of the slough and the emptying of the fluid portions of the infected focus may be undertaken with a suction cup after the method of Klapp. For a half hour several times a day it is api)lied for five minutes at a time with a pause of three minutes. The edge of the suction cup, as well as the vicinity of the furuncle, must be well greased. In this way the sliding off of the glass and the injurious pressure of its edges will be prevented, and the sur- rounding tissue be protected from exposure to further infection through the pus evacuated. The negative pressure in the glass should never be so strong as to cause pain. The hyperemia which is obtained by suction exerts a painless and healing influence upon the course of inflammation. Unsoftened fresh furuncles may be healed without pus formation by the ajiplication of an unirritating ointment sjiread over the surface of the hyperemia induced by the suction cup ; or a moist 90 per cent, alcohol dressing covered with some impermeable material with holes cut in it exercises a favorable influence. If under this treatment healing does not result, the application works as a poultice, which hastens local softening. One should discontinue the bloodless treatment as soon as an ex- tending thrombosis is apparent in the neighborhood of a furuncle. If hard and sensitive cords may be felt by careful palpation of the skin, the infected tissues must be deeply and widely opened in order to jjrevent transportation of purulent particles into the circulation, and a pyemic intoxication. For the same reason squeezing and pressure u])on the infiltration region about the furuncle should be guarded against. The ordinarily harmless but protracted multiple furunculosis should also be treated after the foregoing principles. They extend their chronic com-se over the limbs, over the hair line on the neck and over the entire body. In conjunction we have the formation of all manner of furunculous nodes, which vary in size, painfulness and in the stage of inflammation. The funmcidosis of nurslings, which spreads all over the body, is particularly prone to abscess formation. It heals up most rapidly when each single abscess is opened by incision TREATMENT OF FURUNCLES 87 under proper precautions. In this way sometimes we have to make 150 to 200 incisions in the course of several weeks in infants before it is finally overcome. We have never seen the slightest result either therapeutically or prophylactically from the use of yeast. Vaccine thera2)y sometimes acts well in chronic cases. Furuncles of the upper lip and cheek follow in the majority of cases the same clinical course as isolated furuncles in other portions of tile body. They may, however, be very virulent, and they are particularly disposed to indvice pyemia and purulent meningitis. For that reason they should always be considered and treated as a danger- ous affection. The severity of the symptoms does not give indication of their possibilities. The ordinary malaise, fever and local changes are exhibited to a greater extent in the face than in other locations. The inflammatory edema usually extends to the up^jer portion of the face, so that one or both eyes may be closed by swelling of the lid. In fiu'uncle of the lip the entire lip may project like a proboscis, and on the nose the soft parts may exhibit so great a swelling that the nasal passages are closed. The particular danger in lip and cheek furuncles consists in the tendency for the infection to extend to the facial vein and its branches. By this means masses may be carried off to the most remote places. In j)yemia after funmcles of the face, the joints of the lower extrem- ities and the pararenal tissue are particularly involved. I^ess favor- able even than pyemia is the course of an extensive putrid thrombosis of the face. This may involve the sinus cavernosus and other vessels of the base of the skull. It may include the veins of the eye or may even induce a purulent meningitis. Since the course of a lip or cheek furuncle cannot be foreseen and since it may lead to a fatal termination, one is justified in making early and extensive incisions in order to open up the infiltrated tissue. Such a radical procedure is particularly indicated if the development of the inflammatory changes does not remain limited to the neighbor- hood of the furuncle, but if in the course of the disease a hard cord painful to pressure appears at the site of the facial vein. ^^'hile early incision of the furuncle has been demanded in every case by the majority of surgeons, recently efforts have been made along the line of conservative and bloodless treatment. This point of view has its justification in the fact that uncomplicated lip and cheek furuncles run a benign course in the majority of cases if they are protected from all mechanical insult. Particularly all palpation 88 TREATMENT OF WOUNDS OF THE HEAD and squeezing of the affected area must be avoided in order not to force bits of necrosed tissue or bacteria tliemselves into the rich lymphatic and blood circulation. Chewing and talking should be lim- ited as far as possible for the same reason. The patient should be kept in bed and treatment should otherwise be limited to covering the furuncle Avith a piece of compress thickly smeared with ointment, to protect it and to overcome the feeling of tension. In the clinic of Bier a light hyperemia M'ith the rubber bandage about the neck for twenty to twenty-two hours is employed. We can obtain a definite result with the suction cup, as in other furuncles, only when a necrotic slough has been already formed in the centre. TREATMENT OF CARBUNCLE The same principles are employed in the treatment of carbuncle as for furuncle of the face. Since the purident infiltration includes several hair follicles, it is clear that the danger increases with the circumference of the focus. Carbuncles, like furuncles, are particularly malignant on the lip. They demand, on account of the danger of metastasis, an early and broad incision along the border of the mucous membrane of the upper lip. This incision divides the mass in a line which will give a scar of passable cosmetic appearance. If such a splitting of the infiltrated area does not sufl^ce, another incision is made at right angles to it directly across the infiltrated tissue. This sometimes exposes the facial vein, which must be tied off. In contrast to this radical pro- cedure. Bier recommends treatment with passive hyperemia just as for furuncles. The danger of metastasis of jiurulent material to the other parts of the body is more safely avoided by excision of the carbuncle. This radical procedure is to be considered on the face only in severe cases. But according to Riedel, all neck and back carbuncles, without regard to their circumference, should be extirjjated just as a malignant growth, a procedure which we have followed as a rule, and which may be typified by the following observation: A thii'ty-year-old man had a carbuncle the size of a baby's fist on the right side of the neck. In order to excise it entirely, the skin was divided at a distance of several mm. from the border of the infiltrated zone. An elliptical incision being made on each side, so that the ends met above and below (Fig. 2, Plate 1), the carbuncle was seized by double hooks and was extirpated by incision through Krause-Heymann-Ehrenfried. Tab. 1. Excision of a Carbuncle. Carbttn mann-Ehrenfried. Tab. 2. Excision of a cystic Endothelioma. Incision \ Portion of tumor at/herent to skin Fig. 5. Elliptiform incision tlirongh skin. Retracted lower edge Fig. 6. Dissection of fat of cheek. Forceps exerting traction on tnnior Fig. 7. Completion of the extirpation. Rebman Company, New York. Cut Surface Subcutaneous fat Fig. 8. Tumor, split after removal. CHAPTER 6— EXTIRPATION OF TUMORS IN THE TISSUES OF THE FACE SM^iLL AND BENIGN GROWTHS: LIPOMA, FIBUOMA, SEBACEOUS CYSTS, FIBRO-EPITHELIAL TUMORS The removal of small benign tumors or tumor-like formations on the soft parts of the face can, as long as the skin is not adherent to them, be carried out subcutaneously through a linear incision. If the skin has become adherent to the tumor or has been partly destroyed, the t>imor must l)e shelled out after an oval incision. Injuries of the branches of the facial nerve may be avoided in most cases in the manner described vmder purulent infiltrations. The incisions should run in radiating fashion forward from the root of the lobe of the ear, and so long as one continues parallel to the line of incision and divides the deep layers carefully, danger of cutting across the nerve is not great. This is diminished if the tumor in growing to the surface has pushed the nerve fibres to one side. As an example of the removal of a tumor from a cheek the follow- ing observation may serve: A tumor the size of a cherry was apparent upon the left cheek of a young woman just in front of the edge of the parotid and on the level of the lower teeth. It was very slightly movable upon the deep tissues; the skin had become adherent to it. Since it was probably a case of cystic adenoma, the extirpation was carried out in a short ether "rausch." The skin, which had grown to the tumor, had to be incised in tlie form of an oval (Fig. 5, Plate 2) until the wound edges above and below could be retracted with sharp hooks (Fig. 6, Plate 2) and the whole tumor could be cut out with a wide margin of normal tissue (Fig. 7, Plate 2). Since all the incisions were made in the direction of the branches of the facial nerve and the separation of the subcu- taneous tissue was carried out carefully, injury to the nerves was avoided. After ligation of the spurting vessels, the oval incision \vas sewed up in a straight line. Out of the removed tumor (Fig. 8, Plate 2) there poured a thin, seromucous content. The inner wall of the cyst was thin, smooth, white and shiny. It lay everywhere embedded in fat except on the outside, wluic it had grown to the epidermis. No connection with the j)arotid could be made out. 91 92 TUMORS OF THE FACE HEMANGIOMA OF THE FACE: HEMANGIOMA SIMPLEX In the new-born or in children in the first months of hfe, on the skin of the face more frequently than in other parts of the body, a tiny, level, fiery red birth mark may appear. On close examination one can recognize at the edge of the affected area individual ectactic blood vessels, of which the entire mass of the formation is composed. Such hemangioma may grow rapidly and in the course of months and years spread to include the lips, nose, lids and ears. On account of this it is advisable to remove small red birth marks which lie near the orifices of the face as soon as they show a disposition to extend. This is best carried out in the first weeks of life with a Paquelin cautery, carbon dioxide snow, or liquid air. Larger hemangioma must be excised and the skin defect closed by suture or, if necessary, covered by epidermal transplantation. ANGIOMA CAVEKNOSUM Cavernous angioma, just as the simple isolated angioma, is usually congenital or arises in the first few years of life. It is composed of a crowded throng of blood sinuses, which contain venous blood. If these, in their growth, press through to the surface of the skin, they appear as blue knots or varicosities through the skin of the cheek and the margin of the lip. On the other hand, they may grow deep into the fatty pad of the cheek, so that, after Virchow, they have been also named lipogenous angioma. As an example of the appearance and treatment of these timiors, the following observation may serve: A nine-months-old child Avas born with an angioma on the scalp the size of the head of a pin and a varix on the cheek the size of a grape seed. Gradually the tumor of the cheek grew, and while it was still about the size of a quarter an attempt had been made to destroy it with alcohol injections. As a result the tumor and the skin which covered it became gangrenous. In a short time erysipelas set in, starting from the wound of the cheek and spreading over the entire body of the child, which put an end to further treatment. After the erysipelas and a series of posterysipelatous abscesses in various portions of the body were healed, the tumor, which had been destroyed in its centre, had attained the size of a small apple (Fig. 9, Plate 3) . For the extirpation of the scars and the skin of the cheek, which had become adherent to the tumor, an oblique oval incision was made (Fig. 10, Plate 4), directed downwards and inwards, because it was apparent that in this way distortion of the ej'elids and of the corner Krause-Heyinann-Ehrenfried. Tab. 3. An^ioni.-i cax'crnosuni of the check. I. Scarred portion of the tumor ^ ..^ w\ Fig. *i. Tiie skin has been destroyed as a result of alcohol injections. ;ebni;in Company, Ne* York. Krause-Hevniann-Ehrenfried. Tab. 4. Tumor Extirpation of an Angioma of the cheek. 11. Zygoma Muscles of the corner of the mouth I he finger within the mouth pushes out the mucous membrane Fat of cheek Fig. 10. The tumor which has been dissected remains attached only by a strip of connective tissue Fig. 11. Completion of the Extirpation. Scar Redundant fold of skin Fig. 12. The face healed without distortion of the features. Rebnian Company, New York. .\NGIOMA 98 of the mouth would be kept at a niininiuni. The incision first sep- arated only the skin about the tumor. At the forward ed^e the dis- section was carried on until the base of the tumor was perfectlj' free; every spurting vessel was seized and tied off. The same was done in the lower border and in the neighborhood of the corner of the mouth. The tumor here went into the depths as far as the mucous membrane of the mouth, but it was not adherent to this. In order not to destroy this and in that wav favor infection of the wound, the little finger of the right hand was placed in the mouth and with this the mucous membrane was pressed forward so that the tumor might be separated from the submucosa piecemeal with scissors (Fig. 11, Plate 4) . Here likewise all spurting vessels were immediately seized and tied. After freeing the skin of the cheek behind, the tumor could be exposed down to the fat pad of the cheek and the zygoma. Out of regard for the later cosmetic effect the fat of the cheek was preserved so far as possible. When the tumor was freed from its bed and removed, the muscles which run to the corner of the mouth were exposed as well as the zygoma and the fat pad of the cheek. P^inally the skin was sewn up with interrupted sutures without causing any deformity or displace- ment of the lid or corner of the mouth. After completion of the suture the small angioma on the scalp was excised by an oval incision. In such an excision all bleeding may be prevented if an assistant presses upon the bony substructure with the fingers on either side of the designed incision and a continuous button- hole stitch is placed while the compression is continued. At first the right corner of the mouth was paralyzed so that in crying and laughing the mouth was di-awn strongly to the left, but this impi-oved within the next ten days and upon discharge, fourteen days after the operation, only a very slight paresis persisted. The wound healed smoothly, so that on the seventh day the stitches could be removed. At the lower corner of the mouth a little fold of skin had resulted from the suture, which at first projected consider- ably, but by the day of discharge it had fiattened out to a small ele- vation. The linear wound of the cheek was only noticeable on account of its redness (Fig. 12, Plate 4). The scar on the head was hardly visible. RACEMOSE ARTEKIAI, HEMANGIOMA Much less frequent than simple and cavernous tumors on the face and the head is the arterial angioma. It is apt to develop as a "creep- 94 TUMORS OF THE FACE ing" angioma in the neighborhood of the ear, and it then stands in relation to the superficial arteries. Its recognition depends upon palpation and upon pulsation. Avhich is usually visible. Although the skin lies over it only in a thin bluish layer, the single Acssels as a rule are not visible. The following case cited by H. Berger* is repre- sentative : A nine-year-old boy had since birth, according to his father, a tumor on the right side of the head, which at times showed an increase in size and at other times was stationary. Several weeks before his admittance to the hospital the tumor had begun to grow rapidly, and the right eye, which had previously not been involved, had begun to swell. There was no pain. According to the parents, he at times complained of headache but not of roaring, buzzing or similar mani- festations. On the right side of the head was a broad tumor for the most part movable imder and with the skin over the bone, made up of numerous coils of vessels, which jjulsated synclironously with the heartbeat. With the pulsation one could feel and hear in the tumor a definite thrill. The temporal artery, which was the size of a lead pencil, showed marked pulsation, and unusual pulsation was also to be seen in the neighborhood of the tumor and even in the neck and clavicular fossa. The extent of the tumor Avas as follows: The lower border, beginning at the right tragus, ran obliquelj' upwards to the outer corner of the eye and through the upper lid as far as the glabella. From here it went, following the sagittal sutin-e, upwards to the middle of the frontal bone. Only in the region of the anterior edge of the scalp did it pass beyond the middle line. From the middle of the temijoral bone, the posterior border of the tumor returned to the right ear and from the concha of the ear back to the tragus. The pulsation in the tumor could not be decreased either by compression of the common carotid artery or at any point between that and the tumor. The right upper lid was a dark bluish red and swollen, but the lobe was not pushed forward and the fundus as well as the vision was normal. At the operation, through a skin incision which ran obliquely from the outer corner of the eye downward, in the direction of the facial branches, to the tragus, the temporal artery and numerous other arteries the size of a lead pencil, which were exposed, were double tied and divided. This tying off affected only that part of the tumor which •Bruns Beitrage z. klin. Chir. XXII. iie:\iant,T()ma 95 lay just in front of the ear, otherwise the pulsation continued. From a second skin incision above the glabella the hcniorrhatife was just as stron<>' as in the first. Here the skin vessels were compressed between two fingers and the incision carried down to the periosteum. The supra-orbital artery was exposed as a thick cord and between double ligatures it was divided. The second incision was then carried obliquely through the upjjcr lid until it met the first, and down througli the entire tumor mass, so that the cut vessels could easily be seized and tied. Only a lew of the larger and more easily exposed vessels were tied before cutting. After completion of the skin incision and most of the ties, the entire tumor along tlie lower oblique incision from the upper lid down, together with skin, muscle and fascia, was freed from the healthy under layer with the help of raspatory, which made more tying off necessary. In se\eral places the periosteum had to be taken away because in and and under it further arteries were present. Repeatedly vessels spurted directly out of bone and could onlj' be stoj^ped by boring in with a pointed clamp. The bone itself was everywhere intact. After about one- half of the tumor was freed from its base in this manner, the operation had to be intcrru])ted on account of the condition of the patient. The wound was packed with .) per cent, iodoform gauze and a light pressure dressing applied. ^Ml told up to this time 113 ties had been necessary. For this reason the loss of blood had been small ; for either the vessels were exposed by the incision and tied or the separation of the skin and tumor mass was accomplislied between the compressing fingers of the assistant and the cut lumina seized before a drop of blood was lost. After three days, during which no distm-bing symptoms such as hemorrhage or fever app.'ared, the patient being in good condition, the extirpation of tlie tumor was completed. It appeared, wliere the skin had not been severed, generally edematous. It was possible to free the tumor after extending the skin incision upward from the glabella along the sagittal line close to the pericranium, partly by blunt dis- section and partly witli tlie scissors. All of the numerous vessels were seized, in the ])eriosteum as well as the vessels of the tumor itself, whicli contimied to bleed copiously. The bone was not in the least eroded. After the entire tumor together with the skin for a finger's breadth around its border had l)een turned up, he created a flap of skin tlie j)e(iicle of wliich lay between the tragus and the frontal protuberance. In order to remove the tumor from the skin and in 96 TUMORS OF THE FACE this manner to extirpate it, all the vessels supplying the tumor through the pedicle of the flap were divided and the tumor mass removed from the inner surface of the skin. Even in this manoeuvre several good- sized vessels spurted and had to be tied. In some places the mass was so closely attached to the skin that the skin was buttonholed. After all traces of the tumor substance had been removed, the skin flap was laid back over the wound surface and sewed loosely around the periphery. In three places small fine drains held the line open to avoid possibilities of danger. In the second oijeration, which com- pleted the extirpation, 76 ties were necessary, so that the total nmnber of ties was 189. The operation was again over without any pronounced loss of blood. A slight tendency to fever, caused by partial necrosis of the flap, dis- appeared within a few days. After a week, the portion of the flap which survived had healed in place. The necrosis involved an area the size of a nickel upon the right forehead, as well as the entire eye- brow and the loosened portion of the right upper lid. After two weeks the patient was out of bed. With the further advance of the scar for- mation on the regions not covered with skin, distortion soon became apparent. The upper eyelid was pulled up so far above the super- ciliary ridge — about one inch — that he could close the eye only by pulling the lower lid up to meet it. This defect was covered in by a plastic operation and skin transplantation after the method of Krause, and the eyebrow was replaced by skin from the scalp (see p. 152). After this, complete recovery occin'red. Abnormal pulsation could not be made out either in the former tumor region, in the immediate neighborhood or at some distance. The entire treatment took three months. EXTIRPATION OF LAKGE OR MALIGNANT TUMORS ON THE FACE The wounds which result from the removal of benign tumors usually allow of easy closure by drawing the edges together by direct suture. This is the most successful, in so far as one is as sparing as possible of the normal tissue, because the skin defects whicli result are usually smaller than the subcutaneous pocket from which the tumor is re- moved. Since malignant tumors possess the property of growing through the infiltrated tissue, in every case a portion of the neighboring tissue which does not appear involved must be also removed; for the borders of the tumor and their transition into normal tissue are not recogniz- MALIGNANT TUMORS 97 able by the naked eye. In order not to leave behind any suspicious tissue, the extirpation of the tumor must always include the tissues a half inch or so beyond its apparent boundary. ^Moreover, the zone of inflammatory infiltration, for instance, whicli surrounds practically all carcinomata, particularly those of the skin, should never extend be- yond the line of incision. No regard should be paid for the preserva- tion of neigliboring oryans, nerves and vessels, particularly if doubt exists as to Iiow far the tumor has proceeded. Naturally with every radical removal of a malignant tumor there results a tissue defect of considerable size. Since the tumor may destroy portions of the face over a considerable extent, so the defect after extirjjation may extend considerably. Sucli wounds cannot be closed by suture alone without serious mutilation, as after the removal of most benign tumors which can be shelled out, but the loss must so far as possible be replaced by the aid of plastic methods. The worst cosmetic effect and the most severe functional difficulties are suffered after the destruction of the bony framework of the face and the skin which covers it. In the replacing of both these structures lies the chief indication for plastic operations on the face. CHAPTER 7— PLASTIC OPERATIONS ON THE FACE SIMPLE METHODS- OF DERMOPLASTY The simplest method foi' covering surface defects on the face is by undermining the skin edges and sewing them together in a straight line. This method is adapted only for small defects. In larger wound surfaces one must make tension incisions at either side and mobilize the wound edges. Various methods for doing this are shown in the following sketches, which are taken from Hochenegg's "Lehrbuch der speziellen Chirurgie." Fig. 13 Fig. 14 A wound with irregular edges is transformed into an oval \vound by trimming the edges, and two parallel tension incisions are made (Fig. 13) ; after mobilization of the flaps the wound edges are sewed together (Fig. 14). Fig. 15 Fig. 10 A small rectangular surface (Fig. 15) is covered by a mobilized flap (Fig. 16), which has been formed between incisions continuing two parallel edges of the wound. (Celsus.) Fig. 17 Fig. 18 98 Sl.Ml'LK .MHTIIODS OF DKRMOPLASTY 99 Larjife rectaiiuiilar defects (Fig. 17) may l)e covered by several flaps taken similarly from two or more sides (Fig. 18). 'riiree-coriiered defects (Fig. 19) are covered by a flap whicli is foiiind l)y a cirNceiilic incision in a line continuing the base of the triangle (Fig. 20). ■'^]^.4'!! Fig. 10 Fig. 20 Large triangular defects (Fig. 21) may be covered by a mobiliza- tion of the wound edges upon both sides (Fig. 22). Fig. 22 Burow's modification (Fig. 23) of this procedure is as follows: One edge ( A B ) of the isosceles triangular sm-face is lengthened (ABBA). The proximal edge (B C) is mobilized to a considerable distance and c A Fig. 2.3 Fig. 24 the skin is drawn in the dii-ection of the arrow. In order to allow the skin to slide over, a new triangle (ABC) is excised analogous to the first, but reversed, and the suture is completed (Fig. 24). Burow's modification for covering rectangular defects consists in the mobilization of the flaj) and skin sliding after the excision of two tiiangles (Fig. 2.5 and Fig. 2(»). 100 PLASTIC OPERATIONS ON THE FACE After these methods all sorts of superficial woiinds may be covered with skin. Numerous opportunities not limited to the face will pre- sent themselves, in which these simplest of all plastic methods may be used to practical purpose. Their unlimited employment in the face is not permissible; for instance, the angles of the eyes and mouth should never be dragged or displaced, as tension may result in func- tional as well as cosmetic disturbances. But these may follow direct suture of a wound which is pulled to a straight line, as well as after undermining and plastic mobilization of wound edges. On the other Fig. 25 Fig. 26 hand, on the large surfaces of the forehead and scalp these methods maj' be employed Avith or without \ariation. Naturally all large wounds of the soft parts on the head and face as well as those which have resulted from the extirpation of malignant tumors may be covered by plastic flaps, such as wounds from trauma, after burns, and destruction of the skin as a result of tuberculosis, syphilis or noma. Before plastic procedures such wound siu'faces must be completely fi-ee of all diseased and necrotic areas and the woimd edges trimmed. FLAP GRAFTS Before application of the foregoing methods it is necessary that the wound siu-face should have an oval, triangular or rectangular shape. If these conditions cannot be fulfilled, we have at our disposal another form of plastic operation, which consists in cutting out a flap in the immediate neighborhood and turning it in on a pedicle over the raw surface. In order to lay the flap in evenly and without con- straint, various conditions must be fulfilled. First, the flap must be similar in shape to the wound surface. But since skin which is freed from its bed shrinks considerably, allowance must be made in all directions in outlining the flap. In the second FLAP GRAl rs 101 place, one must leave the pedicle of the flap so wide that not only the arterial inflow, but the venous outflow will not be in the least restricted. For this reason unnecessary cutting of vessels nnist be avoided when the flap is being made. This may be carried out if one edge of the new formed flap is the same as one edge of the original wound ( Fig. 27). and the skin incision for the other edge of the flap made in the direction of tile vessels and not across them. Moreover, in turning in the flap on its nutritional bridge the pedicle should not be twisted so nuich as to compress the lumuia of the vessels (Fig. 28) . Fic. 27 I'^lG. Finally, the stitches which fix the flap should be limited in nmnber in order to avoid danger of neci'osis of the edge of the flap from sutures. The secondary wound surface is covered ovei- \\ilh the aid of tension sutures, after undermining the wound edges, or by epidermal grafts after the method of Thiersch. INDIAN JIETPIOD The modern flap graft corresponds substantially to the old Indian technique. This method consisted in making a flap on the forehead, with its nutritional bridge at the glabella, which resembled in form the superflcial tissues of the nose. ^Vftcr separation from its bed and turning on the broad pedicle the flap was employed to reform a nose which had liecn cut off. At the present time the technique of nose formation in this original form has been given up because skin alone is not sufficient to insure a lasting result. Xoses which are made of skin alone shrink in a short time and in the place of the originally suc- cessful feature there shortly appears a shapeless, disfigured nubble. The pediculated fla]) made out of the neighboring tissues and resembling the wound in its form finds its most favorable application in the covering of large defects on the head and face. I'articularly the irregular wounds which result after extirpation of epithelioma in 102 PLASTIC OPERATIONS ON THE FACE the neighborhood of the facial clefts may be covered by this method. As an example we cite the following case: A seventy-year-old man had been blind in the right eye since his twentieth year, as a result of injury with a steel splinter. The nasal half of the left iipj^er lid extending to the glabella and upward over the region of the ej'ebrow was destroyed by an epithelioma the size of a quarter. The conjuncti\a and the eyeball were intact and the outer two-thirds of the lid were not affected. The patient had noticed it first one year before. In order to remove the new growth an incision was made through normal tissue about l/icm. from its boundary and it was freed up from its bed (Fig. 29, Plate 5), At the inner corner of the eye it was in such close relation to the bone that the bone-scraper had to be used to separate it. During this procediu-e the eyeball was protected by the index finger ( Fig. 30, Plate 5 ) . At the inner corner of the orbit considerable tissue had to be removed on account of the extension of the epithelioma, to insiu'e that no remnants were left behind. After the removal of the ulcer about two-thirds of the skin of the upper lid was missing and about one-third of the conjunctiva. In order to hold the lid in its proper position during the rest of the opera- tion and to protect the eyeball in the subsequent manipulations, the lids were sewed together at the corner by a provisional stitch (Fig. 31, Plate 5). The conjunctiva of the upper lid could be easily dra^vn inward, and was attached to the medial edge of the orbit with three catgut sutures; by this means the defect of the conjunctiva was com- pletely overcome and a good l>ase supplied for the flap. The large defect which resulted could be covered by a flap taken from the forehead with a pedicle over the glabella. The flap was made rather large so that the inner corner of the eye might be covered without tension. In order to fit it in. the spur of skin which projected from the uj^per medial edge of the defect, as the result of the outlining of the flap, had to be freed from its base (Fig. 32, Plate 5). The medial edge of the flap was then sewed doA\ii, covering in the lateral wall of the nose, the inner corner of the lid, and the mucous membrane of the upper lid. After inidermining the skin on the right half of the forehead and the spur of the skin already mentioned, the entire wound surface which resulted from the removal of the flap could be closed with the help of three tension sutures, leaving only a small fissure (Fig. 33. Plate 6). Finally, what was formerly the right lateral edge of the flap was Krausc-Heymann-Ehrenfried. Tab. 5. C'uttinp- and implantatinn of a pcdiculated flap. I. Edge of wound in normal tissue Epithelioma Fig. 2Q. Epithelioma at the inner cantiius. Raspatory Fig. 30. Freeing the malignant tissne from the bone. Outline of flap Suture of conjunctiva Provisional stitch bcturcn upper and lower lids Fig. 31. Showing extent of wonnd surface to be covered, and ontlinc of flap. Projecting y spur of skin Undermining skin of forehead Line of suture Fig. 32. The freed np flap has been turned and partly sewn in place. Rilmi iM Comp.iiiy, New York. Krause-Heyniann-Ehrenfried. Tab. 6. Cutting- and im])lantati()n of a ])edi dilated flap. II. Fig. 33. The undermined skin of the right side of the forehead and the projecting spur have been sewed together with 3 tension sutures. Scar along upper lid Scar in region of secondary defect Scar along upper lid Fig. 34. Condition after 4 weeks, eyelids open. Fig 35. Eyeh'ds closed. Rebman Company, New York. INDIAN METHOD 103 united to the lower edge of the loosened spin-, and, likewise without tension, the ri<>ht lateral e(i<>e of the defect to the right corner of the flap. The suture which held the upper and lower lid together was removed and a monocular handage was ajiplicd. The flap from the forehead held satisfactorily without necrosis of the edge and after ten days all stitches were removed. The tension suture ])laccd ol)li(iuely over the root of the nose had cut through the skin somewhat, hut the Assure which remained had Hllcd in with granulations. Four weeks after the operation the patient could fully open and close the lid (Fig. 34, and Fig. 3.5, Plate 6), the skin of which in its inner thii-d was formed of the flap, and the wound of the forehead was completely closed and covered with skin. In this case the eye had to he preserved under any circumstance, because the patient was blind on the other side. Even if this necessity did not exist, its preservation was well justified, for the epithelioma had nowhere invaded the conjunctiva. "\^. Graefe stated that in epithelioma of the inner corner of the eye which invaded the con- junctiva the eye must be sacrificed. Our patient suffered no recur- rence up to tAvo and one-half years after the ojjeration, and the cos- metic results have remained good. IXAP GRAFTS IN OTIIEK PORTIOXS OK THE BODY Since flap grafts find their chief application in jdastic operations on other portions of the body, it should he stated that they do not show the same disposition to heal in as well everywhere as on the face. Flaps taken from the arms and legs heal fairly well, but the skill of the shoulder, thorax and abdomen is more likely to become necrotic after transplantation, particularly about the edges. The reason for this probably exists in the fact that the skin of the face is the most richly ju-ovided with vessels, while the arms and legs possess fewer superficial vessels, and the skin of the buttocks is still more poorly provided in this regard. For this reason it is important in such places not to lay out too narrow a ])edicle, and not to interfere with the nutrition by sutures Avhich are placed too closely together. At the same time the loosened flap should never be twisted so far about its pedicle that the skin is blanched as a result of the tension. In a seventy-year-old man, after the extirpation of a recurrent glandular carcinoma, the wound surface on the right side of the neck 104 PLASTIC OPERATIONS ON THE FACE was covered by laying on a broad pediculated flap from the shoulder. The primary timior was situated on the upper part of the shell of the ear and had been removed a year and a half before. In the meantime ulands had been twice removed. At the last operation, a considerable area of skin and the upper half of the sternomastoid muscle had to be removed at the same time witli the infected glands. The tij) of the mastoid was chiseled off, and the internal jugular vein as well as the common carotid artery was exposed for some distance. On account of rather profuse venous hem- orrhage, which could not be controlled by continued compression, the wound was packed with vioform gauze and the plastic operation post- poned for five days. The flap was taken from below in the neck and shoulder region, since here there were no scars to endanger nutrition, and because in addition the secondary wound, on account of the movability of the skin in this region, could be readily closed by direct sutin-e. Accord- ingly, a flap was outlined with a broad anterior inferior pedicle (Fig. 36, Plate 7) and with a thick layer of subcutaneous tissue was loosened up from the soft parts beneath (Fig. 37, Plate 7). It was then brought upwai-ds and forwards onto the defect (Fig. 38, Plate 7) and sewed in place without tension or distortion. The secondary defect, after undermining the wound edges, Avas closed in a horizontal line by direct suture (Fig. 39, Plate 7). At the point where three lines of suture came together, and accord- ingly considerable danger of necrosis existed, only the epidermis and the uppermost layer of the corium were sewed together by superficial stitches. After the suture was completed, no folds were apparent in the skin. Four weeks later the flap had healed in completely without necrosis. A few of the stitches between the edges of the secondary wounds had cut through, but the flap closed in rapidly Avith an appli- cation of silver nitrate. Immediately after discharge, in spite of the wide extirpation, new glands appeared in the region of tlie upper wound edge, and the patient died a year later from extensive metastases. THE ITALIAN METHOD If for cosmetic or practical reasons the formation of a flap from the forehead does not appear feasible, the Italian or Tagliacotian metliod may find application. This consists in dissecting up a piece of skin on the arm corresponding in size to the woimd, which remains Krause-Heymann-Ehrenfried. Pediculatcd I'l.i]) in the rci;"it)n of shoultlcr and neck The tip of the mastoid has been chiseled off Granulations Neck vessels Tab. 7. 1 outlined, with base below. Fig. 38. Provisional implantation of flap Fig. 39. Completion of sittnre of flap, and closure of secondary defect. Rclimaii Company. New ^'ork. Krause-Hevniann-Ehren fried. Italian method of rhinoplast)' I. Tab. 8. Limits of the scar Pedicle with subcutaneous fut Y'w. 40. Scar on nose, followinsr burn. Fig. 41. Flap from upper arm. Wound surface after excision of scar Excised scar tissue Fig. 42. The excised scar serves as pattern for outlining flap Pedicle Fig. 43. Implantation of flap upon the nose. Rebinan Company, Nc\x' York. ITALIAN METHOD 105 in connection witli its original sin-i-oiindings by a wide pedicle, and sewing it in by its other three edges. In a week or ten days the flap has nsually healed in about the edges, and the young vessels which have grown into the tiansplanted flap suffice to care for its nutrition. The pedicle can then be cut through, and the arm. Avhich had been bandaged uj) to the head during this time, can be freed from its constrained position. The disadvantage of this procednre, in addition to the discomfort to the patient during the first ten days, consists particularly in the difference between the color of the skin of the face and of the skin of the flap. The skin of the flap, previously covered by clothes, is usually to be readily differentiated by its pallor from its new surround- ings. Moreover, this lack of agreement is compensated very slightly in the course of time, and the lack of pigmentation of the transplanted flaj) is never completely made up. The advantage of the Italian method consists in the fact that the flap can be made of any desired thickness so far as the subcutaneous tissue goes. Also before transplantation bits of bone or cartilage may be allowed to heal in under the flaji. if it is deemed advisable that the new piece of skin on the face shall have some sujiport. Originally the Italian method, like the Indian, was applied wholly to rhinoplasty. Both had the same disadvantage, that the new nose, which was composed entirely of skin, began to shrink immediatelj'^ after it had healed in. For this reason both methods aie no longer used for this purpose without modification. But in their simplicity they still serve as valuable methods for replacing skin defects. The following is the history of a case of transjilantation after the Italian metliod: A forty-year-old sanitary officer, after a long sojourn in the tropics, developed extensive telangiectases on the bridge of his nose. Several exposures to the X-ray had resulted in a burning of the entire skin of the nose three years before. The scar (Fig. W, Plate 8) consisted of shiny tissue under strong tension showing a rich development of vessels about the edge, and in addition to the cosmetic disadvantages it in- volved a series of rather severe symptoms. Under the influence of the slightest psychic disturbances and as a reaction to the influence of sunlight, cold or heat, the transparent scar epidermis liecame colored intensely red or blue, so that the jjatient suffered extreme anguish. Also from time to time new islands of telangiectasis appeared in sev- eral places. For six months the patient could not be persuaded to 106 PLASTIC OPERATIONS ON THE FACE undergo an operation, but gradually the depression increased, and this in conjunction with the limited outlook for improvement of the local symptoms seemed to justify operation. The skin of the entire nose except for a narrow margin had to be removed. The forehead or other portions of the face could not be used for plastic purposes because the new scar might give rise to a similar condition of jisychic depression. The employment of a free flaj) from the arm was considered, but by tliis method not infrequently irregu- larities of pigmentation occiu', which strongly interfere witli the cos- metic result. There remained, therefore, only the Italian method. The patient himself had made the trial for one day to see whether fixation of the left arm would be bearable, with the flap taken from the medial side of the upper arm. The entire scar was excised within the normal skin, so that the incision ran about 1 or 2 mm. from the boundaries of the scar. The outlhied scar was removed in one piece in order to hold it as an exact model for the flap. The cut edges of the skin of the nose, which remained, were undermined for about 1 mm. in order that the plastic flap (Fig. 41, Plate 8) could be sewed in exactly. Naturally the flap had to be outlined in a considerably larger size than the pattern, shice the skin separated from its surroundings always shrinks. The size of the excised scar, which when sjiread out had the shape of a trapezium, were on the parallel sides 33 and 40 mm. and on the other sides 33 and 38 mm. The flap was made about one-third larger and the pedicle (Fig. 42, Plate 8) was to the outer side of the arm, and after division was to be sewed down to the left edge of the defect. In its upper half the flap was taken away practically without fat, because this jjortion was to replace the thin part of the skin of the nose, and the skin of the upper arm contains more fat than is desirable. On the other hand, the lower part of the flap M^as made thicker, and close to the pedicle all the fat and subcutaneous tissue Avere allowed to remain. After outlining the flap, the arm was lifted high and flexed over the head. It Avas apparent that the flap could be laid in place and sewed in without twisting the pedicle. The flap Avas approximated carefully by sutin-es to the right, the upper and the loAver edges of the defect (Fig. 43, Plate 8). On the left margin the suture naturally could not take place because this corresponded to the pedicle. The defect which remained in the upper arm Avas diminished in size bj' three interrupted sutures. Finally the arm Avas fixed in its place by a plaster of Paris dressing, enclosing the Kraiise- H eymann-Ehrenfried. Tab. 9. Italian method of rhinoplast)'. II. Portion of fin f) healed in place Fig. 44. The pedicle is divided after ten days. Stihculaneous fat, sliranhen together Fig. 45. Tlie flap is made tliiniier by removal of the fat layer. Wound edge Fig. 46. The wound edge is again freshened up. Lehman Company, New York. Krause-Heymaiin-Ehrenfried. Tab. 10. Italian method of rhinoplasty. III. fi \ Strip of fid/' cut away Fig. 47. The divided pedicle is sewed to wound margin. V :"^'^:^.- Fold of skin New skin of nose Fig. 4S. Nose after completion of suture. Wound Fig. 49. Excision of the fold. Suture line Fig, 50. Suture after excision. s^ ^^^^^fp^^<*j^fl^r Rebman Company, New York. Fig. 51. Appearance after six weeks. ITALIAX METHOD 107 head, chest and arm. In order to jjreveiit any jiressure between areas of skill hiyiriii' next to eadi other, and maturation as the result of perspiration, a eonsiderahle niiiiil)er of sterile i)ads made of al)sorbent cotton enclosed in gauze were laid between tlie arm and the face, and the forearm was bent so that its volar side rested over the forehead. In tliis way tlie flap was held approximated without tension. Twelve days later the plaster of Paris was removed Avithout anes- thesia. The transplanted skin had healed in well without the least necrosis at the site of the stitches. In tlie young scar there appeared small injected areas which marked the entrance of vessels from the surroundings. Accordingly, the pedicle was divided, so that the flap from now on had to be noiu-ished entirely by the vessels of the nose (Fig. ■t4.. I'late 9). ^^'hen the pecHcle was cut several hardly visible vessels bled ; the hemorrhage ceased under light comjiression. Sewing in of the new edge to the left margin of the defect was delayed in order to determine whether or not there would be an^' necrosis as the result of the separation of the flap from the arm. A light sterile dress- ing was applied and the jiatient was put back to bed. After ten days, it being apparent that the flap was well nourished, the wound on the left wing of the nose was closed. In order to attain the same favoral)le cosmetic result as had been obtained upon the right side, most of the thick fatty layer of the flap had to be trimmed away before it was sewed in (Fig. 45, Plate 9). This could be done without I'cstraint, because during the ten days which had passed, new vessels had grown in from the under layers. The flap was put on the stretch and a knife was wielded so that no injury to the flap could result. It was found that there was plenty of skin to cover in the defect. In order to make as fine a scar as possible, the left margin of the nasal wound, which had grown in somewhat, as well as the edge of the flap itself, were freshened up again (Fig. 46, Plate 9). Tlien followed the suture; it was carried out with the finest needles and silk, so that the stitch holes lay as close to the edge as possible. A small superfluity of skin of the flap was removed (Fig. 47, Plate 10) . The suture was com{)leted as far as the l)ri(ige of the nose. Here a fold stood uj) which had not been sewed down, to see whether the very thick flap would heal down along the entire line of suture, and to have a piece of skin in connection witli the rigiil sidt' of the nose (Fig. 48, Plate 10) in ca.se of any necessary patch work later. Heal- ing followed so satisfactorily from a cosmetic ])oint of view that the small fold was removed after a fortnight. It was excised by means ]08 PLASTIC OPERATIONS ON THE FACE of an elipsoid incision and the skin was united by means of four stitches (Figs. 49 and 50, Plate 10). Six weeks after the operation the patient was - out of tlie anesthetic continually move the lip, the flap was made fast by means of four silk sutures — this was the only case in which I had been induced to insert stitches. Plealing followed without incident, the cosmetic result was very good, as is shown by a photograph (Fig. .56), taken ]March ;30, 1898, that is nine months after the plastic operation. The flap had not shrunk; it was thick and soft." Fig. 57 Photograph hefoic operation, showing extensive lupus. The following is another example of skin transplantation after deeji-lying and Midcspread destruction of the skin of the face as the result of tuberculosis, taken also from Krause: A thirty-four-year-old seamstress suffered since her seventh year fi-om lupus of the face. In spite of continuous treatment, the lupvis had extended until it involved the greater part of the face. The tip and alae of the nose were wanting, and no normal skin was at hand for plastic restoration (Fig. .57) . The entire bridge of the nose which Avas affected with lupus was extirpated down to the jjcricondrium and periostcun'. as well as the neighboring sections of the cheek. The de- feet was immediately covered in with two flaps taken from the volar 116 PLASTIC OPERATIONS ON THE FACE side of the right and left upper arms. Four weeks later the skin of the lip and in addition most of the affected skin of the right side of the cheek up to the ear and down to the neck was extirjjated; the external maxillary artery was destroyed and the bleeding controlled by torsion. A flap from the left thigh was planted over the defect. Finally, after a fortnight the rest of the infected skin on the left cheek was extirpated, and since here the new skin could not be turned to Fig. 58 Interniediate stage: photograph. account for further plastic purposes, the svn-face was covered with Thiersch grafts (Fig. .38). The free flap which covered in the entire nose up to the inner corner of the eye and the upper part of the cheek at that time was still recognizable from the scar about its periphery. This new skin was everywhere normal in appearance and possessed normal mov- a))ihty upon the underlying stratum ; it was accordingly employed four months later in tlie form of two pediculated flaps to restore the wings and tip of the nose. Avhile the new defects which resulted on the bridge of the nose and the cheeks were covered in by Thiersch grafts. The end result of this plastic operation was unusually satis- factory in every respect, the entire treatment consuming two and one- half years (Fig. 59) . Nowhere did lupus nodules appear in the trans- WOLFE-KKAUSE ]METHOD 117 planted flaps, but four small nodules appeared in different places in the contiguous sound skin, and were burned out with the actual cautery. Radical excision and restoration of the defect by free flaps is, of course, necessary for stubl)orn and recurrin*^' cases. Otherwise all superficial and still ap])arently yount)- cases of lupus are first curetted. and the floor as well as the region of transition into apijarently healthy Fig. 59 Appearance 9 months after transplantation; photograph. skin is burned out with the Paquelin cautery. Particular attention should be paid to the pale nodular thickenings in the deejjer layers of the coriuni. If they are not radically i-enioved with the curette, recur- rences occur from these foci. Hemorrhage which does not stop of itself is controlled by compression with a pad of gauze, which may be smeared with boric ointment. It is wonderful how quickly even ex- tensive sui-faces which have been treated by the curette and the cautery heal over after the scab drops off. TRANSPLANTATION OF FREE FLAPS AFTER EXTIRPATION OF MALIGNANT (iKOWTIIS Free flaps are also employed for covering in wounds of the face resulting from the removal of malignant tumors. Since these demand the most radical excision of all suspicious tissue, at times extensive portions of the face without regard to position are inchided in the 118 PLASTIC OPERATIONS ON THE FACE woiuul surface, so that it may extend over an entire cheek, or inchide the entire npper hp or chin. Cancer of the face, of the extirpation of which such wounds are usually the result, comes under om- observation in two forms: the flat idcer-like skin cancer or epithelioma, and the true carcinoma, which proliferates in the depths. ^Vhile both these forms are similar in histological characteristics, the flat skin cancer as well as the carcinoma of the skin taking their origin from the flat ejiithelium which is in transition to become horny, clinically they differ in many character- istics. The true carcinoma of the face, the location of which by choice is at the line of junction of nnicous membrane and skin, for example on the lower lip, manifests all the malignant properties of other can- cers; on the other hand the superficial epithelioma grows very slowly and lasts for many years, often for ten or more, in the same layer of the skin and shows in rare cases only a tendency to extend to the regional lymph nodes, or other metastases. In its centre the new- formed tissue in both forms is likely to become necrotic on account of the poverty of circulation, so that ulcers are formed which extend slowly and steadily over the surface, with a margin made up of an elevated wall of carcinoma. In the true carcinoma a rapid extension into the deep tissues goes hand in hand with the necrotic ulceration, while the flat ejiithelioma usually undergoes shrinkage and scar for- mation on the floor of the ulcer, as well as of one or more edges. The superficial and clinically benign epithelioma may develop on any portion of the face, but particularly on the nose in the vicinity of the inner eyelid, and in places where the folds of facial expression are particularly impressed. With the extension of the ulcer in the course of years considerable sin-faces of skin are destroyed without the deep tissue becoming involved. On the other hand this form of ulcer, which is the result of the activity of the proliferating ej)idermal carcinoma cells, tends to scar formation and covering over Avith epithe- lium, if all the necrosed tissue has fallen away and it has been pro- tected from mechanical injury. This process is such as to deceive one into the belief that the idcer has healed, while in fact the cells of the new growth are continuing their development imder the surface and proliferating actively. Similarly the result of X-ray or radium treat- ment, of antiseptic and lightly cauterant applications, as well as heliotherapy and cauterization in the most cases is a temporary and apparent healing only. A wide removal of an epithelioma by an incision in normal tissue Krause-Heymann-Ehrenfried. Tab. 1 1 . Transplantation of a free flap to the chin. Line of excision Scaneii portion of tumor Fig. 60. Extirpation of an epithelioma. Sliin flap Fig. 01 . Free flap from front of the thigh. Sittnre Line for removal of excess of flop Margin of flap Fig. 62. Sutnre of flap in place. Scar Tiansition of flap to normal skin Fig. 63. Condition 1 ", years after operation. Rebnian Company, New York. FREE FLAPS AFTER KXriSIOX OF NEOPLASMS 119 and painstakino- cleanin<>' out of all suspicious tissue in the depths can alone guarantee a cure of this nialif^nant disease, as with other malig- nant conditions. The following observation will serve to show how the loss of tissue may be provided for by means of a free flap: In a forty-nine-year-old school teacher a tumor the size of a silver dollar had deve]o])ed during three years upon the right chin furrow. In the middle the tumor was scarred over (Fig. (iO, Plate 11 ). At the perij)hery it consisted of numerous readily bleeding tubercles and ulcerous excavations. The slowly growing tumor had never caused symptoms. Microscopic examination of a small portion of the margin Avhich was readily remo\ed with forceps showed epithelioma. L'nder general anesthesia, the tumor was removed by a rhomboid incision, which included about 1 cm. of normal tissue (Fig. 60, Plate 11) . The skin was seized with two toothed clamps at the upper corner after the incision had been carried down to niuscle, and the entire new growth with the underlying fascia was removed. Nowhere was suspicion aroused that the epithelioma had penetrated the fascia. Several layers of gauze were laid upon the wound surface and the bleeding Avas controlled through strong pressure while the flap was being cut. The defect was not covered by Thiersch grafts because the upper edge of the wound reached close to the corner of the mouth and there was danger that as a result of scar contraction ectrojiion of the lower lip would ensue. In order to prevent this a flap of practically twice the size of the defect was cut from the anterior thigh (Fig. 61, Plate 11). During its removal the flaj) was held carefully with the fingers by its epidermal surface so that the wound surface came in contact only with the knife, and with the same care it was carried over to the primary wound on the chin and unfolded, after the l)leeding had been stopped satisfactorily by the compression. As the generous sized flap shrunk to a marked degree, it fitted satis- factoi-ily the wound defect as far as the upper edge and two sides were concerned; but below it oveilapped the wound edge for several mm., and this su])erfluous skin was removed with scissors. With regard for the continuous activity of the jaw in chewing, talking, etc., it seemed wise that, in exception to the general rule, the flap should be maintained in position by a few sutures (Fig. 62, Plate 11). In order to obtain rapid adhesion of the new skin to the base, light pressm-e was exerted from the middle outward toward the edge by means of small sponges. The woujid of the thigh after undermining and mol)ili- zation of the surrounding skin could be satisfactorily closed by suture. 120 PLASTIC OPERATIONS ON THE FACE Six days later the flap was everywhere adherent to its bed and the sutures were removed. It had assumed a waxy white color, but it was warm and dry to the touch. At later dressings this pallor grad- ually was replaced by a bluish red shade. Part of the uppermost layer of the epidermis became elevated in the form of blebs and could be removed, after incision with a knife, in several places. Three weeks after the operation this shedding of epidermis was over and the flap had healed in solidly, so that the patient was discharged. A year and a half later the boundary line between chin and flap coidd hardly be recognized and the skin was movable upon its entire bed (Fig. 63, Plate n). No recurrence had appeared within five years. CHAPTER 8— SPFXIAL PLASTIC PROCEDURES There is a great deal of surgical satisfaction in the fact that other tissues as well as the skin allow of transplantation and remain viahle in their new abode. Such transplantation may be free, in that for example a ])iece of bone or fascia, a bit of fat, or a slice of cartilage may be freed entirely from its original surroundings and brought into new relations with tissue in other places. This free transplantation stands in oj)position to the older method by which, for instance, sec- tions of muscle, l)its of bone with periosteum attached, or flaps of mucous membrane remained in relation to their original site through nutritional bridges which carried the circulation. iVlso a combination of the free and of the pedicnlated grafts, such as the IMuUer-Konig method, by M'hich a sliver of bone removed in connection with a flap of skin is nourished by the pedicle of the skin flap, flnds extensive application in plastic surgery of the face. For this pm-pose it makes' IK) difl'erence whether these combined flaps are taken from the imme- diate neighborhood of the wound or from other ])ortions of the body after the Italian method. By the aid of the methods already described, not only broad and flat surfaces of the face may be covered, but ])rominent features may be artificially restored, if destroyed by disease or injury. By suitable choice of methods atul judicious employment of the material at hand portions of the face of complicated structure, such as the nose, eyelid, mouth and ear may be built up in satisfactory fashion from a cosmetic point of view, and a total or j)artial loss may be agreeably restored. Among the causes of the extensive mutilations which demand plastic repair, wounds made in the course of o])erative removal of malignant tumors stand in the first rank. Xext come injuries, among which ai-e particularly to be considered loss of tissue l)y l)iiriis and freezing, gunshot wounds and crushing injuries, which are very likely to carry in their train the loss of j)rominent features. In the third rank stand congenital deformities of the face, particularly of the lips and palate, which demand plastic treatment for the closure of clefts which result from inconii)lctc fetal union of tissue. The essential function of plastic surgery of the face consists in restoring a mouth bordered by lips, building up a nose with its proper 121 122 SPECIAL PLASTIC PROCEDURES support, restoring form to the shell of the ear, and in palliating accept- ably the loss of an eye or one of its lids. Of the most important surgical diseases and the operations which are necessary in their treat- ment we shall hi what follows give illustrative cases; but it is im- practicable to relate here all the methods which have been described and recommended, particularly as each case necessitates variations, and in no instance can a described procedure be strictly followed. PLASTIC OPERATIONS ON THE LIPS: EXTIRPATION OF CANCER OF THE LIP Carcinoma of the lower lip develops by predilection at the point of transition from skin to nnicous membrane. It appears first as small tubercles or jjalpable nodules, which after a time develop into clusters of scabby and raj^idly growing idcers with irregularly raised margins. A considerable portion of the lip and of the skin of the cheek may be destroyed by its growth, and usually with the extension of the infiltration and of the idcerous necrosis, carcinomatous infiltra- tion of the submental as well as of the lateral glands of the neck appears. So long as the carcinoma is reasonably small and does not include more than two-thirds of the lip, radical operation l)y means of a wedge-shaped excision with direct union of the remnants of the lip suffices, as the following case shows. Cleaning out of all submental nodes sliould always be carried out after the extirpation, in carcinoma of the lip which has existed for some time. A landed proprietor nearly eighty years old had had removed, eight years before entering the hospital, an ulcer of the lower lip Avith a hard margin about the size of a penny. During the course of a year or more a raw surface had developed again in the region of the seal-, ^vhich extended rather rapidly. Upon entrance practically the entire lower lip was destroyed by a carcinoma, which was 3 cm. wide and almost 2 cm. high; only a small segment of the lower lip remained intact at each corner (Fig. 64, Plate 12). In addition, on either side could be jialpated small and hard submental nodes. In spite of the extent of the carcinoma, wedge-shaped excision was carried out, since because of the emaciation, the small remnants of the lower lip were readily movable and serviceable; and on account of extreme age the patient seemed too weak to be submitted to an extensive plastic operation. As soon as the patient was placed upon the operating table severe collapse developed. For that reason the excision was carried out with- Kr.uise-Hcvniann-F.hrenfried Fab. 12. Wedge excision of cancer of the lip. Carchiomu Fig. 64. Carcinoma in tlif middle of the lower li]i. liurU'd Sllflir Fig. 65. Wedge excision, arteries being compressed by fingers. Fig. 66. Snture of nnicons membrane. Protntdi/if; it/r/it'r lip Fig. 67. Skin suture, siiovi-ing lack of Fig. 68. The distortion of the corners of the correspondence between upper and lower lips. month and the protnberence of the npper lip have completely disappeared after four weeks. Ri'bm.in Company, New \m\i. EXTIRPATION OF CAXCER OF THE LIP 123 out anesthesia. Tlie lower lip was seized between the thumb and the forefinger at ri^ht and left, in this way conipressino- the eoronary artery of each side at the corner of the mouth ( Fi<>'. 0.5, Plate 1'2) . The operator could do this with his left hand at the right side himself, while the assistant compressed the left corner of the mouth. The lower lip was excised in wedoe-shaped fashion with the knife down to the chin without loss of blood and without necessity for the tying of a single vessel. The mucous membrane of the mouth and lip was united by seven buried sutures of fine catgut in such fashion that the needle did not perforate the mucous membrane, but penetrated the tissues just within it (Fig. 66, Plate 12). This was followed by an exact approximation of the skin of the chin with interrupted silk. The external woimd was finally covered with airol paste. As the greater part of the lower lip was gone, the two corners of the mouth Avere pulled tightly together when the remnants of the lip were sewed up. As a residt the upper lip was puffed out so that it projected like a tumor (Fig. 67, Plate 12). l?ut within two weeks this lack of conformity between the wide upper lip and the narrow lower lip had gradually equalized itself, and a month after the opera- tion the patient was discharged with the wound healed and a good functional result (Fig. G8, Plate 12). The state of collapse sufficed to carry out the excision without pain; it did not seem expedient to start local anesthesia for finishing up the operation. ^Toreover, local anesthesia was renounced in advance, be- cause it ordinarily renders difficult the judgment as to whether tissue is suspicious of carcinoma or normal. Xo other opei'ative procedure could be considered in this frail old man, while in other cases cleaning out of the submental glands would have followed excision of the tumor. PLASTIC RESTORATION OF THE I.IP rKO:\I THE CHEEK (DIEFKENBACH) Wedge-shaped excision of the tumor and direct suture of the rem- nants of the lip leads to a useless result if the lip in entire or i)ractically entire extent is destroyed by the disease. By direct suture of a large defect the orifice of the mouth l)ecomes too narrow, and motion of the jaw is restricted as well by scar contraction; besides the exposure of the lower teeth and gum is cosmetically unsightly. By the help of various operative j)rocedui-es these disadvantages may be avoided and a lower lip created which, without being loo unattractive, gives a good functional result. 124. SPECIAL PLASTIC PROCEDURES If the remnants which remain after excision of the tumor do not suffice for the formation of a useful hp, the method of Dieffenbach, which creates a new hp out of skin of the cheek, hned with mucous membrane, practical and of good appearance, really answers every jiurjiose. By dissecting off a small flap of mucous membrane from the upper lip and drawing it down to meet the skin flap, one is in a position to prevent any considerable scar contraction of the orifice of the mouth from the corners. Also the lip which is newly made out of the whole thickness of the cheek remains mobile, so that solid and liquid food and saliva will not be spilled. A scar distortion of the flap into a small, tightly stretched bridge of skin which does not reach the level of the lower teeth may be avoided if the whole- thickness flap taken from the cheek is cut sufficiently high. The fol- lowing observation will serve as an example of an individual case: In a seventy-three-year-old letter-carrier the lower lip was prac- tically completelj' destroyed by carcinoma. The left corner of the mouth was also involved by the tumor, but on the right side a portion 1 cm. wide remained healthy. Within, the tumor extended in the middle line as far as the point of transition of mucous membrane of the lip to gum. Outside it extended 2^0 cm. below the border of the lip and down to the dimple of the chin. It had been present more than a year. The patient had been accustomed to smoke a pipe a good deal. Since a row of enlarged lymph nodes were palpable, these were extirpated first, and for this purpose, with the head strongly bent backward, an incision was made in the neck, through skin, platysma and fascia in a line joining the two angles of the jaw. The flap was dissected up in the direction of the chin, exposing on each side the edge of the sternomastoid muscle and the vessels in their sheath. All the fat of the neck, that surrounding the submaxillary glands and the masses along the vessels which included the lymph nodes, could be removed easily through this incision up to the level of the larynx. After the extirpation of all suspicious tissue the wound of the neck was sutured. The plan decided upon was to excise the carcinoma in the form of a wedge cut in the normal tissue of the lip and cheek, and to form a new lip by means of skin sliding from the neck. For this purpose the thumb and forefinger of the assistant seized and compressed the inferior coronary artery of the lip at each side in the pouch of the cheek. The entire tumor could then be excised, in addition to the Krause-Hevmann-Ehrenfried. Plastic restoration of lip from the cheek (Dieffenbach). Tab. 13. Small flup of mucous mem- brant' for left corner of mouth Transverse incision of cheek, to form lower lip Carcinoma Wedge excision Mucous mem- brane of cheek, to form border of lip Fig. 69. Line of excision of carcinoma of lower lip. Flap for corner Oblique incision in skin of cheek Fig. 70. Completion of excision and exposure of mucous membrane of cheek. Redundant portion of skin, after oblique incision for relief of tension Plastic forma- tion of corner of mouth Fig. 71. Plastic formation of border of lip Mucous mem- ^^^K^^^M^Ml^^^^ Folds caused by braue for margin ^^^Kt^^^^^^^^^ pulling of \ of lip, taken from ^^^^^^^^^^^ cheek flap inside of cheek Fig. 72. Completion of suture of lip, formation of corner of mouth. Fig. 73. Appearance after 14 days, mouth open. Rebnian Company, New York. RESTORATION OF LIP 125 neighboriiifT skin of the chin and cheek and a piece of the npper hp 1 cm. wide (Fi^. (59. Phite 13). The incision started close to the rih the border, on the other it is oidy cariied down to the margin between mucous mem- brane and skin, so tliat the mucous border remains attached by one end (Fig. 79). This flap is then turned down so that the other freshened edge fits into the angle. The line of suture then corre- lici. 70 Fic. SO sponds with one edge of the filtrum (Fig. 80) ; the suture of the mucous membrane is run obliquely in such fashion that no nipple results. Division of the mucous border should take place oil the larger half of the lip because in the neighborhood of the split this is usually thinner and runs more obliquely to the apex of the fissiu'c, so that in suturing only the least amount of tension is created. The smaller but stronger remnant of the lip gives rise to the pediculated nmcous membrane flap. The Mirault method finds its application also in complete harelip, but in such cases particular attention must be paid to the deformity of the nose, since the fissure continues into the nasal cavity and the ala of the nose is apt to be flattened out and shoved over to one side. The rectification of this half of the nose and the closure of the hind wall of the nasal orifice can oidy be brought about if the upper lij) is mobilized together with the ala. In order to accomplish this the upper lip can be loosened with a knife and periosteal elevator from the superior maxilla as far as the lower margin of the orbit. The hemorrliage which results may be controlled by pressure. Further mobilization when necessary may be accomplished by the undulating incision of Dieff'enbach, which, starting from the fissure, is carried around the base of the ala up to its up])er end and then transversely across the check (Fig. 81). 130 SPECIAL PLASTIC PROCEDURES Once the ala is well mobilized, a deep silver wire stitch is carried from one naso-labial sulcus to the other, a perforated shot is threaded on each end, the alfe compressed between them, and the shot squeezed bv a clamp. If only one ala is flattened, the stitch can come out on the other side of the septum. There is no l)etter method of correcting a flattened nose in all forms of harelip, but care must be taken that the Fig. «1 shot does not cause a pressure slough, or. in one-sided cases, perforate the septum. The stitch should be out by the sixth day. If the remnants of the lip are unusually thin and under strong tension, the zigzag incision of J. Wolfe unites the edges with con- siderable assurance. At the border of tlie skin and mucous membrane or just above this line the two halves of the lip are divided horizontally Furrow Fig. 82 Fig. 83 (Fig. 82) and the sutiu'e is carried out in a zigzag line. At the jjoints Y and Z (Fig. 83) tension sutures may be inserted through the entire thickness of the lip. On both edges the portion of the mucous border which is situated at the apex of the fissure is sacrificed, while the remaining portion is emploj'ed for the formation of the new mucous border. " Double harelip is treated on the same principles as single. The Krause-Heymann-Ehrenfried. Projecting premaxiUa Tab. 14. Operation for double hare lip. Exposed voniei Mucous membrane^ covering the vomer Cleft palate Fig. 84. Exposure and division of vomer. , Suture of mu- cous membrane Superior maxilla PremaxiUa Stitch holding two portions of vomer in place #% Fig. 85. The anterior lial: displaced backward. Fig. 86. Formation of lip flaps. Fig. 87. Sewing in place and freshening the premaxiUa. Fig. 88. Tension incision of Dieffenbach. Stitch supporting ala of nose Suture line Fig. 89. First holding stitch placed in centre of npper lip. .;^;^^C Fig. QO. Suture of lip. Prent axilla ^ Fig. 91. Suture of lip and cheek. Fig. 92. Suture of iiuier side of li]i. Fig. 93. Scar 8 days after operation. Rebman Company, New \'ork. HARELIP 131 choice of operative procedures depends entirely upon the size and width of the defect, and still more upon the situation of the prcniaxilla, which projects in the middle. This clement offers severe diHicidties if it projects beyond the level of the lip sva-face, as usually occurs in these cases. The necessary replacement of the premaxilla is carried out on the principles devised by Bardeleben, through a subperiosteal division or we(li>e-shapcd resection of the vomer. Kven if it is deter- mined that the replaced premaxilla does not enter into solid union with the two halves of the upper jaw, nevertheless its maintenance in this position is important for the cosmetic and functional results. For in the first place if the premaxilla is retained the two halves of the alveolar process cannot fall tooether later on, and in the second place the arc of tlie upper lip maintains its natural prominence in the middle line. The following case will serve as an example of an operation for double harelip and replacement of the premaxilla: A ten-weeks-old girl baby was born with double harelip, a markedly projecthig premaxilla and a cleft of the soft and hard palates. The vomer was displaced somewhat to the right, so that the cleft in the hard palate was particularh' definite on the left side and on the right it a])pcared much smaller. The harelip was closed first. For this purpose the premaxilla was replaced backwards after the method of Bardeleben: After the muco- periosteal covering of the lower edge of the vomer, which projected into the cleft, was incised longitudinally (Fig. 8-1. Plate 14), it was freed up on both sides by means of the jieriosteal elevator, and the vomer was di\ided with bone cutting forceps. This allowed the pre- maxilla to be replaced by light pressure, causing the two bony seg- ments of the divided vomer to overlap (Fig. 8.5, Plate 14) . In order to hold the vomer iti its replaced position a catgut suture was carried with a strong needle through the overlapping segments and tied; the mucoperiosteal covering was then completely closed (Fig. 86, Plate 14). Freshening of the edges of the premaxilla and of the fissures in the lip followed as the second step in the operation. This began with the formation of a flap of the mucous membrane of the lip on each side by means of a transverse incision several mm. long carried above the red border through the entire thickness of the lip (Fig. 86, Plate 14). This was followed by freshening of the lower border of the premaxilla where it was covered with mucous membrane, and here 132 SPECIAL PLASTIC PROCEDURES the mucous membrane was separated on a level to avoid injury to the tooth buds (Fig. 87, Plate 14). Tlie hemorrhage which resulted was controlled by short compression. In an attempt to close the cleft by approximation of the freshened edges the tension on the two halves of the lip appeared too great, and in spite of the suture of the vomer, the premaxilla sprung back into its original position. In order to overcome this it was held in place by a suture on each side, uniting its mucous membrane with that of the alveolar process (Fig. 87, Plate 14) . To overcome the tension, Dieffenbach's incision was made, separating the ala by a crescentic incision, and carrying a transverse incision through the cheek (Fig. 88, Plate 14). In this way the upper part of the remnants of the lip were rendered freely movable, so that suture of the mucous membrane of the lip on the further side could be begun. The first stitch, which was placed at the tips of the mucous membrane flaps (Fig. 89), was left long after tj^ing, to be used as a hold in introducing the other stitches. Approxi- mation could be made without distortion until a sufficient height of lip was obtained (Fig. 90, Plate 14). This left the flattening out of the alse, which would interfere badly witli the later cosmetic result. It was accordingly corrected on each side by means of a deep-lying suture, which was jilaced transversely from just behind the nasal orifice to the apex of the division between premaxilla and ala (Fig. 90, Plate 14) . By the suture of the previously closed upper lip to the cheek (Fig. 91, Plate 14) which now followed, a permanently good position of the nasal orifices was obtained. The operation ended with sutiu'e of the inner surface of the mucous membrane of the lip (Fig. 92, Plate 14). It was carried out by everting it by pulhng on the ends of the suture which had been left long, which made the sewing up of the edges of the defect on the premaxilla as well as the lip easj' of performance. No dressing was applied. Eight days later the freshened surfaces had healed together so that the sutures could be removed (Fig. 93, Plate 14) . On discharge ten days after operation the child had gained over three ounces in weight. The suture of the cleft palate was postponed until later. Since harelip involves considerable danger for the child during the first months of life and tlie mortality without operation is high, the question arises when such a child should be operated upon. The de- HARELIP 133 termination of this question depends upon whether it is strong enough to stand the limited hut .serious loss of hlood during the operation, and the interferenee with nutrition whieh results during the first few days after the operation. The first danger may be met by unremitting compression on the two halves of the lip during the operation; the other by accustoming the child beforehand to taking milk with a spoon. The interference with nursing and drinking endangers the child with harelip so seriously in its nutrition that it should be operated upon if possible within the first few days after birth. The danger of the operation grows less as the child grows older, but it is a mistake to believe that in later years the conditions are more favorable for plastic operation than in the early days. It is true that the plastic material increases in amount with age, but the defect in- creases proportionately, and the gradual atrophy of the edges of the defect and retraction of the remnants of the lip easily renders difficult a good cosmetic result. Also in late cases the soft parts and bones lose their adaptability, so that in spite of a successfid plastic operation the lines of expression are apt to continue distorted. In any case nursing children with nasal or bronchial catarrh, intestinal catarrh, or stoma- titis should be opei-ated on only after recovery from these diseases. Also nurslings should be guarded from any change in milk before the operation. A child brought into the hospital shoidd be given a few days to see if the change in nourishment causes any trouble. Finally, no attempt should l)e made to disinfect the mouth. The operative field does not allow of asepsis, and the stomach and intestines are injured by antiseptic agents, while the useful activity of the mucous membrane of the mouth is diminished or entirely lost. Usually no dressing is necessary. If the freshened wound is to be protected from soiling with milk or nasal mucus, the rapidly harden- ing airol paste may be painted along the line of suture. If the suture threatens to give way during crying, a strip of adhesive cut in the shajie of a dumbbell or butterfly, with wide ends and narrow in the middle, will lessen the tension. The broad surface is stuck down on the skin of the cheek on either side while the cheeks are brought together so as to pucker the lip; the narrow bridge in the middle lies over the region of the suture and is kept from contact with it by means of a small bit of gauze, which is laid under the plaster. Or the same thing may be done with crepe lisse and collodion. The wound must be protected from the hands of the child by enclosing them in cylinders of pasteboard and bandaging them down to the body. 1.34 SPECIAL PLASTIC PROCEDURES If the tension is slight, the wound, as is usual in small children, heals rajjidly, and after eight days the sutures can be removed. But if they cut through before that they should be allowed to remain nevertheless until they become entirely loose; for the small bridges of the skin between the sutures serve as satisfactory sources of scar formation if the tension increases. Small fistulie or gaps may be closed later by secondary operation. PLASTIC CLOSURE OF CLEFT PALATE Double harelip as well as marked cases which are limited to one side are usually associated with congenital cleft of the hard and soft palate. Since both these deformities originate in the same way and also have much in common in the way of operative treatment, we shall give consideration here to the more important points in the treatment of cleft palate. If the cleft extends from the lips through the hard and soft palates, there residts a complete split of the upper jaw, which is called uranoschisis. Since the floor of the nasal cavity and roof of the mouth coincide, the two cavities are thrown into one. The lower edge of the vomer projects in such cases into the common oro-nasal cavity, and since it divides the cavity into two portions, one speaks of such a case as a double cleft palate. This is in contradistinction to the clefts which occur to one side of the vomer. These result from the fact that the lower edge of the vomer has become adherent on one side to the premaxilla and the half of the palate while this closure has not occurred upon the other side. If the cleft is limited to the roof of the mouth, that is to say the soft palate or the hard and soft palate together remain ununited, but union of the lips, the premaxilla, and the alveolar process has taken place, such a deformity is called a simple cleft palate. Cleft palate, like harelip, may have a serious influence upon the vitality of the child. This is particularly the case if the two deformi- ties occur together. The special danger lies in the interference with nutrition which results from the fact that the infants are not in con- dition to suck and swallow milk in sufficient quantities. In swallow- ing a portion always flows back through the nose. Also such infants are exposed to gastric and intestinal diseases and bronchitis as the result of lack of closure of the lips. Plastic closure of the cleft jnilate may therefore be considered, like the operation for harelip, as a life-saving procedure. Krause-Heymiinti-Ehrenfried. Tab. 15. Operation for cleft palate after B. v. Langenbeck. I. Preliminary extirpation of hypertrophied tonsils. Cleft palate Tonsils Fig. 94. Cleft palate with hypertrophied tonsils. Right tonsil Left tonsil h"ig. Q5. Extirpation of the right tonsil Probe pointed knife wrapped with gauze Fig. 90. Extirpation of the left tonsil. Rebman Company, New York. CLEFT PALATE 135 If these two defoniiities occur together it is advisable first and as early as possible to repair the harelip, and later to close the cleft palate. There are many grounds for this practice. In the first place tlie operation of repairing cleft palate is the more extensi\e jiroccdure, and operative injury and manipulation within the mouth in the first year of life is attended with possibilities of danger to the gastro- intestinal track. In the second place, at a later date one can succeed better in closing the cleft, because the material available for plastic closure increases with the age, and the stability of the suture is in- creased in proportion. Finally, the possibility remains that the cleft may spontaneously lessen in width; this is particular^ apt to be the case if the harelip has been previously closed and the projecting pre- maxilla replaced. Also in the first and second years union of the premaxilla with the alveolar process of one side may take place with- out surgical interference. But the cleft should be operated upon also as early as practicable, and the closure should not be jjut off, as some of the older authors recommend, to the middle or end of the first decade. The outlook for a successful closure is better in infancy than in later years, and the difficult}' of operation and the loss of blood need not necessarily be greater. Helbing* regards as of greatest advantage the functional result, since early operated children learn to speak clearly in a way which is hardly to be difl'erentiated from the normal. And if the cleft palate is not combined with a harelip, it should be operated upon early, because many of the unoperated nurslings die in the first year from the disturbances which result. Plastic closure of the cleft palate is carried out after the method of Langenbeck. It consists in three steps: loosening of the muco- periosteal covering of both sides of the hard palate, freshening the edges of the cleft, and the suture. The following case will serve as an example: In a seven-year-old boy an attempt was made by others in the second year to close a cleft palate by operation. A few scars present in the neighborhood of the edge of the alveolar process originated in this procedure. Since both tonsils were hypertrophicd (Fig. 94, Plate 1.)) and wej-e covered with white plugs, in order that they might not infect the sutures they were seized with tonsil forceps (Fig. 95, Plate 1;5) and excised by means of a knife, the blade of which was wra|)ped in gauze up to the middle (Fig. 96, Plate 15). This could •Hcilin. klin. Woili.. 1909, Nr. 39. 136 SPECIAL PLASTIC PROCEni'RES be done because the two halves of the uvula were well formed and tonsil tissue did not seem to be needed for plastic restoration of the uvula. Bleeding was light, and it ceased after a few minutes under pressure. The operation itself was carried out with the head hanging over the end of the table, in the Rose position (Fig. 97, Plate 16). In order to keep the mouth open a Whitehead gag was introduced. First a linear incision was made on each side close to the alveolar process of the upper jaw, from the posterior margin of the hard palate for- ward through the muco-periosteal layer down to bone (Fig. 98, Plate 16) . Through these lateral incisions the nnico-periosteal cover- ing of the hard palate was loosened up to the middle line with a curved periosteal elevator. This freeing up of mueo-periosteum was carried out in the same way at the posterior margin of the palatal bone and at the hamular process. Since mucous membrane and periosteum are here very closely adherent, they must be torn from the bone with considerable force. In order to overcojne the tension sufficiently to mobilize them to the middle hne, a trial demonstrated that the edges could be brought together so as to overlap several millimeters without tension. The hemorrhage from the lateral incisions was controlled by sponging and pressure. After this preparatory freeing of the flaps, the edges of the clefts were pared in the following manner: A small double-edged knife (a cataract knife will do very well) was introduced in the apex of the defect (Fig. 99, Plate 16) in the neighborhood of the alveolar process, directed obliquely inward, and the border was removed in one piece from before backward through the soft palate and the tip of the Fig. 1115 uvula (Fig. 100, Plate 16). As a result of the obliquity of the knife, more was taken from the oral surface of the mucous membrane than from the nasal. In that wav two wide freshened wound surfaces were Krause-Heyraann-Ehrenfried. Tab. 16. Operation lor clclt palate after B. v. Langenbeck. II. Plastic of Palate. Exposing the hara palate Fig. 97. Operation with head hanging over edge of table (Rose position). Two edged knife Fig. Q8. Freeing up of muco- periosteal layer. Obliquely freshened wound edge Fig. 99. Freshening of the edges of cleft. Separated margin Suture line Holding stitch ' / iilernl j tension Fig. 100. Removal of margin of cleft. Fig. 101. Completion of suture of cleft. Fig. 102. Suture of uvula. Nasal surface of nvnia / Fig. 103. Suture of nasal surface. Gauze packing Fig. 104. Packing the tension incisions. Rebiiiaii Comp.iiiy, New York. CLEFT PALATE 137 created, which was particularly desirable for lasting approximation in view of the scars which remained behind from the old operation. This was followed by the suture of the two halves of the palate. A tension suture to hold the wound svn-faces together was not necessary, and the suture could be laid close to the wound edges (Fig. 101, Plate 16). A part of the stitches were introduced so as not to per- forate the mucous membrane of the nose (Fig. 10.5). Between these sutures others were laid which included the nasal mucous membrane Fig. 100 as well as that of the mouth, but always close to the wound edge. None of these sutures were tied at once, but to avoid snarling and to make it easy to tie them later, they were knotted at some distance from the wound ( Fig. 106) . The sutures were placed by a stab needle with a curve like a fishhook (Fig. 107), but an ordinary small curved needle on a holder will do as well. By this method of alternating sutures it is easy to bring the wound edges together exactly, and where the mucous membrane has a tendency to roll inward, it may be drawn out with tooth forceps at the mouth. moment of tying and turned into the 138 SPECIAL PLASTIC PROCEDURES Finally the two halves of the uvula were carefully united and the last suture at the tip of the uvula (Fig. 102. Plate 16) on the oral aspect was left long, so that by pulling on it the nasal aspect of the uvula could be made approachable with the needle. It was brought together here by means of two sutures (Fig. 103, Plate 16). In each of the lateral incisions in the base of the alveolar processes a short piece of vioform gauze tape was introduced (Fig. 104, Plate 16) and allowed to remain three days. ( Fig. 107 On the fourth day after operation the boj^ developed scarlet fever. He vomited violently several times and as a result some of the stitches pulled through, so that the line of suture gaped for about 1 cm. The rest of the line healed smoothly and the closure of the small ojjenmg in the middle was postponed until later. Similar small residual operations are necessary in many cases of cleft palate as well as in harelip, and it usually suffices in such an event to freshen the edge of the defect anew and to sew it up. The functional result in later years in children who are operated upon does not always correspond Avith the surgical result. In spite of the fact that a satisfactory partition has been created between the mouth and the nasal cavity from an anatomical point of view, never- theless in manj'^ cases a definite nasal quality remains in the speech. This is due to defective mobility of the soft palate, if, for instance, it is pulled backwards against the posterior wall of the pharynx by a stiff band, or if the length of the new ly formed uvula does not suffice, or if it is not compact enough to lay itself against the posterior wall of the pharynx in the formation of certain sounds. But usually by means of systematic exercises in expression and respiration the patients can learn to improve their enunciation. The best prophy- lactic against such speech defects is the earliest possible operation. From the point of view of the dentist even the widest clefts may be closed by means of hard rubber ])rothetic appliances. Not only is the result often not inferior to the operative result, but it may excel it. But a natural separation of the mouth from the nasal cavity is to Krause-Heymaiin-Elirenfried. Tab. 17. Plastic closure of a cleft ala nasi. Fissure Fig. lOS. Incomplete cleft right ala of nose. -&^ Apex of cleft Fig. 109. Freeing margin of cleft. Rhomboid defect with freshened wound edges Fig. 110. Tlie separated margin drawn downwards. Fig. Suture line Vertical suture of freshened wound edges. Rebman Company, New York. CLEFT PALATE 139 be preferred over any prothetic; and moreover, ol)turators cannot be applied until after the molar teeth have a])peared. Nevertheless, there are cases in which recourse must be liad to such appliances. Among the cases to which this treatment can properly be applied are the widely gaping clefts with steep and narrow palatal segments, as well as wide clefts with badly scarred surfaces, such as result from unsuccessful attempts at operation, and in addition all cases in which in spite of successfvd operation the soft palate and the uvida are too small or do not function properly to be of use. In order to protect even the widest clefts from the use of prothetics, Helbing* has attempted to diminish the cleft before carrying out the operation itself. He accomplishes this by chisehng through the zygo- matic process of the upper jaw at the level of the second premolar tooth from within the mouth, and in that way to free the upper jaw from its bony union with the zygomatic process, and further by ap- proaching the mobilized halves of the palatal process of the upper jaw by means of metal plates, which fit about the alveolar arch and are bound together across the mouth with wire. The wire is drawn through the alveolar process at the level of the first premolar tooth, and it is drawn back again posteriorly in the region of the last molar through the alveolar process on the nasal surface of the palatal bone, and is tied over lead buttons. This is similar to the method of Brophy in new-born children. The result consists in a gradual diminution of the cleft, which proceeds so far that even very small palatal seg- ments may be employed for plastic closure according to the method of Langenbeck. PI,ASTIC OPKRATIONS ON THE NOSE Plastic operations for the purpose of restoring portions of the nose and re-establisl)ing its outer form may become necessary for the closure of congenital fissures and later-acquired defects. It has already been explained under harelip how fissures in the pos- terior margin of the nasal orifice may be closed after mobilization of the ala and freshening of the edges. A congenital median or lateral fissure of the nose may be similarly closed. As long as the defect is not too extensive or deep-lj'ing, or is connected with other deficiencies of the face or scalp, an incomplete lateral fissure of the ala (Fig. 108, Plate 17) may be closed by a simple technique similar to that for incomj)lete harelip. Just as in the Xelalon operation (see p. 128), •Zentral f. Chir., 1910, No. 48. UO SPECIAL PLASTIC PROCEDURES an an<4iilar incision is made through the ala, parallel to the edge of the fissure, and the loosened portion is pulled down and the incision sewed up in a vertical line. In a workingman with a congenital fissure of the right side of the nose (Fig. 108, Plate 17) the operation was carried out thus: A small double-edged knife was introduced in the middle of the fissure close to the mucous border (Fig. 109, Plate 17) and an incision was made parallel to the edges of the defect. At both ends the separated margin was left in connection with the skin of the nose. To correct the deformity the loosened margin was drawn downward w^ith a strabismus hook so that the freshened surface took the shape of a rhombus (Fig. 110. Plate 17). and the incision was sewed up in an oblique line from right to left with four fine silk sutures. The result, except for a small protuberance at the upper edge, was a nasal orifice which was normal in every way (Fig. Ill, Plate 17). If the pro- tuberance had not itself shrunk into shape within the course of two months it would have been removed by scissors or knife just as the nipple formation on the lip after a harelip operation. After eight days the stitches were removed. The patient remained in the hospital longer on account of other conditions. Acquired deformities or defects of the nose result from injury or follow operative procedures or destructive disease. The destruction may involve the entire nose; in this case a total rhinoplasty is de- manded, or if jjortions of the nose, such as the tip, the ala or the bony bridge, have to be replaced, a partial rhinoplasty. The form and the extent of the defect determines the choice of plastic procedure, of whicli tliere are many. In order to form a nose which shall give lasting satisfaction first of all requires a bony support and second the formation of an outer as well as inner lining of skin, so that it will not shrink. The Indian method of rhinoplasty from the forehead and the Italian method from the arm have been abandoned in their original form because the nose made entirely of skin rapidly shrinks together into an ungainly lump. They are employed now for repair only, if everything remains intact except the skin of the siu'face. These old methods are useful for building up a nose if bone covered with periosteum is transplanted attached to the skin flap. After the teaching of Kiinig, a small flap of skin is cut out obliquely on the forehead and in conjunction with it a flat shell of bone is chiseled out. PLASTICS ON THE NOSE 14.1 The skin of tliis flap forms the inner hning of the nose, and the bone wliidi is attached to it forms its framework. The outer covering must be made from anotlier forehead tlap (Konig) or from trianguhir flaps from the hiteral halves of the remnant of the nose ( Israel) . In syphi- litic and traumatic saddle nose, wliicli results from destruction of the nasal bones, these modifications of the Indian method find application. In the same way the Italian method, if the result is to be lasting and good, must be coml)ined with an osteoplasty. It may be carried out after the method of Israel, the skin flap being cut over the idna and at the same time a piece of this bone taken for the framework of the nose, or tlie strip of bone which shall serve as a support after the flap is transplanted must in the first place be transi)lanted under the area selected in the skin of the arm and allowed to heal in. The inner lining of the new nose must also be taken, according to this method, from the skin of the forehead in order that soft parts and framework shall not shrivel up or die after transjilantation. The flap on the arm before union with the root of the nose is to be lined with this piece of skin. The formation of an entire new nose after these principles rarely succeeds in fulfilling all the cosmetic requirements. Improvements of greater or less extent must be carried out by later operation, whether it is the nasal orifice, a portion of the bridge, the ala or the columna which requires correction. The following observation will show how the various methods of free and combined plastic procedures may be employed for the building up of a nose: In July, 1008, a twenty-five-year-old locksmith suffered a crushing injury of the face in an elevator accident. The right ujiper jaw and the root of the nose were crushed and the upper lip and the head wounded in various places. The middle portion of the lower jaw was broken free, but still remained attached to the soft ])arts of the chin; it was rejjlaced and made fast by a few deep catgut sutures in the periosteum and mucous membrane. In the nasal orifice which was open the widest a rubber tube was placed as far as the naso- pharynx and the wounds of the soft parts were given a dry sterile dressing. In August a small s])linter of bone came down through the left side of the nose. In ()cto])er a sequestrum al)out 3 cm. long and 14 cm. wide came away from the right half of the upper jaw, in which an air cell could be recognized. At the begimiing of .Tamiary, 1009. all wounds were healed and the nu'ddle portion of the lower jaw had grown in fast to the lateral portions. The upper part of the face as a result of the fractures of 142 SPECIAL PLASTIC PROCEDURES the jaw and of the nasal bones appeared flattened and badly disfig- m-ed, so that many attempts to And a positioii for the injured man failed, on account of his objectionable appearance. His union sent him once more to the hospital, in order to correct the deformity as far as possible. Upon entrance the following observations were made (Fig. 112, Plate 18) : Both sides of the upper jaw were markedly depressed, so that the infraoi'bital margins, particularly the right, were considerably posterior to the level of the cornea. This deformity was the result of fracture of the upper jaw. The cohmina of the nose was lack- ing, except for a tab of skin a few mm. long. The entire cartilaginous nose Avas pressed flat upon the face. The bony framework Avas pres- ent, but likewise sunken, so that the bridge appeared flat and wide. A deeply drawn fiu'row between the nose and the upper lip caused the upper lip, which was deformed by numerous scars, to project tumor-like. First the nose had to be built up, no external defects being visible upon its skin surface. For this purpose the upper lip was separated from the nose in the transverse furrow, and the nose was mobilized through loosening the upper edge from the bone (Fig. 113, Plate 18) . Thereupon a small transverse incision Avas made through the skin at the root of the nose (Fig. 114, Plate 18) and the skin A\^as lifted from the bony and cartilage framcAvork doAAii to the tip by means of a pointed elcA^ator, so that a subcutaneous canal about 1 cm. Avide and 5 cm. long Avas formed. In this process the nasal mucous membrane Avas not injured. The attempt to straighten up the nose Avith the elevator by means of this subcutaneous canal and its mobilization Avas impossible on account of scar contraction Avithin the nose. Accordingly, the bony framcAvork inside had to be divided Avith a chisel. Since the small remnant of tlie columna increased tlie strong tension, it Avas cut through. After the mobilization of the framcAvork of the nose was successfully accomplished, the nose was straightened up Avith the index finger and by means of lateral pressure Avith the other hand the nasal bones Avere shoved together. In this position the nose Avas held by means of a rubber tube the size of a finger Avound Avith A'ioform gauze (Fig. 114, Plate 18). The transverse separation of the upper lip for the time being was disregarded. In order to keep the nose permanently in this corrected position it was given a ncAV support by means of a free transj^lantation of bone Krause-Heymann-Ehrcnfried. Jab. 18. Rhinoplasty: restoration of the ridge of the nose by means of a tibial transplant (Lexer). Elevator Transverse incision at root of nose Transverse incision between nose and upper Up Chisel Fig. ! 12. Deformity 9 montiis after injury. Fig. 113. Mobilization of the soft parts. Drainage tube Fig. 114. Rubber tube wrapped in gauze serving as provisional support of nose. Tibial transplant Tibial transplant I i Fig. 115. Removal of strip from crest of tibia. Retractor Fig. 116. Transplantation of section of tibi; Elevator Fig. 117. Burying upper end of transplant untlcr _ ^ „■ skin nf forehead. Kebman Company, N'cw Nork Fig. 118. Cosmetic result after healing in of tibial transplant. Krause-Heymann-Ehrenfried. Tab. 19. Plastic restoration of sunken cheek bv free transplantation of fat. / Old scar Fig. IIQ. Risjht cheek is sunl\s this observation shows, after injuries of the face, phistics of the nose and cheeks not infrequently have to be carried out together. Accordingly in the following section another case of this sort will be cited. Fritz Konig has replaced defects which involve only the ala of the nose and cause very disagreeable results by using free grafts taken from the shell of the ear. He cuts a wedge comprising all the layers out of the helix and plants it in the freshened defect of the ala. In this transphuitation the flap is so placed that the edge of the helix forms the latei'al border of the nasal orifice, and the surface, which was originally directed backward against the cranium, after transplantation forms the outer surface of the ala. These free trans- plantations of the shell heal in well, but their nutrition should not be disturl)ed by stitches placed too closely together along the edge, or tied too tight; this particularly has to do with the cartilaginous layer. PLASTIC OPERATIONS ON THE CHEEK Plastic restoration of the cheek is indicated in defects which result from injuries, noma, or after the extirpation of malignant tumors. Scar lockjaw, of which the cause, omitting disease of the articulation of the lower jaw, may lie in changes in the soft parts of the cheek, under certain circumstances demands removal and replacement of the affected tissue. In plastics on the cheek, as in rhinoplasty, care should be taken that the mucous membrane as well as the outer skin be replaced by tissue which will not shrink. The laying of a pediculated flap over the defect will cover it externally, but it will leave a fresh wound in place of the mucous membrane of the mouth which, if it is allowed to go uncovered, must 7-esult in scar contraction of the transplanted flap and contraction of the articulation of the jaw. In order to prevent this the oral surface of the flap must be covered with mucous mem- brane or skill. Mucous membrane flaps may be taken from the neigh- borhood and laid over the wound, which is accomplished with fair readiness on account of the elasticity and movability of the oral mucous membrane. For covering with skin Thiersch grafts may be used, or the wound surface may be lined with a second ])ediculated or free flap. If a skin flap from the neighborhood is employed for this purpose, a place which is without hairy growth is to be chosen, so that later hair will not grow within the mouth. In a case of carcinoma which destroyed the entire cheek, following 146 SPECIAL PLASTIC PROCEDURES the proposal of Israels, we proceeded in svich fashion that the defect the size of the palm of the hand which resulted from the extirpation was covered in hy a flap taken from one side of the neck (Fig. 129, Plate 21). The wide and long pedicle was divided ten days later, trimmed properly, and immediately sewed into the upper edge of the defect, so that it filled the defect as a doubled skin flap (Fig. 130, Plate 21 ) . Fourteen days later the doubled edge was cut through and the two fresh wound edges were united, the inner to mucous mem- brane and the outer to skin. Both portions of this flaji healed in, with the formation of a fistula in the cheek. A few weeks later, before the fistula could be closed, the patient died of aspiration pneumonia and internal metastasis. Bardenheuer formed a similar flap for the restoration of a defect of the cheek from the forehead. The pedicle was situated at the zygoma. In extensile malignant growths the destructive effect and the loss of tissue which residts from operative removal is not restricted to the middle of the cheek, but is likely to include also the corner of the mouth, a portion of the nose or the border of the orbit. Accordingly, these, as well as the cheek, must be replaced according to the principles already expounded. The following example will demonstrate what may be done in a severe case: In a fifty-year-old patient, six months before admission, the left half of the nose was removed elsewhere for carcinoma. In addition to the ala of the nose, the nasal cartilage on the left side was also lacking; on the other hand, the cartilage and skin forming the ridge and the tip of the nose were present (Fig. 131, Plate 22) . An attempt made by others to implant a piece of cartilage from a rib under the mucous membrane of the left cheek miscarried, for a fistula in the skin of the cheek exuded pus on pressure. ^Moreover, the left inner canthus was eaten by a deep funnel-like ulcer with hard edges, which was diagnosed as recin'rent carcinoma. Since there was marked injec- tion of the vessels of the conjunctiva of the liulh in the neighborhood of the ulcer, with a certain amount of infiltration, it was decided that radical extirpation with sacrifice of the eye was indicated. The operation began with exenteration of the orbit (see p. 156). The outer canthus was split down to bone and the entire content of the orbit was cleaned out with a raspatory. Both eyelids were spht vertically and the medial halves were removed. In order to excise all the involved tissue, the skin incision was carried down to bone medially Krause-Heymann-Ehrenfried. Tab. 21. Plastic repair o{ cheek after James Israel. T/if skin flap is implantfil into defect in cheek Fig. 12Q. Flap c.nrried to cheek from neck. Rpidennal surface, after foldina flap on itself Fold Fig. 130. Folding (lie flap over after dividing the pedicle. Rcbman Company, New York. Krause-Heyniann-F-hrenfried. Tab. 22. Plastic repair of large defect of face. T. Defect at inner canthtis Defect of a la Fig. 131. Defect after extirpation of a carcinoma. Skill of clieelt turned baeli Fresliened edge of old defect Frontal sinus Orbit Half of upper lid Antrum of High more Fig. 132. Partial resection of upper jaw. Split upper lip Antrum of tine of incision of mucous Right half of iiiiper Up Highmoie membrane of vomer Fig. 133. Chiseling away of hard palate. Left half o] upper lip Infraorbital nerve Frontal sinus Fig. 134. Appearance of wound cavity. Ribman Company, New York. Posterior wall of left nasal cavity Suture of mucous membrane and cheek Fig. 135. Lining nasal cavity with a mucous membrane flap from vomer. PLASTICS ON THE CHEEK 147 to the bridge of the nose in such a way as to suitouikI tlie recurrent ulcer at the inner canthus. Its removal followed in connection with the nasal bone and the nasal process of the frontal bone (Fig. 132, Plate 22). In chiseling off these portions of bone the frontal sinus was exposed. The left nasal cavity having first been packed with sterile gauze, no blood could flow into the mouth. The cilia and the mucous membrane of the remaining portions of the eyelids were excised and the two freshened edges were sewed to- gether. Xext the defect of the ala of the nose in which no carcinoma Avas visible was freshened up by continuing the incision, which ran over the bridge of the nose. In loosening up the old oj^erative scar there appeared under the skin down to the palatal process and as far as the alveolar process hard and suspicious-looking places. After cutting the septum of the nose along its base and after laying back the upper lip split along the median fiu'row, a considerable surface of the upper jaw involved by carcinoma was exposed (Fig. 132, Plate 22). This in conjunction with the left half of the hard palate was separated from the alveolar process by two strokes of the chisel, opening wide the antrum of Highmore (Fig. 133, Plate 22). In oi-der to be sure that all the malignant disease was removed, the nuicous membrane of the antrum and the infraorbital nerve which hung free were removed at the same time (Fig. ItH. Plate 22). All cavities opened by chiseling were packed with iodoform gauze, and the split upper lip was reunited by suture of the mucous and skin surfaces as far as the border of the nasal orifice. To replace the outer border of the nasal oi-ifice and the destroyed ala, it was planned to use the mucous membrane of the left surface of the vomer as a lining flap, and skin cut from the cheek as an outer covering. For this purpose the mucous membrane on the vomer was incised as far up and back as possible (Fig. 134, Plate 22"), and loosened with a raspatory from the columna to the bridge of the nose, where a pedicle Avas left. The under surface of the posterior edge of this wide pediculated flap of mucous membrane was sewed against the skin of the left cheek, which had been drawn over to meet it, and the lower edge to the remnant of the medial border of the nasal orifice (Fig. 13.5, Plate 22). In so far as it lay over the antrum of Ilighiiiore and over the defect in the palate, it closed ott' the nasal cavity satisfactorily from the mouth. At the same time it formed a posterior wall for the nasal orifice. The end of the iodoform drain in the orbit and against 148 SPECIAL PLASTIC PROCEDURES the base of the skull was brought down over this mucous membrane and out through the new orifice, and the defect aliove the orbit was lessened by several stitches. The operation was thereupon interrupted. Ten days later it appeared that the flap of mucous membrane which had been loosened from the vomer had not healed in on account of tension, and the soft parts of the left cheek had pulled so strongly on the stitches that they had pulled out and the flap had retracted. At the scarred edge of the upper lip appeared a few small infiltrated nodes, which were apparently carcinomatous, and for that reason ex- cision of the upper two-thirds of the upper lip together with the mucous membrane was demanded (Fig. 136, Plate 23). In order to carry out a plastic restoration of the left ala of the nose and of the cheek, care was taken first to make a lining flap, since the flap from the forehead which was originally employed to coA'er in the large defect had in the course of time rolled itself up into an unformed mass. To be sure, one had to be sparing with the com- paratively slight material at hand. Accordingly a flap of skin 20 mm. by 55 mm. was cut close above the left eyebrow (Fig. 137, Plate 23). The pedicle lay to the right over the glabella, but it did not go beyond the middle line. In order to assure a permanent suture of this flap in its appointed place, the scarred edge of skin of the ridge of the nose was freshened and undermined for a few mm. The pediculated flap was then turned about at right angles, with epidermal side in, and it was sewed with catgut into the groove under the freed edge of the skin of the ridge of the nose (Fig. 138, Plate 23't. Then for lining the defect laterally a strip of skin several mm. wide was turned down from the edge of the defect of the cheek. Before the cheek-nose flap was planted upon this completed lining flap the defect in the left upper lip had to be restored by a rectangular flap taken from the left cheek with a pedicle running dowuAvard and outward (Fig. 139. Plate 23). in such a way that later the hairs of the beard in their growth would follow the direction of the hairs of the mustache. The lower edge of the plastic flap coincided in part -VAath the horizontal edge of the wound of the upper lip. After exact suture of this cheek flap into place to form a new upper lip (Fig. 140, Plate 23) a large defect still remained behind, which included the medial half of the lids, half of the cheek and the left ala of the nose. To cover in this hole a pro])ortionately larger flap of skin was taken from the left half of the forehead and beyond the middle line. Krause-Hcymanii-Ehrcnfricil. Tab. 23. P^l.istic repair of large defect of face. 11. Shrunken tnncoits membrane flap I Flap from forehead Recurrence Fig. 136. Wound cavity after shrinking; back of ciieek flap; excision of recinTcncc on upper lip. ;"i.s{. 137. Formation of a flap on the forehead, for linins^ nasal passage. Lining flap front forehead Cheek flap for lininji Flap for restoration of upper lip Fig. 138. Suture of lining flap; formation of new lining flap. Fig. 139. Formation of upper lip. m^A Direction of hairs of the heard Fig. 140. Suture of flap from cheek replacing defect of lip. RcbiiLin Company, New York. Krause-Heyniann-F^hrenfrictr Tab. 24. Pla.stic repair of large defect of face. III. Gauze Fig. 141. Gauze used as pattern for size and shape of flap. Gauze pattern W'ontnl ec/o. Forehead flap turned down to cover defect Fig. 142. Outlining the flap upon tlie forehead, from pattern. Fig. 143. Undermining skin of forehead. Mattress suture, to hold olded edge Fig. 144. Formation of anterior margin of left nasal orifice. Rebman Company, New York. PLASTICS OX THE CHEEK 149 The lower ed^e of tliis flap corresponded to the upper edge of the defect which resulted from the cutting of the flap to line the ridge of the nose (Fig. 138, Plate 23). The pedicle of the flap (Fig. 142, Plate 24) lay in the neighborhood of the right inner canthus. The forehead flap was patterned after a piece of gauze (Fig. 141, Plate 24) which was cut to fit the defect. Considerable allowance of skin had to be made for the corner out of which later the edjje of the new nasal orifice was to be created. The flap consisted only of skin and superficial fascia. The periosteum, as is always the case when bone is not to be included, remained undisturbed upon the frontal bone, because otherwise necrosis of the superficial layer of the bone might result through drying, in case the uncovered portion was not immediately covered by suture or transplantation. The defect which remained in the forehead after lifting the flap could, except for a small remnant, be closed after extensive under- mining of the sm-rounding skin (Fig. 143, Plate 24) and by the aid of tension sutures. The border of the left nasal orifice had to be made on the flap which was to be turned down from the forehead, before sewing it in place. For this purpose at the proper place in the skin as much as possible of the subcutaneous tissue was trimmed away, and the thinned edge was doubled over and held bj' a mattress suture so as to form a rounded margin of skin (Fig. 144, Plate 24). The upper edge of the turiK'd-up margin, now lying in the nasal cavity, was made fast within by means of three interrupted catgut sutures. After the for- mation of the margin of the nasal orifice, the flap was united with precision to the skin of the ridge of the nose, the edge of which had previously been undermined. Xow the flap, attached to the ridge of the nose, was brought down over the i-ight side of the face as a cover for the two lining flai)s, one for the cheek (Fig. 14.5, Plate 2.5) and the other for the ala of the nose (Fig. 147, Plate 25), and was united with them on its inner surface by several catgut sutures. The margin of the i\asal orifice made from the doubled-over flap was united below medially with the skin edge at the top of the nose, and in order to form a naso-lal)ial fold (Fig. 146, Plate 25) a small oblique incision was made through the doubled-up edge of the flap at the point of junction with the pos- terior edge of the orifice. Laterally the edge of the flaj) from the fore- head was united with the cheek, first the flap which had been previously loosened up to be used as lining for the cheek being sutured with 150 SPECIAL PLASTIC PROCEDURES catgut to its inner surface (Fif?. 147, Plate 25). In tyintr tliese four buried sutures there resulted a hollowing in which resembled the nor- mal furrow between the nose and the cheek (Fig. 148, Plate 25). Then the skin edges were united to each other. Finally, over the orbit the outer edge of the flap had to be united with the remains of the two eyehds (Fig. 148, Plate 25). Below and to the outer side there remained a rhomboid defect in the cheek where the flap had been taken for plastic restoration of the lip. This defect could be closed, except for a small remnant, by three interrupted silk sutures, which were introduced from the lateral corner forward. The sutures created no tension on the flaps which had been employed for the plastic on the lip or on the nose. Two weeks later the pedicle of the flap from the forehead was divided and turned up. It was used to close the uncovering area in the forehead. During the next four weeks the flaps healed solidly in place, except for the line of suture between the upper lip and the new ala of the nose, which pulled out, so that the deficiencies at the lateral margin of the nasal orifice over the upper lip made further operation necessary. In order to form the lateral margin of the nasal orifice, which was still lacking (Fig. 149, Plate 26), the upper edge of the lip was freed with a two-edged knife, turned upwards, and sewed to the tip of the nose (Fig. 150, Plate 26). By close examination of the edge of the defect of the cheek, which had rolled inward through scar contraction (Fig. 151, Plate 26), it was apparent that a portion of the lining had loosened and retracted. Accordingly for a new lining the marginal portion which had rolled inward was so separated that a sin-face from a few mm. to 1 cm. wide could be employed. For this purpose it was turned inward and loosely held by a few interrupted sutures. As a result naturally the defect of the cheek was considerably increased in size and to cover it in a new flap had to be cut from the neck. This flap (Fig. 152, Plate 26) had a pedicle to the outer side of the corner of the mouth. It was loosened from the chin and the fascia of the neck and Avas sewed with a few catgut sutures to the portion of the skin which had been cut for lining, and to the edges of the defect with silk (Fig. 153, Plate 26). The secondary defect on the neck was as far as possible imited in a transverse line without distortion (Fig. 154, Plate 26). In a short time, after the skin flap had healed in, the patient returned home. Krause-Heyni.inii-Fihrcnfried. Tab. 25. Plastic repair of lari^c defect of face. 1\\ Sutures not tied Fig. 145. Union of external and linin*^ flaps. 1- incision Fig. 146. Formation of naso labial fold. Li/ii/isr the lateral margin Fig. 147. Closure of defect completed. Tension suture Uncovered < Union of flop and remnant of eyelid Nasolabiul fold Defect of check man Company, New York. Fig. 148. Appearance after completion of suture. Krause-Heymann-Ehrenfrieii. Tab, 26. Plastic rc])air of lari^'c defect (if face. Y. Rg. 150. Formation of lateral martjin of nasal orifice. Flj1. 2. 152 SPECIAL PLASTIC" PROCEDURES border of the scalp, for according to oiir experience hair continues to grow on free flaps just as if they were still in their original site. Thus in a nine-year-old boy who had a vascular tumor removed (see p. 96), and whose U2)per lid as a result was drawn upward through scar contraction and fixed immovably in this position (Fig. 1.5,5, Plate 27) . after excision of the scar and loosening of the remnant of the lid the defect, which just covered the superciliary ridge, was covered partly by a pediculated flap from the forehead (Fig. 156, Plate 27 ) and partly by a free flap taken after the method of Krause from the hairy scalp. The transplanted flaps healed satisfactorily (Fig. 157, Plate 27), and the hair continued to grow undisturbed in the new eyebrow. Only in the lateral portion of the flap over an area about 2 cm. long did the growth of hair cease. Eight months after the operation the right upper lid appeared normal and the eye could be completely closed. The hairless portion of the eyebrow flap could be covered easily by combing over it the long scalp hairs of the middle portion, as the transplanted hair in the new site showed active growth. These plastic methods for upper and lower lid can be employed only if of all the layers at least the conjunctiva has remained intact. This is necessary for lining the new flap. But if the destruction in- volves all the layers, a new lid must be formed clothed within and without with epidermis, which will then run no danger of shrinking. For this pin-pose the outer covering as well as the conjunctival surface may be completed out of the portions of the lid which remain, or from the other lid of the same side if this is retained entirely. In order to protect the ocular surface of the new-formed lid from drying and shrinking as far as possible, free flaps of epidermis or of mucous mem- brane may be transplanted with advantage. Attempts to replace the entire lid, in so far as the functioning muscle cannot be replaced, result as a rule only in an immovable, stiff fold of skin. For the lower lid this result may be satisfactory, par- ticularly if by this means the eye may be saved. In place of the movable upper lid. however, only a useless curtain hangs down in front of the eye, which, although it forms a protection for the bulb, never- theless acts as a hindrance to sight. Anomalies of position of the eyelid may be corrected readily by simple plastic operations. Ectropion of the lower lid may be over- come b}^ cutting out a triangle from its conjunctiva and shortening Krause-Heymann-Ehrenfricd. Tab. 27. Plastic from forehead to correct contraction of e\'elid, and formation of ex'ebrow. Upper tid - drawn itpwari! Flap Defect Fig. 150. Defect remaining in region of eyebrow. Fig. 155. Scar contracture on forehead and upper lid. Old scar Free flap trans- planted from hairy scalp to eyebrow defect Rcbnian Company, New \ork. Fig. 157. Cosmetic result after 8 montlis. ECTROPION 153 the lenfj-th of the hd mai-ffin, as are shown by Figs. TOO and IGl, taken from the textbook of Czermak. Fig. Ifil) Fig. Uil Entropion may be corrected operatively if a wedge reaching to the conjunctiva, the base parallel to the edge of the lid, is cut out of the entire width of the lid. The base of the wedge is at the skin sm-face. The suture of the defect, wliich gaps outwards, results in a turning outward of the ciliated margin. CHAPTER 9— SURGERY OF THE EYE AND ORBIT ^Vhile surgery of the eyeball itself must remain a specialty, every surgeon is at times forced to undertake operative procedures on the orbit and its contents. This applies particularly to such diseases as extend from neighboring portions of the face or from the protective coverings of the eye to the organ of sight itself. Only the procedures necessary in such affections will be treated here. Fresh injuries which result in a complete loss or destruction of the lids, and a portion of the ej^e is so far destroyed that sight must be considered lost, demand operative removal of the bulb. This rule finds its justification in the danger of sympathetic ophthahnia, which arises in the other eye in cases of purulent infection. In severe tiiber- ctilous processes in the conjunctiva or the deeper lying coverings of the bulb within the orbit the radical operation comes likewise under consideration. This can be carried out after either of two methods. Enucleation of the bulb consists in shelling out the eyeball from its capsule, Sv pa- rating the conjimctival sack, muscles and optic nerve at their pomt of attachment to the bulb. Exenteration of the orbit, on the other hand, includes a complete cleaning out of the bony orbit; the orbital periosteum is removed in connection with all of the surroundings of the bulb. ENUCLEATION OF THE BULB is indicated in infections and injuries above described and in addition in benign timiors and in malignant tumors the boundaries of which have not overstepped the contents of the bulb. The method for carry- ing it out may be demonstrated by the following case : A thirty-three-year-old workingman had lost the use of his right eye at the age of thirteen years from a bullet wound. The ball entered at the outer canthus and remained lying in the depths of the orbit. Vision was immediately destroyed, but the eyeball was retained. Although the patient for twenty years had suffered no symptoms in the injured eye, four weeks before entrance, followqng a blow on the head, headache began which extended on both sides, laler more on the left, from forehead to occiput. The right eye showed total cataract and complete amaurosis. The 154. Krause-Heymann-Ehrenfried Tab. 28. Enucleation of the bulb. Su/ierior rectus muscle Border of cornea Retraction of upper lid VC'ound edge at margin of cornea Fig. 162. Dividing the cornea. Fig. 163. Pulling out the bulb by the stump of the superior rectus muscle. Stump of superior rectus Cut edge of conjunctiva Fig. 164. l-urther division of recti muscles. Fig. 165. Lifting out the bulb. Rcbnian Company, New York. ENUCLEATION OF THE EYE 155 tension was somewhat lessened and the eye was sensitive to pressure, although the motility was undistvirhed. The conjunetiva of the lower lid was swollen and edematous for several days (Fig. 102, Plate 28). The right infraorljital nerve at its exit from the orhit was slightly sensitive. X-ray showed the hall lying in the back of the orbit. The left eye showed slight pericorneal injection and was also painful to pressure. On account of the danger of sympathetic ophthalmia it was decided to enucleate the useless eye. The lids were held apart with two fingers; the same purpose might be accomplished by two lid retractors or a spring retractor. At the upper edge of the cornea the conjunctiva of the bulb was raised with forceps and cut transversely with scissors, and the superior rectus was dissected out with a few strokes of the scissors (Fig. 162, Plate 28), picked up with a blunt hook, and separated near the bulb. The corneal portion of the tendon was seized with a hemostat (Fig. 163, Plate 28) , so that it might be used as a handle in further manipulations. Then the conjunctiva was cut in a circle about the cornea, and the three other recti were similarly separated near the bulb (Fig. 164, Plate 28). Curved scissors were then introduced on the medial side behind the bulb, and the optic nerve was divided near to its entrance to the eyeball. Then the bulb became loose and could be drawn out from the orbit (Fig. 165, Plate 28). Finally the tendons of the two oblique muscles were di\ided at their insertions. ""N, Fig. I(i6 The muscle stumps were retained so that after healing an artificial eye could be moved voluntaiily in the retained capsule; the edges of tiie conjunctiva were united with interrupted sutures (Fig. 166). Eight days after the enucleation the patient was discharged with a healed wound and later he was fitted to an artificial eye. 136 SURGERY OF THE EYE AND ORBIT The advantage of emicleation over exenteration lies in the preserva- tion of the capsule of Tenon, which makes possible the wearing and to a certain extent the movement of a prothetic. Artificial ej'es made of glass may be emjjloyed that are so deceptive that they do not affect the expression. EXENTERATION OF THE ORBIT is indicated in all malignant tumors which originate in the outer por- tions of the eye or in its immediate neighborhood as well as in pene- trating infectious processes and in progressive celhditis of the orbit. As all the soft parts of the orbit are to be cleaned out, its inner asj^ect may be carefully examined in order that infected areas of bone may be recognized. The extensive wound surface is covered by a flap from the forehead after the method of Kiister,* or if the upper and lower lids are to be retained, it may be closed by uniting them. In this w'ay in a series of cases of perforating tuberculosis of the orbit and of purulent phlegmon both lids have been spared at the edges of the orbit. For cosmetic reasons the preservation and suture of the lids after removal of the mucous membrane and ciliated edge is more favorable than turning down a flap built from the skin of the forehead. The inverted scar at the healed edges of the lid is so slightly noticeable that usually an eyeshade does not have to be worn. EXENTERATION OF THE ORBIT WITH PRESERVATION OF THE LIDS In a twenty-eight-year-old woman a year before, on account of tuberculosis of the right orbit with practically complete loss of vision, resection of all the involved portions of bone was carried out. After an improvement lasting a few months, the vision suddenly vanished with an appearance of marked choroiditis. The marked exophthalmos, headache and the inflamed appearance of the conjunctiva, as well as the swelling over the orbital bones, spoke for a lighting up of the tuberculosis and its spread to involve the tunics of the eyeball. Ac- cordingly, exenteration of the orbit was decided upon. The fissure of the lids was extended laterally with a knife to the outer edge of the orbit, and at the same time a tuberculous fistula in the outer canthus was surrounded by the incision (Fig. 167, Plate 29) . The lids were pulled apart with sharp hooks and the markedly altered edematous conjunctiva was separated from the inner siu'face of the lids with a knife down to the upper and lower edges of the orbit. •Zeiitnil. f. Chir., 1890. Xr. 2. Krause-Hevmann-Ehrenfried. Tab. 29. Exenteration of the orbit, retaininij- the lid.s. Tnberciilou fist ti In, to Edees *'' ^-^f^ist'd of liileral 1 Orbital fiit Raspatory Fig. 107. A transverse incision is made outward throngiitlioontercantlms, to give better exposure, and an incision through conjunctiva is made around the "lobe Optif nerve Fig. 108. Luxation of orbital contents. V Ciliary inaririii J iihriTuloiis irnirir//ti/ioris Fig. loy. Removal of tuberculous granulations. t'' Fig. 170. Removal of ciliary margin. Iodoform packing Suture of freshened edges of lids Fig. 171. Appearance at end of operation. lebinan Company, New York. EXENTERATION OF TFIE ORBIT 157 Tlien tlie periosteum was incised around the orbit down to bone, and witli a wide raspatory separated from the bony wall of the orbit on all sides until it was possible to dislocate outwards the entire content of the orbit (Fig. 1(»8, Plate 20). This brought to view the optic nerve under tension, together with the ophthalmic artery and vein, as the only structures holding the eyeball, and these were cut willi scissors at the optic foramen. The hemorrhage as usual was controlled by pressure, and it was unnecessary to seize and tie the ophthalmic artery in the apex of the funnel. Thereupon all tuberculous granu- lations and necrotic bone of the orbit were removed with a curette (Fig. 169, Plate 29), also a portion of the upper maxilla had to he dissected out on account of tuberculous infiltration. In order to cover in the large cavity which resulted, both lids were made use of. The ciliated edges were removed (Fig. 170, Plate 29) and the freshened margins as well as a part of the lateral incision were imited by interrupted sutures (Fig. 171, Plate 29). Since the case was one of tuberculosis, the orbital funnel was stuffed with iodo- form gauze, the end of which was brought out at the outermost corner of the lateral incision. After five days the packing was removed, so that the already healed lid edges could lie against the wall of the orbit. After eight days more the patient was discharged relieved. As a result of the maintenance of the lids the deformity was so slight that the girl did not have to wear an eye shield. EXENTERATION OF THE OKBIT WITH REIIOVAI, OF THE I.inS If the lids are involved in the disease, as, for instance,, in malignant growths, and particularly in spreading epithelioma at the inner can- thus, they must be removed as well as soft parts and bone in conjunc- tion with the contents of the orbit. There results a wide wound surface with an irregular base, which, after the technique of Kiister, is covered over with a pediculatcd flap from the forehead or temple. After this operation an eyeshade or a dark or ground glass must be worn. Since superficial skin cancer in the region of the canthus or on the lids themselves usually extends slowly, ordinarily, in clearly defined cases of cancerous infiltration and ulceration, excision in sound tissue with maintenance of the eyeball suffices. Only the involved portion of the lid has to be removed, as shown on page 102. But if the disease has extended to the conjunctiva of the iimcr canthus or to the bulb, exenteration of the orbit is indicated, in addition to extirpation of the 158 SURGERY OF THE EYE AND ORBIT lids, even when vision is unimpaired. The operative procedure is demonstrated l)v the follo\vin<>- case: In a thirty-one-year-old Russian, who in his own country had heen operated upon about fifteen times, a crater-like ulcer about 32 nim. deep Avith hard edges was located in the left inner canthus. The in- flamed median surface of the eyeball formed the outer boundary of this crater. In addition there appeared when the eyes were shut a carcinomatous ulcer (Fig. 172, Plate 30) close to the suj^erior edge of the orbit. Although the eye possessed satisfactory vision, it had to be sacrificed ; likewise it was necessary to remove at least the inner halves of the lids. The woimd cavity which resulted from exenteration of the orbit and removal of half the lids was too large to allow of covering over with the rest of the lids and, therefore, before extirpating the carcinoma, the incisions necessary for the skin plastic had to be planned in advance. The lids (Fig. 173, Plate 30) were split vertically at the junction of the outer and middle thirds. They were dissected back laterally and the periosteum at the outer edge of the orbit was divided down to bone. From this point the cleaning out of the bulb and periosteum of the orbit was carried out with a raspatory. But on palpation of the lids which had just been split (Fig. 172, Plate 30) small lumps could also be felt, and so each lid was removed in its entirety by an incision following the edge of the bony orbit. In this way the car- cinomatous, ulcer was surroimded by two incisions, which met at a point over the bridge of the nose (Fig. 174, Plate 30). In removing the orbital contents, beginning at the outer side, by means of the raspatory, naturally some of the carcinoma oii the medial surface of the orbit was left behind. The extirpation of this and several sus- picious areas of bone was readily accomplished, after the orbit Avas emptied. Re-examination showed that the carcinoma had extended over the inner surface of the orbit (Fig. 17.), Plate 30). The supra- orl)ital nerve, which lay free for about 3 cm., Avas resected. In chiseling off the nasal bone and the nasal process of the frontal bone the frontal sinus was laid open (Fig. 176, Plate 31), and after the removal of the roof of the orbit the dura mater Avas exposed. JNIedially likcAvise the bone had to be removed for a considerable ex- tent. As the frontal process of the upper jaw was remoA'ed Avith the chisel (Fig. 177, Plate 31), and as a result the antrum was opened Avide, the entire left nasal cavity A\'as exposed (Fig. 178, Plate 31), and the medial boundarA' of the Avound Avas formed bv the turbinates. Krause-Hf^inannEhrcnfried. Tab. 30. Exenteration ol mlMt with renioxal ot lids. 1. Caicinonuitoiis ulcer Carcinoma at inner canthiis Fig. 172. Carcinoma at iniu-r canthus and on upper lid. Upper lid split vertically Fig. 173. Incising periosteum along outer margin of orbit. Incision alon^ upper margin of orbit Corciuoma Fig. 17-1. Removal of lids. Carcinoma Orhit Fig. 17t. Kxenteration of orhit comjileted. Su/tmorhifal nerve l)iiian ('ompaify, New ^'f^rk. Krause-Heymann-Ehrenfried. Tab. 31. Exenteration and resection of orbit. U. Infraorbital nerve Frontal sinus Dura mater Fig. 176. Resection of roof of orbit. Fio. 177. Resection of frontal process of superior niaxilla. Frontal sinus Septum of nose Lower and tniddlc tnrltiiiates Fig. 178. Exposure of Nasal cavity. Dura mater Sphenoid cells Vomer Xntruni of f/ig/imore Fig. 179. Packing begun; shows extent of wound. ebinan Company, New York Knuise-Hevmann-rhreiifiied. Tab. 32. Plastic covering of exenteratccl orbit after Kiister. III. Pedicle Defect in forehead Pedi Provisional packing Suture at outer canthus Fig. 180. Cutting fiefect forehead. Flap implanted over orbit Fig. 182. Sewing in the flap, and suture of the secondary defect. Unclosed portion of defect of forehead Defect in forehead closed by scar tissue Rebman Company, New York. Fig. 183. Wounds iieaicd \ weeks after operation. EXENTERATION OF THE ORBIT 159 These also showed areas which were susj)icious of carcinoma and were removed in conjunction with the ethmoid cells and the walls of the sphenoid cells, as well as a portion of the mucous membrane of the vomer. The infraorbital nerve was in this process exposed and re- sected. From above downward the inferior meatus and the antrum were ■packed with vioform <>-auze (Fi^. 179, Plate 31), in order that no blood could run down into the pharynx and be insufflated. From the depths of the sphenomaxillary fossa a branch of the internal maxillary artery bled. It was packed with gauze impregnated with iodoform in order to prevent decomposition, because here the packing had to remain for a considerable length of time; this packing was differ- entiated from tile other strips of gauze by tying silk about the end. Likewise, the exposed surface of the dura was protected with iodoform gauze, the end was knotted and was carried out through the left nasal orifice above the other two strips (Fig. 179, Plate 31). The large wound cavity could be partially closed at the outer can- thus (Fig. 180, Plate 32) ; but the tension was too great to allow of more than three interrupted sutures. The rest of the defect measured 55 mm. from right to left and 32 mm. from above downward. This surface was covei-ed with a skin-periosteum flap from tiie forehead, the pedicle of which lay at the right side of the root of the nose, and the upper end came to a point so that it would fit into the defect (Fig. 181, Plate 32). The flap Avas sewed in by interrupted silk, leaving no drainage in the orbit (Fig. 182, Plate 32). Finally the secondary defect on the forehead was closed after underminina; the edges, except for a small area 2 cm. long and a few mm. wide. At the first dressing on the second day after operation the drains were pulled out slightly through the nose. Fight days later the more su])erficial tam])on lying in the ncighboi-hood of the orbit was com- pletely removed and the iodoform ])ackiiig, which was recognized by the silk tie and the knot, was somewhat shortened. Every second day these were drawn out somewhat until they were completely re- moved on the twenty-second day after operation. The small gap in the forehead had filled in rapidly with granulations and had mean- while epidermatized, so that the patient on this day could be dis- charged healed (Fig. 183, Plate 32). Up to this time if the patient were touched with forceps upon the flap, the sensation was always localized on the forehead above the orbit; contact directlv at the base 160 SURGERY OF THE EYE AND ORBIT of tlie flap alone was rightly localized ; only in time was correct locali- zation learned. kronlein's osteoplastic resection of the temporal wall OF the orbit Tumors lying behind the bull), for instance, those of the optic nerve, and inflammatory infections of the orbit, such as cellulitis and tubercu- losis, may sometimes be overcome surgically without the necessity of sacrificing the eyeball. In order to accomplish this, the outer wall of the orbit is resected osteoplastically after the method of Kronlein, and, if necessary, the capsule of Tenon is split. x\fter turning back the bony parts one can penetrate into the depths of the orbit as far as the optic nerve and carry out operative procediu'es here in full view. Naturally, these conservative methods can only find application if, as was explained in the previous section, no indication exists for the removal of the eyeball, for instance in limited benign tumors in the orbit, whether arising from bone, connective tissue, muscle or optic nerve. Kronlein devised this method for the removal of a laterally situated dermoid cyst. It seems to be indicated also if tuberculous masses have penetrated the bony wall of the orbit, and cause the bulb to project without involving it, or if a cellulitis has spread over the floor of the orbit. In a twenty-eight-year-old young woman who had had a tuberculous abscess over the zygoma incised a year before, the Kronlein operation was performed in order to put a stop to the rapid loss of vision which was resulting from proliferation of tuberculous granulations behind the bulb. X-rays showed no bony changes. Retinal examination of the right eye showed papillitis with advancing optic atrophy. The eyelids were swollen and edematous (Fig. 18.5, Plate 33), and there was present a marked degree of exophthalmos. All movements of the eye were present, but limited. The skin was divided outward from the middle of the right eyebrow in crescentic fashion as far as the outer corner of the orbit, and from this point, following the Kocher modification for the purpose of avoid- ing the branches of the facial nerve, contimied transversely outward (Fig. 185, Plate 33). After dividing the periosteum at the edge of the orbit, the bulb in all its coverings could be so far loosened from the outer wall of the orbit with a raspatory (Fig. 186. Plate 33) that the instrument reached in the depths to the inferior fissiu-e of the orbit. There was very little bleeding, but even at moderate depths Krause-Heymann-Ehrenfried. j^^ -jj Kroenlein's osteoplastic resection of the tcm])oraI wall of the orbit. Edematous eyelith Outer and lower corner of bony orbit ~ Fig. 185. Modified Kocher skin incision. Tumor-lihf tuberculous f^rnnulatrons Retractor on lower wound edge Fig. 186. The bulb \x'itli its coverings intact is lifted away from the external orbital wall. • - ■*' Tuberculous srrauulations Fig. 187. Making the bony incisions. Outer margin of orbit with soft parts attached Rebmaii Company, New York. Tuberculous granulationh Fig. 188. The bony wedge is displaced outward. RESECTION OF THE TEMPORAL WALL OF THE ORBIT 161 hard tuniorlike granulations appeared, which resembled in form white beans (Fig. 187, Plate tV.i) . During the freeing up of the periosteum within the orbit all pull on the upper outer edge of the skin was avoided, in order that the soft parts might not become loosened from tiie bone. But on the other hand the wound had to be pulled strongly downward to expose partially the lower margin of the orbit (Fig. 186, Plate 33). There- :Bane incision : Skin incision Fig. 184 upon the outer wall of the orbit was chiseled through abo\e and below (Fig. 184) and the bony incision was carried in the direction of the raspatory, which was stuck in the lower orbital fissure. Above, the chisel was introduced just over the suture, wliich could be palpated between frontal l)()Me and zygoma; below, at the level of the zygoma. A portion of the zygoma was removed by the lower cut. In this way one could form a bony wedge from the lateral wall of the orbit, which, in connection with muscle and skin, could ])e turned backwards over the temi)le (Fig. 188, Plate 33). There now appeared in the orbit tumor-like tuljcrculous granuhi- 162 SURGERY OF THE EYE AND ORBIT tions, which were particularly luxuriant on the floor and along the inferior orbital fissure. These were removed with a curette as well as soft areas of bone, with the result that the antrum was opened. As there was no indication for incising the periosteum of the orbit laterally, thus exposing the external rectus as well as the optic nerve or the pos- terior surface of the bulb, the skin-bone flap was replaced after a strip of iodoform gauze and a thick drainage tube were left behind down to the position of the removed granulation masses. The wound at the outer canthus was closed by a suture, including at the same time skin and periosteum. Five days later the gauze and a few days after that the drainage tube was removed. The bone healed in by primary imion. The removal of the masses of granulation tissue had no effect on the vision. The extrusion of the bulb and the edema of the lids did not completely disappear. Six months later, on account of ad- vancing tuberculosis, the upper jaw had to be resected. TREATMENT OF CELLULITIS OF THE ORBIT Through temporary resection of the outer wall of the orbit foci of pus in the orbit may be exposed. In addition to the regular symptoms of sepsis, phlegmon of the orbit expresses itself in a protrusion for- ward and limitation of motion of the eyeball, as well as in swelling and reddening of the lids. Purulent infiltrations develop from in- fected wounds which are situated near the eye or the orbital veins, and sometimes result in empyema of the accessory cavities of the nose. The prognosis is always unfavorable because there is danger that the phlegmon may extend to the brain and its envelope. On the other hand, the prognosis is more favorable if the abscess is the result of a penetrating foreign body. Small incisions at the canthus or at the upper orbital margin do not suffice to expose all the infiltrated area : moreover, satisfactory drain- age cannot be obtained from such incisions. Orbital jihlegmon and abscess must be opened much more widely. The following observa- tion shows how the Kronlein oj^eration allows free approach to the depths of the orbit: A forty-year-old woman was brought into the hospital in a state of coma with all signs of phlegmon of the orbit and secondary brain abscess. At the inner upper edge of the orbit was situated a wound of the soft parts out of which a drainage tube and iodoform gauze projected. The upper lid was chemotically swollen in the highest degree. In order to open wide the phlegmon the outer wall of the CELLULITIS OF THE ORBIT 16:J orbit was resected after the nietliod of Kronlcin, usinir the Kocher incision to avoid the facial hranches. In l()osciiiii8. I'late 36). Anterior and external there still remained a sharply projecting process, which hindered the view of the passage from the antrum to the middle ear. ^Vith a very small chisel this projection, which by its posi- tion corresponded with the bony frame of the posterior edge of the drum, was chiseled an-ay. Below, this prominence passed over into the eminence of the canal of the facial nerve. As this was removed, it could be seen that the contents of the middle ear had been transformed into a completely unrecognizable greasy mass. The attempt to find the remnants of the ossicles in this mixture of pus, mucus and necrotic tissue was unsuccessful. In consideration of the destruction of the contents of the middle ear and drum, as well as the cerebral symptoms, which had ajjpeared after a three-weeks' course of the disease, it appeared necessary to carry out the RADICAL OPERATION Since the purpose of this operation is to transform the external audi- tory canal, the middle ear, the mastoid antrum and the inside of the mastoid process into a single wide wound cavity, as smooth as jjossible, and opening externally, there remained only the removal of the jjos- terior wall of the auditory canal and a complete opening up of the mastoid process (Fig. 199, Plate 37). Accordingly the forward edge of the wound, together with the auricle, was pried up from the l)ony canal with the helj) of an elevator until the skin lining of the auditory canal tore away within (Fig. 200, Plate 37). The auricle and the portion of the external canal which was torn away with it was next drawn forward, and later in the course of the operation was attached with a few sutures of silk to the anterior wall of the canal. The bony ])osterior wall of the canal was removed with a few strokes of the chisel, holding it always directed ui)ward and inward. In order to maintain tlie direction of the attic and not to endanger the facial nerve, which ran under the floor at the boundary of middle ear and antrum, the teehiuque of Stacke was followed, by which a bent probe was introduced through the antrum and middle ear into the auditory canal (Fig. 201, Plate 37), and on tliis the blows of the chisel were directed (Fig. 202, Plate 37). Further in, the removal of the posterior wall of the canal was limited to the upper posterior 172 SURGERY OF THE EAR quadrant, since the facial nerve runs below in the line of the posterior wall. On the otlier hand, the upper bony wall was removed freelj' above until the communication with the antrum and with the attic lay opened up and the probe could be removed. Below this the prominence of the facial nerve completely blocked the vision, and it was removed in small lamellfE with a small. strai<)fht chisel, until the anesthetist rejjorted that there was twitching of one side of the face. Finally the strip of bone on the roof of the large cavity (Fig. 20.3, Plate 37) was levelled off, partly with the curette and partly with very fine rongein-s. In the attic, also, no trace of the ossicles was to be found. Bleeding was stronger on the floor of the cavity than on the roof. After all bony splinters, inspissated pus and necrotic tabs, as well as the remnant of the drum, were removed by wiping, the bony cavity was packed with iodoform gauze and' an occlusive dressing applied. The facial eminence was lightly sponged and carefully packed with gauze in order to avoid injury to the nerve as the result of tearing with bony splinters or through- jjressure of sponges. On the day after operation the temperature was normal. The symptoms of septicemia improved rapidly. The superficial layer of the dressing was changed in two days and the gauze packing in the cavitv four davs later. From that time on the dressing was com- pletely changed every third day. The entire wound covered in rapidly with vascular gramdations. The secretion of pus ceased. Two weeks after operation the patient left the bed. and soon the cavity, which was the size of the end of the thumb, began to dermatize rapidly from the edges. The sutures which held the jiosterior skin wall of the auditory canal to the anterior gradually cut through. The periosteum and skin of the auricle healed to the anterior wall in the following weeks, so that from here also dermatization of the canal spread. THE PLASTIC PROCEDURE OF PANSE-KORNER When practically the entire wound surface was scarred over, the picture in Fig. 204, Plate 38, presented itself. As not infrequently happens after opening up the antrum, and always after the radical operation, it was necessary to transform tlie bony funnel which lay open behind the ear by means of a plastic operation into an auditory canal protected by the external ear. For this purpose the Panse- Korner method was chosen. First the dermatized edges of the funnel were trimmed in the form Krause-Heymanii-Ehrcnfried. -t-_[j -jg Railical nuistoid: the Panse-Korner method of plastic closure. Bony cavity lined with skin Remains of external audi- tory canal grown together Line of incision Fig. 204. Bony cavity lined with scartissue. Cartilage Lower accessory incision Fig. 205. Freeing up the concha. Ciiinze strip in upper accessory incision Concha after remo- val of portion of cartilage Fig. 206. Freeing up the cartilage. Fig. 207. First sutures applied. Lower accessory incision Fig. 208. Sewing concha to posterior wound margin. rl ,-i- r • 4 ^ Suture tinf h'ig. 209. Completion of suture. Rebmann Company, New Vork. THE PANSE-KORNER PLASTIC 173 of an ellipse, and at the posterior circumference of the wound the soft parts were loosened up from the skull. In front the posterior wall of the canal, wliich had l)ecome adherent, was freed up in all of its three layers from the anterior wall, so that a pair of forceps intro- duced into the meatus was seen in the cavity (Fig. 20.5, Plate 38). ^Vhile the posterior wall of the skin of the canal was hfted from the skull, an oblitjue incision was made through all the layers of the external ear above and below, starting from the freshened edges. Both incisions ran close to the helix above and below in order to give plenty of material for covering the wide bony cavit}\ Since in the flap thus formed movement was limited to a high degree by the plate of cartilage, this was seized with forceps (Fig. 206, Plate 38), over 1 cm. was exposed and removed with scissors. This allowed the base of the flap to be drawn easily and without tension over to the posterior wall by means of a loop of gauze introduced in the upper accessory incision, and there to be made fast with four interrupted sutin-es (Fig. 207. Plate 38). In the same way the rest of the mobilized woinid edges were sewed together (Fig. 208, Plate 38) until the entire bony cavity was covered with the shell of the ear (Fig. 209, Plate 38). Below the obliquely placed accessory incision was satis- factorily employed for uniting the Avound edges, while the upper one was sewed together partially in a horizontal line. Finally, in the external ear, wliich led directly into the large bony funnel, a strip of vioform gauze was introduced. Two weeks later the patient was discharged healed. The bony cavity which resulted from the radical operation had to be packed for a considerable time, later through the canal with strips of gauze. In opening up the mastoid antrum particular difficulties are pre- sented if the mastoid process is converted into a compact mass of bone without means of difl'erentiation between the cortical and the spongy portions. This ehurnlzalion is the result of chronic inflammation, and in chiseling open such a mastoid neither the narrow space, rich in blood, nor the white-lined pneumatic cells are to be recognized; and as a result all points of departiu'e for the recognition of the facial eminence, the sigmoid sinus, the cranial cavity and of the antrum in chiseling are lost. Also more force must be given to the blows of the chisel than are necessary in the cellular bone. The passage to the dark antrum may lie high up under and even above the supramastoid crest, and its cavity may be so narrow that from 174 SURGERY OF THE EAR this point neither the facial eminence nor the prominence of the lateral semicircular canal is to be differentiated. It is better in such cases to make the bonj' funnel too high rather than too close to the tip of the mastoid jjrocess, as opening the middle fossa presents a less danger than injury of the facial nerve in the posterior wall of the middle ear, and at the floor of the antrum. In the radical operation the facial nerve is in particular danger ■while the posterior wall of the external canal is being removed. Even if the probe or the facial protector of Stacke is introduced from the antrum to the bony meatus, and all the blows of the chisel are directed to these instruments, the facial may be injured through a fissure made in chiseling, by a bony splinter or by pressure of the forceps which hold the sponge. It is chiefly endangered in its passage from the posterior wall of the canal over to the medial wall of the middle ear. The sigmoid sinus sometimes deviates from its customary position. While as a rule it runs along the posterior edge of the mastoid process, it may be placed so far to the front in the bony mass of the mastoid as to lie anterior to the middle line of the mastoid, in which case it may readily be injured in chiseling. If this occurs, pressure and pack- ing with a small strip suffice to overcome the bleeding from its injured Avail. The operative procedure need not be interrupted. PHLEBITIS AND THROMBOSIS OF THE SIGMOID SINUS AND LIGATURE OF THE JUGULAR VEIN Abscesses in the mastoid process always endanger the neighboring large vessels. The infection travels from the mastoid cells to the sig- moid sinus and to the gulf of the internal jugular vein from the floor of the middle ear. Either there results a purulent jihlebitis of the wall of the sinus or the formation of a septic thrombus. The throm- bosis in the majority of cases remains stationary and only seldom fills the lumen of the sinus completely. In purulent inflammation of the walls of the sinus first the stream of blood is interrupted within the vessel. Externally the participation of the wall is recognized by the fact that it is covered with a smeaiy, yellowish layer. The passage of pus organisms through the wall of the vessel may follow readily in this stage and lead to the symptoms of pyemia. The symptoms of parietal and obstructing thrombosis of the sinus are at first indefinite so long as the clot is limited to only a short stretch of the sinus and it sticks fast to the wall. Onlv when the PHLEBITIS AM) TIIROMHOSIS OF THE SIGMOID SINUS 175 thrombosis progresses to blood vessels in the immediate neighborhood or further removed and if infected portions of tlie weakened thrombus are torn loose does general pyemia, wliieh is usually fatal, occur. Therefore, among the symptoms of septic sinus thrombosis the sjTiiptonis of ])yeniia stand first. The obstruction to tlic passage of blood expresses itself in the tilled appearance of the veins of the face and head, in swelling of the skin of the face, particularly the eyelids, and further in paralysis of the cranial nerves, which lie close to the thrombosed vessels or in the sinus cavernosas. These symptoms only exceptionally appear sinniltaneously, since they depend on the extent of the throml)osis: but for diagnosis and as an indication for opera- tion a single isolated symptom, such as edema of the lids, an isolated nerve paralysis, or a filled vein, or in connection with the findings in the ear and the symptoms of general pyemia, may be a valuable index. In the further course of the disease one other very characteristic symj)tom rarely fails. As the result of the advance of phlebitis of the sinus to the jugular vein there occurs a definite tenderness along the vein. The point of greatest tenderness is at the posterior edge of the mastoid process, and it extends sometimes as far as the clavicle. The occiput is usually held immovably upon the shoulder of the affected side and the face is turned to the opposite side. The ede- matous swelling behind and under the mastoid process, as well as over the upper portion of the jugular vein, may show externally the pres- ence of phlebitis; it may be definite or it may not be present at all, since the deep fascia of the neck and the sterno-mastoid muscle cover the inflamed and infiltrated tissue. A healthy nineteen-year-old workman was admitted to the surgical section of the Augusta Hospital in a state of coma. Since he himself could give no information, but little could be learned concerning his previous history. For several weeks he had complained of pain in the ears, and the past few days he had frequently vomited in the morning, but he had nevertheless kept at his work until three days preceding entrance. On account of dizziness and severe headache in the morning he could no longer get up. Since then fever and chills lasting more than half an horn- had been observed, and finally he had been sent to the hospital by his physician. It was found that the right side of the neck from the mastoid process to the middle of the sterno-mastoid was markedly swollen. Kvcry attempt to palpate this area for diagnostic purposes was responded to 176 SURGERY OF THE EAR by the patient, otherwise in a state of somnolence, Avitli active expres- sions of pahi. There existed further pauiful swelHng in the left elbow joint and enlargement of the liver and spleen; the temperature was 104 F. and the pulse rate 140 per minute. No dilatation of the veins of the skin of the neck was visible, but there was tortuosity and injec- tion of the veins of the right retina. The right side of the face moved less than the left. Examination of the left ear showed nothing abnormal. On the right side the external auditory canal was filled with a brown, pasty secre- tion, the drum showed a circular hole exactly in the middle, its upper edge was covered with pus and the lower was markedly swollen and hemorrhagic. Nothing was to be seen of the ossicles, but the white light-reflecting surface of the medial wall of the middle ear could be seen. On account of the condition of the patient paralysis of the muscles of the eye could not be determined. On consideration of these symptoms the diagnosis appeared clear. Starting from an old pinnilent otitis media, there had developed a purulent phlebitis of the sigmoid sinus and the jugular vein, which, in addition to a local infection of the right side of the neck, had resulted in a general pyemia. In order to prevent further progress of the pyemia so far as possible in a patient whose life appeared to be in the gravest danger, it was decided that the sigmoid sinus should be exposed and the jugular vein ligated. Under light ether anesthesia the skin and periosteum over the mastoid process were divided !/> cm. behind and parallel to the furrow of the concha, and drawn apart with retractors. Departing from the customary procedure in opening up the antrum, the mastoid process was opened wide and further back than usual, and direct approach was made to the sigmoid sinus. The use of the hammer and chisel was avoided because of the danger that with each jar new pieces of septic clot would be set loose in the vein. For that reason trephining of the mastoid was carried out with the burr (for the technique see chapter on Surgery of the Brain), and the bone was broken out from the edge of the drill hole Avith rongeurs. The exposed sinus was yellow and covered with fibrin and pus. This layer could be removed with forceps. Also imder it the wall of the sinus was discolored, but blood must have flowed in its lumen, since it 'filled and emptied itself regularly with respiration. To be sure it was not under normal tension, but on careful palpation nowhere could Krause-Heyniann-Ehrenfiicd. 'll-irombophlcbitis of the lateral sinus, and lis^ature of the internal jugular \ein. FibrinO'iiiinilfiit layer Knee of sinus Piini iiititrr of the cerebeUum Tab. 39. Squamous portion of oidpital boat' l.ynipli node Lymph nodi Fig. 210. Exposure of the lateral sinus and the great vessels of the neck. Double ) ligature \ Krsrcteil /witiiw of jiigiilur vrin ^ Ciirotid iitlfry Vagus ut'i-ve Fig. 211. Ligation of the jugular vein and its branches. Fig. 212. Resection of jugular vein. Rrbiiian Company, Nevi N'mk. LIGATION OF THE JUGULAR AEIN 177 thrombi be felt. Also the sinus could apparently be emptied in both directions. Further exposure of the sigmoid sinus, or even of the gulf of the jugular vein, as well as any radical operation, had to be given up on account of the bad condition of the patient, lint in order at least to remove the source of the pyemic infection, in addition to the exposure of the sinus, the common jugular vein had to be ligated. For this purpose the incision behind the ear was lengthened down- wards over the anterior border of the sterno-mastoid to near the clavicle. The fascia of the nuiscle was split at its anterior edge and the sheath containing the blood vessels and lymph glands was opened. As the muscle was drawn backward there came into sight swollen lymph nodes as long as the phalanx of the finger, embedded in brawny edema (Fig. 210, Plate 39). These were the cause of the painful infiltration of the neck. After splitting the sheath, it was seized with forceps and removed, the internal jugular vein was ex- jjosed, double tied and divided in the lower end of the wound (Fig. 211, Plate 39) . The common facial vein and a series of small branches were divided after double ligature and a piece of the internal jugular vein 6 cm. long (Fig. 212, Plate 39) was resected. The exposed sur- face of the dura and the wound over the vessels was packed with iodo- form gauze and the edges of the skin were loosely united over the gauze by three sutures. In spite of the short and very superficial ether anesthesia, the patient collapsed at the end of operation. After the operation no more chills ajjpeared, and the fever remained moderate. On account of the in- crease in pulse rate and persisting disturbance of consciousness, the prognosis, however, appeared hopeless. On the second day after operation the patient died. From the autopsy protocol (Professor Ostreich) it appears that a purulent thrombosis was found in the right transverse sinus. The wall of the vessel was three times as thick as normal, was discolored and infiltrated with pus. The brain substance was injected, but with- out foci. The wall of the jugular vein was thickened. Below the point of ligation in the neck the large veins were free of thrombi. There were present also septic infarcts in the lungs, fibrinous deposits in the pleura, softening of the cardiac muscle and septic enlargement of the spleen, as well as fatty degeneration of the liver and kidneys. If the patient had come to operation in better condition, radical 178 SURGERY OF THE EAR operation on the ear and exposure of the transverse sinus would necessarily have followed trephining of the mastoid and ligatiu'e of the internal jugular vein. If one finds in a similar case that the sinus is plugged by infected thrombi, its walls should be opened and the thrombus removed. Bleeding from the sinus after opening may easily be controlled by introducing a narrow strip of gauze, impreg- nated with iodoform on account of the sepsis, and allowing it to re- main for about seven days. After this time innocuous clot formation is apt to put a stop to further bleeding. The complication of pmndent middle ear disease with disease of the brain and its envelopes will be considered in a special section. CHAPTER 11— SURGERY OF THE NOSE AND THE ACCESSORY SINUSES INJURIES OF THE NOSE may be danfrerous if combined with profuse bleeding from the mucous membrane or if wound infection occurs in the tortuous nasal passages. I'ractically all fractures of the nasal bones result from direct violence and the majority are complicated with wounds of the nnicous mem- brane lim'ng. In every case of fracture of the nose, in addition to the control of hemorrhage and prevention of infection, the threatened facial disfigurement above all things demands surgical intervention. Usually sim])le packing of the nasal cavity with iodoform gauze suffices to stop bleeding, and infection in comjjound fractures is best guarded against by such procedure. In order not to completely obstruct nasal breathing after packing of the nasal cavity with gauze, a small but stiff-walled rubber tube should be introduced at the same time as far as the naso-pharynx. Iodoform gauze is to be recommended for this purpose over plain sterile gauze because it may remain in place for several days without decomposition taking place. The gauze should always be used in the form of ta})c. for a packing composed of several tapes may be removed much more readily than a single strip. The packing should, however, not be allowed to stay in too long, as we have seen meningitis develop four days after an apparently mild injur}" for which the nose was packed, and on withdrawing the packing free pus followed, Avhich apparently had been retained under pressiu'e. Auto|)sy showed a fissure fracture of the etlinioid. Markedly dislocated fragments which projected freely into the nasal cavity should be removed at once, for they often become necrotic, and if they are allowed to come away of themselves as sequestra the process is slow and often accom])am'ed by disturbing syniptonis of inflammation in the anterior ])()rtion of the nose. Cracks in the bony wall and fresh (Irviations of the ficpium as a result of injuries are corrected at once by packing. For the hematoma which results from fractures, and at times also the subcutaneous em- physema, immediately renders dillieult the view within tiie nose. ^^'hile at first the displaced fragments may be replaced readily, later 179 180 SURGERY OF THE NOSE AND SINUSES on this is impossible. Accordingly, many nasal fractures heal with permanent disfigurement. Improvement can then be offered by sub- cutaneous osteotomy Avith the help of fat or bone transplantation, as has been shown hi the section on plastics of the cheek and nose (see pp. 105 and 139). Spontaneous bleeding from the nose results from small ectactic veins, and less frequently arteries, which are situated in the lower anterior section of the mucous membrane of the septum, the so-called Kesselbach's spot. In order to stojD the bleeding it usually suffices to press the alte of the nose together for several minutes between thumb and forefinger. If this does not control it the nasal cavity shoidd be packed from in front with gauze, which may be saturated with a mild solution of suprarenin. If- this treatment does not succeed, the nose must be packed from behind, particularly if the blood, without appearing in the nasal orifices, runs down the wall of the jjliarynx. The packing is inserted through the mouth into the naso-pliarynx by means of a Bellocque cannula, or better still, a soft rubber catheter. The catheter is passed along the floor of the nose until its end appears projecting below the soft palate, when it is seized, brought forward through the mouth and the gauze strip is attached to it by a string of silk and drawn back into the naso-pharynx and the posterior nasal orifice. The plug should be of such size that it will not wedge in between the velum and the pharyngeal wall, but will be drawn into the posterior nasal orifice and plug it effectively. The silk cord is made fast to the cheek with a strip of adhesive plaster. After the posterior pack- ing is applied, the anterior nares is packed so as to completely fill the nasal fossa. Iodoform gauze may remain in for a week or more ; other packing should be changed earlier, not later than forty-eight hours, because it may decompose and become a source of danger to the patient. Removal of the packing is rendered less difficult if it is previously softened thoroughly by soaking with oil or liquid albolin. In order to prevent return of the epistaxis, it is recommended to cauterize the bleeding point on the septum or on the turbinate with a galvano-cautery, the Pacquelin cautery, or by means of chemical agents, such as silver nitrate or trichloracetic acid, and in this way induce scarring of the vessels w^hicli are inclined to bleed. It is neces- sary to first dry the bleeding point as thoroughly as possible and have the cauterant agent ready to apply immediately upon withdrawal of SINUITIS 181 the pressure sponge. The neif^-hboriiig portions of the nasal orifice should be protected from burning by a speculum. Death following epistaxis is not uncommon. We have recently seen two patients who in spite of the fact that the bleeding was con- trolled through j)osterior and anterior packing, died a few days after admission to the hospital from anemia and exhaustion. INFLAMMATORY DISEASES OF THE ACCESSORY SINUSES The source of inflammatory disease of the accessory sinuses is acute and chronic rhinitis, which extends along the mucous membrane lining the open passages wiiich lead from the nose to the sinuses. Of these, the duct of the frontal sinus opens anteriorly below the middle turbi- nate in the hiatus semilunaris. Somewhat posterior is the orifice of a second canal which leads to the anti'um. Between the two projects the largest of the anterior ethmoid cells, the bulla ethmoidalis. Both cavities are easy to probe through the middle meatus after some practice, and to irrigate for therapeutic purposes by means of cannulas. The passage to the sphenoid cells is more difficult to reach; it opens in common with the posterior cells of the ethmoid in the upper meatus below the su])erior turbinate. The Eustachian tube opens in the naso- pharynx at the end of the lower meatus, connecting the naso-pharynx with the middle car. Simple, acute or chronic sero-catarrhal inflammation of a sinus may disappear like the same affection in the nose without permanent disturbance; in the same way acute purulent inflammations may often be overcome without special surgical procedure. Fever, dull pain in the jaw and forehead, neuralgic pains in the region of the supra- and infra-orbital nerves, as Avell as nasal speech and the appearance of purulent secretion, are the principal symptoms which denote that the sinuses are involved. The pain is apt to increase in severity on sneezing and coughing. Chronic inflammation is evidenced also by the long course of the disease, and particularly by fluctuations in the .symptoms. Thus the symptoms decrease if the swelling of the mucous membrane in the orifice of the canals diminishes and the pus is allowed to drain away into the nose or pharynx. The disagreeable odor and the taste of pus is then found to be very un])leasant by the patient. In the interval asthmatic conditions not unusually api)car. Progression of purulent inflamuiation to the orbit, or even to the interior of the skull, presents in acute as well as chronic suppuration of the sinuses a dreaded but infrequent complication. 182 SURGERY OF THE NOSE AND SINUSES Diagnosis of suppuration of a siiuis is not difficult to make if one finds pus in the middle meatus through the speculum. Here the secretion empties itself from the frontal sinus, the antrum, and from the anterior cells of the ethmoid. As suppuration of the anterior cells of the ethmoid without the posterior is practically never observed, the antrum and the frontal sinus are usually the source of the pus. If the chronic purulent inflammation is limited to the ethmoid, in addition to the secretion under the middle meatus one will be able to see pus flow from the upper meatus by means of posterior rhinoscopy. Chronic suppuration seldom occurs here alone. As a rule it is com- bined with the same disease of other cavities. In the same way a primary and isolated abscess in the antrum without involvement of other sinuses is practically never observed. The presence of disease of the sphenoid may be determined by finding secretion from the pos- terior cells of the ethmoid with the aid of posterior rhinoscopy. In the differential diagnosis between suppuration of the frontal sinus and of the antrum of Highmore, no great weight can be laid upon the statements of the patient, for the symptoms of the two affections may be very similar. Particularly spontaneous frontal headache and neuralgic symptoms in the first and second divisions of the trifacial are observed without distinction in disease of either sinus. The most reliable means for diagnosis Avith reference to the seat of suppuration is irrigation of the tAvo cavities through the middle meatus. If tlie cannula with an S curve cannot be introduced, the anterior portion of the middle tin-binate may be removed under local anesthesia, so as to expose the ducts of the antrum and of the frontal sinus. As the result of the local anemia which follows cocaine anes- thesia and the removal of the remnants of secretion and of dried crusts, pus usually appears at one or the other orifice; but that cavity alone is diseased from which pus flakes or clots may be washed out, and from which after irrigation no more pus appears. To confirm the diagnosis, oral transillumination is of service. If an electric lamp is introduced into the mouth in a dark room, the normal frontal sinus and antrum are distinguished from their surroundings by a rosy illimiinated area, while in case of inflammation of the lining membrane, or, to a greater degree, in the presence of suppin-ation, the liglit rays are obstructed and the opacity in comparison with the unaffected simis is striking. Fluoroscopic examination shows a shadow on the affected side, and OPENING UP THE ANTRUM 183 should be employed in doubtful cases for further support of the diagnosis. OPERATIONS ON THE ANTRUM Of all the accessory siinises of the nose, the cavity of the upper jaw, the antrum of Highmore, is most frequently affected. This is ex- plained partly by the unfavorable situation of its duct, which does not originate, as in the frontal sinus, at the lowest jioint of the cavity, but is situated in the wall at a place which is comparatively high. In the upright position a considerable amount of secretion may collect in the antrum before the surface reaches the level of the exit. The frequency of eni{)yema of the antnmi is increased by the fact that it residts not only from inflammatory affections of the nose, but also from carious teeth. OPENING A SINGLE ANTRUM While acute suppuration of the antrum usually disappears under local applications and irrigation, chronic inflammation demands operative exposure of the cavity, removal of the diseased mucous membrane and the institution of favorable drahiage. The longer the disease lasts, the smaller is the outlook for cure without operation. According to the method of Kiister, the antrum may be opened through the canine fossa of the alveolar process, the mucous membrane of the mouth and the periosteum being divided transversely or from above downward, and the anterior wall of the antrum drilled and removed. It is of advantage to enlarge the exit into the nose from within the cavity, in order to procure faA^orable conditions of drain- age. This is done by the method of Cadwcll-Luc, by which dressing forceps are ])assed from the antrum thi'ough the lateral wall of the nose into the nasal cavity, and the bony partition is removed down to the palatal process. Resection of the lower and anterior portions of the middle turbinate should not be omitted. The following observa- tion may serve as an example of the operation for inii'alcral on pi/onn of the antrum: A very deaf sixty-year-old woman stated that for fifteen years she had suffered from headaches, which were focused in the forehead above the right eye. At first the ))ain came infrciiuently, then it came as often as every eight days, particularly in the evening, and lasted until midnight. She felt as if a nail with a large head were sticking in her skull. On the same side there were disturbances in hearing, roaring 184 SURGERY OF THE NOSE AND SINUSES and ringing in the ear. The attacks at first were unbearable, but later increased niarketlly in intensity and duration until her physician sus- pected brain tumor. But on examination no signs of this were found. On the other hand, the X-ray demonstrated a shadow over the right antrum, and transillumination in a dark room showed that all the accessory sinuses were transparent excej^t the antrum; accordingly, although the statement of the patient pointed toward the frontal sinus, the right antrum was opened. A large sponge was packed in the right loAver cheek pouch and a strip in the right posterior nasal orifice. The right upper lip being retracted upward and the corner of the mouth outward (Fig. 213, Plate 40) , incision was made through mucous membrane and periosteum at the top of the canine tooth jjarallel to the edge of the gum down to bone, so that a strip of mucous membrane of the gum about 1 cm. wide remained. JMucous membrane and periosteum were stripped upwards with the raspatory until the anterior wall of the antrum was exposed from incisors to the first molar. Thereupon opening was made with a gouge and enlarged with rongeurs until the index finger could be inserted comfortably. Upon opening the mucous membrane a polyp- like formation projected which had to be removed with a curette (Fig. 213, Plate 40). The opening in the anterior wall was large enough to introduce the curette alongside the index finger and to re- move completely the hyperplastic mucovis membrane lining the cavity. JMeanM'hile there flowed out a tenacious muco-purulent fluid. With the left index finger in the antrum, a strong curved dressing forceps was shoved through the partition wall from the right middle meatus (Fig. 214, Plate 40). In order to establish wide communi- cation between the nasal cavity and the antrum, the projecting mar- gins of bone were removed with chisel and rongeurs, as well as the lower and middle turbinates. The irregularities of the floor of the antrum were leveled off' with a gouge (Fig. 21.5. Plate 40) until the index finger could enter the nasal cavity through the antrum without hindrance. After the antrum had been freed of the thickened inflamma- tory mucous membrane and all the pockets and hollows were disposed of, it was packed tight with an iodoform strip, the ejid of which was carried through the wide passage to the nose, and out the nasal orifice. Periosteum and mucous membrane were vmited over the canine fossa with four interrupted sutures (Fig. 216, Plate 40) in order again to close off antrum from mouth. The packing was removed through the nose on the foin-th day. From the day of operation the patient's Krause-Heymann-Ehrenfricd Tab. 40. 0]ienin<^" of the Antrum of 1 li^limore. Right corner of mouth Aittrum of H 101 mo re Mitcoits potyi}__. Curved dressing forceps Fig. 213. Removal of lllu^.olI,^ polyp with curette. Fig. 214. Tlie lateral wall of the nasal cavity is broken through by forceps introduced through nose. Ridge of bone Stitch Fig. 215. Smoothing out the uneveness of the interior of the cavity. Fig. 216. Muco-periosteal suture. ^ebinan Company, New \'ork. Krause-Heymann-Ehrenfried. Tab. 41. Radical operation for double empyema of the antrum, after the method of Partsch. The upper lip is drawn upward by blunt rake ret'rat tors g. 217. Incision of mucous membrane. Defect in teeth Fig. 218. Chiseling through the bony nasal septum. Scissors Fig. 219. The alveolar process, chiseled free, is drawn bovcn by hook. Gauze packing Fisj. 22U. Resection ol ni;ln lower turbinate. OiuiZf strip Gnnzf strip sat; sit tun' Fig. 221. The eno ««^^ of the strip is \^^Pi brought out \ ^ \, u"onoh the nasal _.. _„,, ,, ■ . i , orifice '^'S- 222. Muco-periosteal suture. Rebman Conip.Tny, New York. BILATERAL EMPYEIMA OF THE ANTRUM 185 temperature was normal, and. as she complained of no symptoms, she was discharged two weeks later. OPENING UP BOTH ANTRA AFTER THE METHOD OF PARTSCH In empyema of both antra, in case of larthenhiff the skin incision; externally the upper periosteal incision had to be lengthened for several cm. in a horizontal direction until a piece of bone fully 1 cm. across of a lengthened oval shape representing the entire frontal wall was removed (Fig. 225, Plate 42). Thereupon the mucous membrane of the sinus could be easily investigated; it showed the changes of clironic inflammation and appeared like a thick white membrane. In the attempt to remove it by sponging the unusually tliin posterior bony wall broke through in several places. The same thing haj^pened when the mucous membrane was being removed with the curette from the medial wall and the orbital surface. While the mucous membrane in the lateral half of the sinus was being removed, it was found that the paper-thin lamelte of bone com- prised the anterior wall of a second cavity 2 cm. deep by 4 cm. wide, which lay externally and posteriorly. After this partition was com- pletely broken away with forceps another third cavity of about half the size was found medially in the direction of the sj^henoid. After removal of the mucous membrane and bony septa, the cavity was packed with 10 per cent, iodoform gauze and the removal of the orbital wall was begun. Here also the burr drill and the cranial rongeurs were employed (Fig. 225, Plate 42). The enlargement of the bony orifice on the floor of the sinus and its extension to the lateral nasal wall was carried out with the ron- geurs, by which procedure the ethmoid cells were simultaneously opened. Here the mucous membrane appeared similar to that of the frontal simis, and it was removed, together with the middle tur- binate, so far as was possible, through the lateral opening. Thus a wide communication was established between frontal siiuis and nasal cavity, and a dressing forceps could now be introduced without diffi- culty through the nasal orifice (Fig. 226, Plate 42) to draw up a drainage tube. The tube was left together with a drainage strip in the frontal sinus; the drainage tube alone was carried out through tlie nasal orifice, but the skin was sewed with four interrupted sutures over the iodoform packing along the superciliary ridge. Four days later one suture was removed in order to take out the iodoform gauze; to remove this tlu-ough the nose would have been too painful for the patient. The drainage tube was allowed to remain for about one week longer; at the beginning it drained off a bloody 190 SURGERY OF THE NOSE AND SINUSES fluid, but later a pure mucous secretion. Foin-teen days after opera- tion the patient was dischar cm. from its anterior edge through an incision running parallel with the anterior edge of the cartilage, taking care not to injure the mucous membrane on the opposite side. Between the cartilage and this nnicous membrane a raspatory is introduced, and the mucous membrane is freed on this side also from cartilage and bone. By means of the branches of the nasal speculum the two leaves of mucous membrane are held apart, and in this way a medial cavity is created in the nose, in which on both sides the cartilage, stripped of its mucous membrane, is visible. This is removed by one cut of a cartilage knife, whereupon the vomer and the perpendicvdar plate of the ethmoid are resected in large part with l)one forceps. So far the operative procedure is identical with the submucous resection of Killian. "To expose the anterior wall of the sphenoidal sinus, it is necessary that the mucous membrane on l)()t]i sides of the origin of the vomer on the sphenoid ])e lifted away. This ma}' be done readily; when this stripping up is ended, one can reach the anterior surface of the sphe- noid, and here also can raise tlie mucous membrane on both sides until the raspatorj^ falls through the sphenoidal osteum into the sphenoidal sinus. Now within the mucous membrane sack tlic posterior portion of the vomer and the sphenoid is broken through with a few blows of *Endonasal operations for tumors of the hypophysis, Archiv fiir Laryngologic, Vol. '21, N. 1. 196 SURGERY OF THE NOSE AND SINUSES the chisel and the opening is enlarged with a hone punch, whereupon after removal of the partition between the two sphenoidal sinuses, the hypophyseal tumor is seen lying free in its surroundings. After chiseling open the sella turcica and division of the dura the hypophysis or the hypophyseal tumor is completely exposed." CHAPTER 12— SURGERY OF THE TRIFACIAL NERVE NEURALGIC PAINS Of all peripheral nerves, the trifacial nerve is hy far the most frequent site of neuralgia, that is to say, of pains which come in paroxysms of greater or less severity, and which limit themselves at least in the ])eginning of the disease to the track of a particular nerve or nerve trunk. Predisposing etiologic factors apj)ear in many nerves, such as the passage of the nerve through a long, bony canal, many branches distributed over a wide field, or a superficial situation which exposes it to many sorts of trauma. The pains are sometimes preceded by a sort of aura, such as itching, a feeling of tension, twitching of the facial nmscles, etc. But usually they come suddenly and are of various grades of severity. All tran- sitions occur from a mild burning sensation to the feeling as if the face was being cut up with a red-hot knife. In other cases the pains are described as stabbing, rending, boring and cutting, and as the case proceeds they sometimes attain unbearable severity, so that the patient is driven to suicide. The attacks appear without occasion, or they are aroused by insignificant causes, such as touching the skin, a cold draught, mimic motions, talking, chewing, swallowing, etc., as well as by psychic excitement. They last at first seconds or minutes, and later often considerably longer. They may repeat themselves as often as several dozen times a day. In very severe cases the interval between attacks maj^ disappear en- tirely, so that one can no longer consider them as attacks. The night is often not free of pain. At times there may be a periodic recur- rence of the pains, for instance, in the spring-time. With the course of the disease ordinarily the sensitiveness of the skin to touch increases; but there may be numerous exceptions to this rule. At times there remains jjermanently in the aff^'ected area a feel- ing of painful tension. PAINFUL POINTS Certain points in the course of the affected nerve may be partic- ularly sensitive to pressiu'e; from these attacks maj"^ originate. Pain- ful jjoints may, however, be lacking in the most severe neuralgia; at times, indeed, the severity of the pain during an attack may be de- creased by pressure. 19T 198 SURGERY OF THE TRIFACIAL NERVE The painfvil points have their situation generally in places where the nerves emerge from hony canals or furrows into the soft parts, and where they accordingly can be pressed against an unyielding bone; also wherever the nerve trunk passes over from the deep-lying tissues to branch out in the skin or mucous membrane; and finally where the terminal branches of two nerves anastomose. As points of this sort we recognize in neuralgia of the first division of the trifacial the supraorbital point at the sujiraorbital notch, the palpebral point in the upper eyelid, the nasal point at the bony wall of the nose; in neuralgia of the second division the infraorbital point at the infraorbital foramen, a point in the upper lip to one side and below the ala, a point at the anterior portion of the temple and the cheek point on the malar bone; finally, in infra-maxillary neuralgia the chin point at the mental foramen and the temporo-maxillary point just in front of the tragus. A painful point in the neighborhood of the parietal eminence or a bit above it, which often is particularly sensitive (jiarietal point) , may belong to the distribution of either the first or the third division. As the major occipital nerve, and at times the minor also, send branches to this place, it must be determined by exact observation which nerve in any particular case is responsible. This impresses upon us the fact that a number of described painful points may lie in the distribution area of two different divisions of the trifacial, which is explained by the anatomical property of anastomosis. Careful examination of other painful points and close observation of the cases and regard for the history will generally serve to determine the affected branch, but not always. For that reason one must at times remove neighboring branches of two divisions; for instance, if pain is located exactly at the corner of the mouth, the infraorbital nerve and the inferior dental. IRR^VDIATION Every sensory branch of the trifacial nerve may become attacked by neuralgia. Often enough the attacks limit themselves throughout the entire course of the disease to a definite tei-minal branch; for in- stance, the supraorbital nerve of the first, the infraorbital nerve of the second and the mental nerve of the third divisions. Accordingly one speaks of neuralgia as being supraorbital, infraorbital, etc. In the begin- ning the pain starts usually from a well-marked point, but only seldom does it remain limited for any length of time to such place. JNIuch IRRADIATION PHENOMENA 199 more likely is it for the pains to spread very rapidly over the entire distrilnitioii of the diseased branch, or to irradiate immediately into neii'liboriny territorv. Usually this is a question only of the phenomenon of irradiation. This may involve wide areas; in disease of the inferior ilental. for example, it may reach into the region of the temple (auriculo-tem- poral nerve). The irradiation pains in severe cases are no less keen than the original, and if the coiu'se of the disease is lengthy the patient loses the ability to delimit exactly the region of the primary affection. The pains are described as vague. They include uniforndy one side of the head or face, and they irradiate even down to the neck. At times one loses on examination the impression that it is a question of a case of trifacial neuralgia, for it is impossible to determine in which of the three divisions the neuralgia took its origin. This experience we have had in several patients in whom a series of peri])heral nerve resections had previously been done, and in whom finally the Gasserian ganglion had to be removed. The entire hyperestbetic skin of the affected side was hardly less sensitive to pressure than the typical painful points. DETERMINATION OF THE AFFECTED BRANCH It is our task in every case to ascertain the nerve or nerves which are primarih' affected; in this we may be assisted by the following- considerations: In the beginning of the disease the painful area is likely to be more definitely limited, and the irradiation comes on only as the affection progresses. Also in the later stages the attack begins in the primarily affected area, the irradiation pains accompany it after a shorter or longer period, not infrequently after a few moments; in addition, the latter are not consistent; they may remain through sev- eral attacks or they may change their course, and usually they are not so severe as the pain in the primarily diseased area. The permanent sensitiveness which persists between attacks is evi- denced in the distribution of the nerve primarily affected. If the patient practices strong pressure in a certain j)lace for the alleviation of ])ain. this is as a rule over the primarily diseased area, and not in the irradiation zone. At times an injection of moi-phine prevents the irradiating pains without stopping the attack, and in this way may find use in diagnosis. Nevertheless, all the described characteristics may be without value in severe cases; then only the exact investigation 200 SURGERY OF THE TRIFACIAL NERVE N. lacrimaMs Ciliary ganglion N. supratrocHlearis i N. etbmoidalis N. infratroclilearis i N. nasocillaris Sphenopalatine ganglion N. canalispterygoidei (Vidil) Plexus carotlcus internus Otic ganglion I Oasserian ganglion K. eupraorbitalis N. zygomatlcus Rami nasales anteriores Rami nasales pcsterlores S. Infra- orbitallB Rami alveolares superiores Nd. palatini .Portio major i i {- of Trifacial nerve jPortio minor ) i N. petrosus superfieialls major ; N. petrosus superfieialls y I minor I ; Chorda tympanl N. auriculotemporalis N. caroticus Interoug- Plexus meningeus Superior cervical ganglion A', dentalis inferior Nn. carotid extern! 'A'. Ungualis Submaxillary ganglioa ■^Plexus caroticus externus Plexus maxillaris externusj V Common carotid artery A', meo talis Plexus alveolaris inferior Fig. 233 The Trifacial Nerve ; Schematic Drawixg of Its Branches and Their More Important Anastomoses (The nerves shown in red are the motor oculi (III) and the facial (VII) ; the root of the trifacial is shown by \'. and the glossopharyngeal by IX. The ganglia of the trifacial, as well as the branches of the sympathetic system, are colored blue.) (From Toldt. Anatomisch'er Atlas, 7th edition, 1911, Fig. 1298, page 859.) of the origin of the pain may be of help, just as the history may be of considerable importance. If one can determine clearly how far the affected area reaches, it is DETERMINATION OF THE AFFECTED BRANCH 201 ordinarily not difficult, with the help of a knowledge of anatomy, to determine the affected nerve. One must have due regard for the law of the eccentric phenomenon, acconhng to wliich the sensation that a sensory nerve has heen stimulated on reaching consciousness is always referred to the peripheral distribution of the nerve at the i)Iace in its N. opbtbalmlcus N. zygomatico temporalis N. occipitalis major N. zygomatlco- facialis N. infraorbltalla ' N. occipitalis minor N. aurlcularls magnus Nn. cervUalcs \ posteriores (dor- y^ Bales) Nn. cervlialea laterales (ventra- les) Fig. 2.'54 Scheme of the Distrihition- of the Sensory Nekves of the Head, After Fritz Frohse (From F. Khat.se, Die Necrai.gie des Trioemini'S, etc., Leipzig, 189(>, p. 57) The areas supplied by the 1st and 3d divisions of the trifacial are shaded, a ^ the blaelv area, represents the distribution of auricuhir braneli of the va<;us in the concha. course where the nerve fibres may be encountered. Moreover, regard nuist l)e ])aid to the fact that according to our present anatomical knowledge the area of distriliution of single branches is not by far so clearh' and regularly outhned as we have been accustomed to believe. The investigations of F. Frohse have indeed modified our opinions not only as to the branches of one and the same division, but also as to the relations of the three divisions to each other. Furthermore, one must have j)roper regard for the findings of Zander, according to which many areas are co\ere(l by several nerves. In spite of the dilfi- 202 SURGERY OF THE TRIFACIAL NERVE culties which these anatomical facts give rise to, they give us a basis for the fact known to every person who has had experience, that the area of distribution of single nerves is poorly definal)le. Exceptions occur when branches of both trifacials are affected, as occurs very early in certain general diseases, such as diabetes, influ- enza or certain intoxications (mercury and lead), or if the neuralgia passes over from one side to the other. We naturally except here all cases in which the neuralgia is caused by central disease, or is only a symptom. ACCOMPANYING MANIFESTATIONS During the attacks there appear irritative symptoms on the part of the secretory, vasomotor and trophic branches of the trifacial; for in- stance, reddening of the conjunctiva, increased secretion of tears, nasal mucus and saliva, reddening and swelling of the skin of the face, secretion of sweat and an increased sensation of warmth. Among the trophic disturbances is to be considered herpes, which occvu's on the forehead. The facial nerve may partake in the disturbance and set up fibrillary contractions and twitching, more rarely clonic spasm. In certain cases the motor portion of the trifacial is stimulated, causing contraction of the muscles of mastication and of the muscles of the tongue. At the same time as the pain in the face there may appear neuralgic symptoms in other portions of the body, such as intercostal neuralgia and sciatica. Pains in the occipital region which are observed in tri- facial neuralgia should not be assumed at once as being due to occip- ital neuralgia, for frequently they may be referred to irradiation. In severe cases practically the entire body may be involved. The patient trembles, cardiac activity is stimulated and the general sensi- tiveness is increased. There is nausea and often vomiting. At times one observes slowing of the pidse. THE TERMINATION OF NEUEAT.GIA AND RELAPSES Trifacial neuralgia ends, if recovery occm-s without operation, usually not all at once, but as a rule the pains disappear gradually after fluctuations up and down. After successfid operative proced- ures also the neuralgia does not disappear at once, but usually the attacks recur at times in the first few days, growing less severe and of shorter duration until they finally disappear. This property is observed only in peripheral nerve operations; in extirpation of the DIAGNOSIS OF TRIFACIAL NEURALGIA 203 Gasserian ganglion the neuralgic pains always disappear with the awakening from the anesthetic. Trifacial neuralgia tends to relapse and recurrences are common, particularly after all peripheral nerve resections, no matter by what method thev have been carried out. As a rule these affect the oriffinal nerve distribution, but at times they include other branches of the same division, or even the entire division. The severity of the pain in recurrences is usually decreased, and this fortunate circumstance may spare us further operative procedures. In other cases the severity equals that of the earlier attacks, and they maj^ reach a frightful de- gree and irradiate out into an ever-increasing area. DIAGNOSIS OF NEURALGIA In diagnosis one considers the picture as a whole and is not swayed in his judgment by one or another isolated symptom. The beginning of the disease is to be investigated closely, because at this time the symptoms are much more clearly defined than after the condition has long continued. Attention should be directed in every case as to whether or not any disease of the accessory sinuses or teeth, tumors in the peripheral course of the nerve, or within the cranium in the region of the trifacial may be present and cause the neuralgia, which will then be only a symptom of the underlying disorder. In the same way aneurysms in the arteries of the head, particularly the internal carotid near the Gasserian ganglion, or syphilitic disease of bone and peri- osteum may set up or imitate nem-algia. Mention should also be made of ueuritic processes, neuralgia in hysterics, headache and migrain, which may offer considerable diffi- culty in differentiation from idiopathic neuralgia. Each of the three divisions of the trifacial sends a branch to the dura mater to sup2)ly it with sensory fibres. It does not seen) improbable that tlicse branches also may become affected as in neuralgia, and that certain types of headache result therefrom. PROGNOSIS OF NF.ITUAI.GIA Trifacial neuralgia in itself is not dangerous to life, and one is ever astonished that people who suffer from a severe form of the disease seem reasonably well and in a good state of health, lint as a result of insufficient nourishment, it is not infrequent that a severe cachexia develops. Those in whom attacks occur at night, preventing sleep, suffer much more than others. Death, so far as we know, has never 204 SURGERY OF THE TRIFACIAL NERVE been observed in a neuralgic attack, except in the presence of some organic disease of the brain; but these cases cannot be classified with pure neuralgia. Loss of strength makes the organism on the whole less resistant to intercurrent affections and increases their danger, but nevertheless manj' patients in spite of the severest suffering reach an advanced age. Prognosis depends entirely on the cause of the neuralgia. If this may be removed, one may under skilful treatment in many cases induce a cure. Commonly the prognosis is more favorable if the neuralgia is of short standing and if it occurs in a young, well-nour- ished person. The outlook for cure is poorer if the disease is well settled, the attacks frequent and severe, and the patient exhausted and frail. Under operative treatment the prognosis as a rule is better in many respects. But one is still frequently met with the opinion that opera- tion should be considered only after all other means have been ex- hausted. This point of view should be strongly opposed. Likewise one frequently comes in contact with patients who, after thej' have been left in the lurch by all methods of internal medication, have de- scended to the frequent use of morphine by advice even of well-known nerve specialists, who hesitated to turn them over to the svu'geon. The morphinism is about as bad as the disease itself; and. above all, mor- pliine supplies only temporary relief in severe cases. ETIOLOGY OF NEURALGIA A neuropathic taint, exhausting disease with the resulting anemia and cachexia, prematiu-e old age, and above all. arteriosclerosis, play a role in the etiology of this condition; men and women in the prime of life are equally affected. ]\Iany infectious diseases may induce neuralgia, particularly intermittent fever, which does not infrequently give rise to supraorbital neuralgia. Of the acute infectious diseases, influenza is most frequently followed by typical neuralgia, and this affects usually the supraorbital and less frequently the infraorbital nerve ; facial neuralgia is also observed after typhus fever and small- pox. Certain poisons after long absorption work the same result; among others, mercury, lead, alcohol, nicotine. The neuralgia Avhich develops in diabetes and gout may be referred to a faulty blood and lymph cir- culation. In diabetes the third division is particularly affected, and frequently on l)oth sides. ETIOLOGY OF TRIFACIAL NEURALGIA 205 Amon^ tlie chronic infectious diseases syphilis should be considered, especially in so far as it gives rise to periosteal thickenino-. In the bony canals the nerves arc crowded rather closely, and there is room besides for only the nerve sheath, the accompanying vessels and the thin periosteal layer. Under these conditions even the slightest swell- ing must result in pressure. This refers particularly to the smaller canals, such as those for the dental nerve, the zygomatico-temporal and the zygomatico-facial canals, etc. Moreover, the nerve itself or its sheath may be attacked by the specific inflammation, and at times, particularly in the beginning of the disease, it is impossible to make any other diagnosis than that of neuralgia. Indeed, it has not yet been determined whether a true neiu'algia may occur as a result of syphilis. Syphilitic inflammation of the membranes of the brain should also be mentioned. Rheumatism and exj^osure play a role in the etiology, and also dis- turbances of digestion and chronic constipation. Finally, among the causes should be named chlorosis, diseases of the pelvic organs in women and mental emotion. In many patients the neuralgia is laid to injury of the bones of the face or skull. CENTRAL OR PERIPHERAL SEAT OF THE NEURALGIA It is very important to know whether the cause of the neiu'algia has its seat in the brain or in the periphery. If changes are to be observed in the pcri])hery which we know cTupirically to induce pain, such as scars, foreign bodies, tumors, one is justified in seeking here the cause. IT the neuralgia has come on in a definite portion of the face after a severe cold or injury, and it limits itself to this region, one may determine in favor of a peripheral location. But one must always remember that nerve changes once instituted may advance along the nerve to the brain itself. Ordinarily, in accorchmce with the law of eccentric manifestations, the cause is to be sought the higher up, the more branches of a division are really affected, excluding, of course, the area of irradiation. Ac- cordingly, in the unusual event that all three roots were affected from the beginning, it may be stated with some certainty that the disturb- ance exists within the cranium. Here it may be located near the an- terior portion of the ganglion, where the three trunks lie close to each other, or in the '••anylion itself, or still further centrad, in the course of the sensory root from the nucleus. The same effect may be pro- 206 SURGERY OF THE TRIFACIAL NERVE duced by periostitic processes which occur in the middle fossa and involve all three roots. But in case as ordinarily the neiu'algia is limited to one or a few branches, one cannot always determine definitely that the cause is peripheral. Even when tumors or aneurysms of the internal carotid compress the trifacial in its intracranial course, only certain branches may show neuralgic symptoms. The motor root resists the injurious pressure longest, and even the sensory fibres are not affected equally, for at times in such cases instead of neuralgia, anesthesia develops in the trifacial region. If at the same time a patient shows signs of cerebral disease, one frequently refers the neuralgia to a central cause; but this assump- tion is often ungrounded, for there may be no connection between the neuralgia and the brain disease. In other cases, in spite of the absence of all cerebral symptoms, even if the condition has lasted for years, the cause may, nevertheless, exist within the cranium. This short con- sideration demonstrates how difficult is the localization of the seat of the causative agent, and how frequently it is really impossible. GENERAL TREATMENT OF NEURALGIA Before instituting treatment, one should attempt to determine the cause in each case. If successful, treatment should be directed along this line. To determine the cause, the history is of some value, but of more importance is a careful investigation of all the organs from which we know empirically that the disease may originate. To this group belongs the teeth, the ear, the eyes and the accessory sinuses. Even in teeth which are externally sound, exostosis of the root may be present and give rise to neuralgia. The neuralgia which originates from the sclerosis of toothless gums may be relieved by resection of the alveolar process. If supraorbital neiu'algia is caused by frontal sinuitis, relief may be obtained by the regidar use of nasal douches (lukewarm 7 10 per cent, salt solution or 3 per cent, boric acid solu- tion). Chronic inflammations of the nose and catarrh of the middle ear must be submitted to the regidar form of treatment. If splinters of bone are left after extraction of teeth, or if foreign bodies, scars or tumors are present in the coin-se of the nerves, atten- tion should be directed at once to their removal. The use of morphine should be avoided entirely in chronic cases. The danger of habit formation is particularly great in long-standing cases. One should not delude one's self with the purpose of giving a ALCOHOL INJECTIONS 207 few hours of peaceful sleep to the unfortunate sufferer. The drug in really severe cases of neuralgia ^ives relief for only a short time, and even large doses rapidly lose their effect, and then as a permanent sequel the morphine habit persists. Surgery possesses, even if medical treatment fails, a series of procedures which offer aid to the patient, and in the worst eases the final and most serious operation, the removal of the Gasserian ganglion, is always to be given consideration prior to the continued use of morphine. ALCOHOL INJECTIONS As in sciatica, we have attempted to relieve trifacial neiu'algia by means of the injection of anesthetic agents. In the first and second divisions of the trifacial Lange injected 30 to .50 cc. of salt solution under strong pressure into the nerve sheath or the immediate neigh- borhood, in order to cause separation, stretching or mechanical tear- ing of the fibres. The proportion of cures was small, and so Schlosser employed 80 per cent, alcohol and injected 2 to 4 cc. directly into the diseased nerve trunk with the purpose of killing it by inducing degeneration and absorption of all but the neurilemma. This method . offered a substitute for nerve resection. The enthusiastic adherents of this method believed that all periph- eral trifacial resections could be satisfactorily rei^laced by alcohol in- jections. There can be no longer any question of this; for in the last few years many patients have come with the in\gent request for opera- tion, in whom alcohol injections have been made by exjjerienced men, at first with result, but after repeated relapses with less result, and finally without any effect. True neuralgia can be treated effectively only by operatiAC methods, and frequently only by very radical meth- ods; for many ])atients who have been under treatment for years, and in whom all methods have been employed, come to the surgeon with the determination finally to be rid of a disease which is driving them to suicide. Of IS^ patients operated upon up to April, 1907 (Krause), not less than 17 had made previous attempts at suicide. The Schlosser method is indeed a great advance, and after its em- ployment many neiu-algics have doubtless experienced lasting relief from pain. The method should be practiced more frequently, in so much as it renders the peripheral branches readily accessible without danger. .Somewhat more difficult is the basal injection of the second root at the foramen rotundum, and of the third root at the foramen ovale. Whoever knows anatomy may find these places with the 208 SURGERY OF THE TRIFACIAL NERVE cannula without difficulty (see p. 42). To inject alcohol into the Gasserian ganglion is, however, too rash a procedure, and likewise the hranches which run through the orbit must be excluded, since the eye muscles and probably the optic nerve might readily be injured. PERIPHERAL OPERATIOXS GEXERAI, ANESTHESIA AND LOCAL ANESTHESIA Neither in peripheral resection of the branches of the trifacial nor in extirpation of the Gasserian ganglion is general anesthesia uncon- ditionally necessary. All the ojierations under consideration may be carried out by means of novocain and adrenalin anesthesia with com- plete success, and for the region of the trifacial it is to be particularly recommended. For the technic see the chajjter on Anesthesia, page 42. Xevertheless, there are many patients who earnestly request gen- eral anesthesia, since through this most jiainful of all diseases their capability of resistance has been so decreased that they can no longer stand the psychic excitement which any operation, even if carried out painlessly, induces. In such cases we have never exercised any pressure, but have always given general anesthesia the preference, excluding only cases in which it is contraindicated by the presence of uncompensated heart disease or lung or kidney affections. Just the most severe type of neuralgia is often accompanied by arteriosclerosis, and according to accepted opinion it is even caused by this condition, so that general anesthesia is not infrequently contraindicated. With the aid of local anesthesia one can consistently extend the indications for radical operation on the branches of the trifacial, and particularly also for extirpation of the Gasserian ganglion, much further than in the time when we were limited to general anesthesia alone. INDICATIONS Operative treatment should not, as so commonly happens, be con- sidered the last refuge. There is no question but that as a result of this attitude many patients who could have been cured at the begin- ning by comparatively simple procedures lose, in great measure, their chance of relief through long continuance of the disease. The neural- gic changes which at first lie peripherally in the nerve steadily advance centrally, and finally in deep-seated cases no extra-cranial operation can be of lasting value. We can expect cure earher if the origin of NERVE EXTRACTION 209 the iieuralfi;ia can be located in the re<^i()n of the peripheral dis- tribution. The detcnnination as to which nerve should be removed is not always simple. Irradiating ])aiiis may render tiic cpiestion a difHcult one to sohe. as we have already shown. A good knowledge of ana- tomical relations, a careful consideration of history, as well as an exact observation of the attacks, are unconditionally necessary before the decision should be made. As a general rule it may be stated that the peripheral branches must be followed up from the smallest to the place where all the branches which are affected bj^ the neuralgia have united into one trunk ; and at this point the division should be made as early as possible. EXTRACTION OF NERVES The extirpation of nerves centrallj^ as well as peripherally is the object of the nerve extraction introduced by Thiersch. The affected nerve is exposed in its surroundings, and without being divided is seized crosswise by a clamp, which will grasp the nerve securely and not allow it to slip. A clamp ridged longitudinally is satisfactory, provided the ridges are not sharp enough to cut through or crush the nerve fibres. The nerve being securely grasped, the clamp is rotated slowly on its long axis, according to Thiersch, about a half turn every second, but it may be slower still with advantage. This procedure causes the peripheral section to be twisted out down to the finest ter- minal branches. Of the central portion one usually gets a ])iece about 3 or 3l'o cm. long if it runs through soft tissues and is not closely attached to a bony canal; it usually tears after this much has been removed. It is to be observed that centrally only those nerve fibres are pulled out by the slow drag which are tightly seized in the clanij); branches which are given off higher are only torn, but are generally not divided. The best rule to follow is to remove centralh* as much of the nerve as possible. Moreover, all the nerve branches which run through long bony canals must be exposed to a point behind these and removed. How great an extent of nerve may be removed by this method is shown by the Figs. 23.5 and 236. Since the anastomotic fibrils of the facial nerve are removed also in their terminal portions (see a in Fig. 23.5), it is not unusual at times for paresis to appear, particularly in the muscles of the upper lip and the ahc of the nose, but tliis dis- appears rapidly. 210 SURGERY OF THE TRIFACIAL NERVE The advantages of the method are clear. Insignificant incisions are sufficient for the exposure and extraction of extensive portions of the nerve, and the operation is attended with verv little danger or sacri- FiG. 235 I. Frontal >rerve; II. Infraorbital Xerve. Removed after the method of Thiersch, from a 78 year-oUl i>hysioian. Natural size. In II aljove and to the left may be seen the be<;in- nings of the Superior Dental nerves pulled out at the same time, a shows anastomosis of terminal branches of Infraorbital with filaments of Facial. fice. Theoretical discussion has little place here; tlie best evidence as to permanent cure is offered by the considerable number of patients who come rei^eatedly to operation to be freed from their sufferings for a time at least. Every active surgeon has had such experiences, NERVE EXTRACTION 211 and W. W. Keen, of Philadelphia, has reported a case in which a dentist had undergone fourteen operations for trifacial neuralgia dur- ing the space of thirteen years. Fig. 236 Inferior IMaxillarv nerve exposed hy dividinjr tlie ramus of the jaw, and twisted out after the method of 'lliiersch, from a 43 yo:ir-ohl m:ui. Natural size. Ch. t. = chorda tympani nerve. 1 =: linfjual nerve, a. i. = inferior dental nerve. 212 SURGERY OF THE TRIFACIAL NERVE RESULT AXD PROGNOSIS OF PERIPHERAL OPERATION After the peripheral operation — this inchides all methods — the iieuraloic pains do not always disappear so completely that the patient on awakening from anesthesia only feels the jiain of the wound. Often enough in the first few days after operation attacks recur, which soon, however, decrease in number and severity and finally disappear en- tirely. Clearly the cause of this lies in the injury which the nerve has suffered during the procedure, and particularly in its separation. One should advise the jjatient of these possibilities before operation in order that later it may not give unnecessary anxiety. In a few cases, luckily infrequent, the neuralgic pains remain un- affected by the peripheral operation. This we have personally ob- served twice. Peripheral resection, although used extensively, is in many cases only a palliative operation. But the early as well as the later recur- rences are after all much more mild than the original disease, so that the patient is satisfied with his condition, and does not de- mand further operation. According to the statistics worked out by Dr. Dege up to April, 1907, of 134 cases operated upon by one of us (Krause), 14 per cent, remained free of recurrence. The average painless period, according to these statistics, lasted two years and two months ; there was, however, one recurrence after eight years. On the other hand, several old persons have died without ever having recurrence of pain, and the longest painless interval observed lasted seventeen years, until death (infraorbital and maTidibidar) . All these facts refer to the resection of peripheral trifacial branches. In 27 per cent, of the cases the recurrence was slight, so that no further operation was necessary. ]More than half the patients had to be operated on again, and in not a few the Gasserian ganglion was later extirpated. As regards the immediate prognosis of peripheral nerve operations, the majority, including those which were carried out after the method of Thiersch, were trivial procedures. The wounds healed rapidly and left insignificant scars; the stay in the hospital was limited to few days. The anesthesia which resulted bothered the patient little, and more- over in the course of time the area grew smaller and smaller, with the exception that once after extraction of the supraorbital nerve we observed severe keratitis, which healed, leaving a corneal opacity. Extra-cranial procedures which are carried out at the base of the skull are, on the other haiid. to be considered serious operations. Even Krause-Heymann- Ehrenfried. Tab. 44. Resection of the frontal nerve. Su/ynwrbital n erve Branch of sitpraofbital Branch of supraorbital Supraorbital nerve Fig. 237. The frontal nerve is exposed. Fig. 238. The margin of the orbit over tiie foramina is chiseled away. Frontal nerve Fig. 239. The trnnk is seized and torn out. Fig. 240. The terminal branches are twisted out. Rcbnun Company, New \ork. FIRST OK OI'HTIIAL.MIC DI\ ISION 213 thou<>h life is only exceptionally endangered, nevertheless extensive scars and at times interl'erence with the movement of the lower jaw result. Of the f>i-eat number of methods devised and employed we shall give only the most jjractical. One should always be famihar with several methods for the severe operations on the base of the skull, as the scars of previous operations may make one or another imjirac- ticable. During- all resections of the trifacial the patient is held in the half- sitting posture. FIRST OR OPHTHALMIC DIVISIOX OF THE TRIFACIAL RESECTION OF THE FRONTAL NERVE A fifty-eight -year-old woman suffered for several years with severe neuralgia in the region of the sujjraorbital nerve, due in all probability to arteriosclerosis. Injections of alcohol had brouglit temporary re- lief, although when repeated they showed themselves to be useless for a permanent cure. A skin incision 3I/2 or 4 cm. in length (Fig. 237, Plate 44) was made along the upper edge of the left orbit through the middle of the shaved eyebrow. The supraorbital notch, which could be palpated through the skin, lay about in the middle of the incision. After di- vision of the skin and a few fibres of the orbicularis palpebrarum muscle, a few fine twigs of the supratrochlear nerve came into view, which were carefully preserved, so that by following them up one could the more easily reach the trunk; they were freed for a short dis- tance. (Since the branches of the facial which run to the orbicularis and the frontalis muscles enter these muscles from the outer side, they were not met in this incision.) Below these peripheral l)ranches the periosteum was now incised down to bone. The supraorbital nerve was found to lie in a supraorbital foramen; the fine twigs already mentioned were given off from the supratrochlear nerve, which like- wise came out through a small canal at the edge of the orbit. In both places the small l)ridge of bone was removed M'ith a fine chisel and hammer (Fig. 238, ]'late 44), until a notch remained in which the nerve fibres lay free. (Ordinarily the supraorbital notch is bridged over only with stout connective tissue, which has to hv cut awaj\) 214. SURGERY OF THE TRIFACIAL NERVE llamas fi-oDtalla .Occipitofrontalis muscle '- Trochlea \, Superior oblique muscle Orbicularis palpebrarum muscle N. supraorbit&lls N. etbmoidaJis Orbital periosteum N. supraorbit&lla Levator palpebrae superioris muscle Superior rectus mutcle /// [External rectus muscle N. opticus if. ophtb&lwicus N. maxillaria superior N. trochlearls A sttpratrofblearis K iatra.trocbleans tacrlmal gland Basoclllarls Anastomotic branch th zygomatic nerve N. menlngeus medius ddle meningeal artery Hiatus of th', facial canal H. tentOTli Tentorium cerebelll N. splnosus Root of oculo- motor nerve Root of troch- lear nerve Root of trifacial nerve Root of abducens nerve Inclsura tentoril Straight Binns Occipital sinus Transverse sinus Conflnens sinuum (torcula) Fig. 241 The FrasT or OpiixnALMic Division of the Trifaciai, Nerve, With the Superior Branch of the oci lomotor, and the trochlear, as tlley appear after removal of the Roof of the Orbit The nerves supplying the dura mater: the tentorial nerve (from the ophthalmic division of the Trifacial), the meningeal (from the superior maxillary division), and the recurrent spinous (from tlie inferior maxillary division). (On the left the upper margin of the orbit is left; the levator palpebrae superioris and the superior rectus muscles arc divided at their origins, and turned over, to show the branches of the oculomotor entering them.) (Fres of gauze held by forceps, until the trunk of the frontal nerve was exposed for a considerable distance ( Fig. 2.'}0, Plate 44). AN'hile the orbital contents were carefully held downward out of the wav bv a retractor — one carefully refrained from tearing periosteum, because then the orbital fat would fall apart and inter- fere with vision — the nerve trunk was readily loosened from its sur- roundings by blunt dissection. It was grasped with the nerve clamp as far proximally as possible, and torn out by a slow, strong pull. The peripheral branches were extracted down to the finest termini by very slowly rolling them up on the clamp (Fig. 240, Plate 44) . From this mana'inre, through the tension on the fine branches, there resulted deep folds in the skin of the forehead. Hemostasis was attained by temporary pressure with gauze. A small drainage tube was kept in the middle of the incision for two days in order to anticipate the for- mation of hematoma in the orbit, the rest of the skin wound being sutui-ed. After four days the patient was discharged without jjain and with the wound healed. OTHEK BRANCHES OF THE OPHTHALMIC DIVISION The branches of the frontal nerve do not always come off in the same way. If one of them is left behind relapse may readily occur. Therefore, as a rule the frontal nerve should be sought far back in the orbit, before it has given off the suj)ratrochlear branch. One may succeed in freeing the ophthalmic trunk even to the point of origin of the lachrimal branch by going back far enough into the funnel of the orbit aftei- lengthening the incision somewhat externally, but not to the origin of the nasal nerve. We can expose one of the terminal branches of the nasal, the an- terior ethmoidal nerve, where it jjasses through the anterior ethmoidal foramen at the inner upper wall of the orbit, to reach the upper sur- face of the cribriform plate. For this purpose the incision is carried to the inner edge of the orbit; the stripped up periosteum together with the contents of the orbit are shoved downwards and outwaids. If the lachrimal gland interferes it must l)e ))ulled out from its recess. In lifting uj) periosteum the ethmoidal nerve is ])ut on the stretch, and is visible about 2 cm. behind the medial end of the supraorbital margin; one can grasp it in the clani]) and twist it out. In operations on the medial half of the orbit the trochlea or pulley must be carefully avoided, in order to prevent disturbance of function 216 SURGERY OF THE TRIFACIAL NERVE in the superior oblique muscle and diplopia. The arteries which ac- company the nerves are only to be isolated if the two structures he AT. A-aots/te Superior rectus muscle Superior obli/iue muscle . Bupraorbita \ Nn. clllaros breves Nn. clUares loDgl ( Levator palpehrae superioria I muscle, turned back Ciliary ganglion Radix looga ganglil ciliarie 14. aasociliaris External rectus muscle, turned back I N. opticus i N. oculomotorius ; / / N opbtbalwicus I ! I I Internal carotid artery I / ; N. abducens ' Gaseerian gaaglion Jtamvs frontalis Rami palpebrales yiJ/ inferiores Branches to the skin of the cheek Ramus nasalis externus Rami labiales superiores , / i Branches to mucous membrane of cheek N. maiillariB superior maiillaris inferior Radix bievis ganglii cillaris \ Sphenopalatine ganglion X. inf^aoTbitalis t Rami alveolares superiores posteriores Ramus alveolaris superior medius Branches of facial nerve N. den tales superiores Ramus alveolaris superior anterior Fig. 242 The Second or Superior Maxillary Division of the Trifacial, With Its Anastomosis BY Two Sphenopalatine Nerves With the Sphenopalatine Ganglion, the Superior Dental Nerves. The Infr.\orbital Branch of the Superior M.^xillarv Distributino Over the Face. After Leaving the Infraorbital Foramen. The Frontal Nerve and THE Ciliary Ganglion, With Its Branches Going to the Eye-ball, Co.me Off From the First DmsioN. Left Side of the Face, Frosi the Left (The skin of forehead and cheek witli the siij)erfioial muscles of expression is divided behind and turned forward. The lower jaw is taken oil', and the lateral wall of the antrum as well as the lateral wall of skull down to pterygopalatine fossa is removed. Levator palpebrae superioris and external rectus muscles are divided and the posterior portions turned hack. The quadratus labii superioris muscle, which hides the bTanching of the infraorbital nerve, is lifted away on ,