front of the ear and easily felt, must not
be injured.
2. After the soft parts and the peri-
osteum Jiave been reflected, tJie neck of the
maxilla is exposed ; this is di\'ided trans-
versely by careful strokes with the chisel
(Fig. 883). The articular end, which
Jias become loose, is removed with bone
forceps. The internal maxillary artery,
coursing closely behind it, must not be
injured. This artery might easily be in-
jured if the resection were made with
the metacarpal saw or with the bone-
cutting forceps.
During tJie after treatmcjit, a inofable
neartJirosis, to as high a degree as possi-
ble, must be obtained by frequent gym-
nastics of the jaw.
In ankylosis, whether produced by
cicatricial bands, or possibly by boiy
union of a portion of the inferior with
the superior maxilla, the simple division
of the bands and of the shortened musclts
is of little avail, even if it is followed by a gradual stretching of the same by
means of oral specula and gags. In cicatricial contraction of the masseter
and the pterygoid muscles the operator may try to detach the insertions of
these muscles from the bone (^Le Dentu). Cicatricial bands of the mucous
membrane of the cheek are extirpated ; the defect thus caused must be cov-
ered by major plastic operations, according to the rules of meloplasty (see
Fig. 912. Topography of the Temporo-
iM.\xiixARY Articulation. Z, zygo-
matic process; JI, mastoid process: a,
capsular ligament; 1^, accessor}' lateral
ligament; Tp, temporal muscle: San,
sternocleidomastoid; £i, biventer; St,
stylohyoid: mi, internal maxillary arten.-;
ts, superficial temporal artery: tm, middle
temporal artery; af, posterior auricular
artery; oc, occipital artery; at, auriculo-
temporal nerve
492 SURGICAL TECHNIC
page 88, Gussenbaiiei-). In cases where this is not possible, or where it does
not produce the desired effect, the jaw bone must be laid bare in front of the
site of the cicatrix, and a piece about two or three centimeters long must be
sawed out from its thickness {yon EsmarcJi) ; a false articulation is thereby
produced, consisting of fibrous union, which enables the patient to open the
mouth and masticate. Bauin resected a li'edge-like piece from the angle of
the jaw. The simple division of the jaw by sawing {Rizzoli^ tends very
rapidly to produce a bony reunion of the fragments. Resection of the articu-
lar etid (see page 491) has been recommended by Bottini and Konig as the
most successful procedure in osseous ankylosis. Kiister divided also the
coronoid process to relieve the tension of the temporal muscle. In serious
cases, with considerable contraction of -the muscles and ligaments, even the
whole upper portion of the ramus of the lower jaw directly over the lingula
may be removed {Mears^ by adding a transverse incision along the lower mar-
gin of the malar bone to the incision mentioned on page 491. To prevent
a reunion {by grozvth) of the resected jaw with the acetabulum (glenoid
cavity), Helferich interposes a flap taken from the temporal muscle, which at
the same time prevents too great a displacement of the lower jaw in an
upper and backward direction. By this means, the position of the jaw and
the form of the face are better preserved than by a simple extensive
resection.
He proceeds as follows : —
1. A longittidinal incision four centimeters long is made a finger's
breadth in front of the ear, penetrating deep down (protecting the parotid
and also the temporal artery) until the bone in the region of the articulation
of the jaw is exposed.
2. The articular process of the lower jaw is resected with the chisel to an
extent of more than one centimeter above and below, without preservation
of the periosteum.
3. After enlarging the external incision in an upward direction, a longer
flap three centimeters broad with a lower base is excised from the temporal
viuscle and turned over downward, so that it can be placed around the malar
bone into the defect, where it is fastened by a few lateral sutures. If the
turning over causes any difficulty, a corresponding portion is resected from
the zygomatic arch.
4. The wound in the temporal muscle is diminished by buried sutures ;
the external wound is closed completely without drainage.
Subperiosteal resection of the lower jaw for phosphorus necrosis, Dum-
reicher makes as follows : —
OPERATIONS ON THE HEAD
493
From an incision made along the lower margin of the jaw throughout
the whole extent of the swelling of the bone, the gums and the ensheathing
periosteum are detached from the bone on the anterior and posterior sur-
faces. The bone thus exposed is divided at both limits of the necrosis with
a metacarpal or a chain saw, and the loosened portion is extracted. The
bone can also be removed subperiosteally from the mouth after an incision
has been made at both limits of the necrotic area about 3 centimeters in
length along the lower margin of the jaw; and, after the detachment of the
soft parts from the anterior and the posterior wall, the bone is sawed
through on both sides.
Concerning the temporary resection of the lower jaw, see below (amputa-
tion of the tongue).
NERVE STRETCHING AND NERVE RESECTION
In obstinate diseases of the peripheral nerves, which will not yield to
any internal remedies, a surgical operation is justifiable and proper.
Least destructive, but at the same time productive of permanent relief
only in rare cases, is
Neurotony, nerve stretching.
With a knife, the nerve is laid bare at an easily accessible place, grasped
with a blunt hook or with the fingers, separated from the underlying tissues,
2LXvdi forcibly stretcJied. This force, of course, must be adapted to the tensile
strength and the thickness of the nerve trunks ; for example, while the
facial nerve is easily torn, on the other hand the whole leg may be lifted by
the sciatic nerve. Whether the stretching has been sufficient may be deter-
mined by the serpentine positioji of the nerve after the operation.
Neurotomy, simple division of the nerve, is only temporarily useful, be-
cause, by the rapid reunion of the severed ends, conductivity is too soon
restored. Its place, therefore, has been taken by
Neurectomy, nerve resection, that is, the excision of as long a portion of
the nerve as possible. This procedure is especially suitable for the purely
sensory nerves (trigeminus), for which prelivmiary operations of consider-
able magnitude are required. TJiiersch, however, has shown that sufficiently
large portions of the nerve can be removed without these preliminary meas-
ures by
Neurexairesis, nerve extraction, that is, the tearing ont of the nerve.
For this purpose it is necessary to expose the nerve at one place only.
Next, with the Thiersch forceps (Fig. 913), it is grasped transversely and by
494 SURGICAL TECHNIC
slow tnriis tvrapped aroujid the forceps. During this traction, the periphe-
ral, as well as the central, parts of the nerve, together with its ramifications,
may be stretched considerably before they tear off as a result of too great
Fig. 913. Thiersch's Forceps for Nerve Extraction
tension. In this manner, portions of nerves from 5 to 7 centimeters long
may be torn off from one point, while the parts still remaining are greatly
stretched.
Nerve stretching has been made : —
1. In disturbances of sensibility and motility {iieuralgias, tonic and clonic
spasms), especially when their cause consists in a peripheral disease, incur-
able in itself.
2. In reflex epilepsy, if it originates from the peripheral nerves.
3. In trmmtatic tetanus.
Resection and extraction of nerves is more especially made for the relief
of obstinate neuralgias of tJie several branches of the trifacial nerve (Fig. 914).
THE SITES FOR LOCATING THE SEVERAL NERVES
are as follows : —
SUPRA-ORBITAL NERVE
'Y\iQ. first branch of tJie trigeminus, the ophthalmic nerve, enters the orbit
through the siiperior orbital fissure, and takes its course as tJie supra-orbital
nerve, between the roof of the orbit and the levator of the upper eyelid, and
then in a straight anterior direction to the supra-orbital notch, where it divides
into branches in the skin of the forehead. Not rarely it gives off some
branches previously, which, 2i^ frontal and sjtpratrocJdear nerves, extend up
to the forehead and over the internal portion of the superior margin of the
orbit (Fig. 914, /).
1. External incision in tJie form of a curve 3 centimeters long, taking its
course closely below the shaved-off eyebrow along the orbital margin.
2. Division of the fibres of the orbicular muscle and the tarso-orbital fascia.
OPERATIONS ON THE HEAD
495
ophthalmicus
upramaxillaris
^g sphe7iopalaf
r yFor. ovaL
'ramaxillaris
Fig. 914. Diagram of the Divisions of the Trigeminal Nerve, Zygomatic
Arch, and jNIandibular Plate, resected according to Kronlein
3. With a spatula, the levator palpebr<2 snpcrioris muscle is pushed
downward together with the eyeball ; the nerve can then be seen running
Exposing Scpra-orbital Nerve
Fig. 915
along the roof of the orbit between the fatty orbital layer and the periosteum,
and can easily be grasped and drawn forward with a strabismus hook ; tJie
frontal nerve is found more toward the inner side (Fig. 916).
496
SURGICAL TECHNIC
The accessible portion of the nerve may be cut off with Cooper s scissors
near its entrance into the orbit, and its ramifications in the skin of the fore-
head may be torn out bluntly ; for extracting them, the forceps are applied
at the supra-orbital notch.
SUPRAMAXILLARY NERVE
The second brancJi of the trigeminus, the snpraniaxillary nerve, takes its
course from the foramen rotnndiim in the spJietio^naxillary fossa through
the inferior orbital fissure to the orbit, in the floor of which it runs along in
the infra-orbital canal as far as the ijifra-orbital foramen, where it ramifies in
a fascicular manner, as the pes anserinus minor, in the canine fossa under
the levator labii superioris (Fig. 914, //).
Fig. 917
Exi'OSiNG Inkra-orbital Nerve
Fig. 918
1. External incision in the form of a curve 4 centimeters long along
the lower margin of the orbit down to the bone (Fig. 917).
2. With an elevator, the periosteum, together with the soft parts, is
detached from the floor of the orbit as far as the iifra-orbital groove, and
all the contents of the orbit are lifted from the bone by means of the reflect-
ing hollow refractor {^Wagner, Fig. 919), a spoonlike spatula, the external
surface of which is as smooth as a mirror. If necessary, a silver teaspoon
may be substituted for this instrument. By the side of the artery the
ivhitish nerve can now be seen distinctly, shining through the thin upper
bony wall of the infra-orbital canal (Fig. 918).
3. In case a larger portion of the nerve is to be resected, the ////;/ tvall
of the infra-orbital canal is opened with a fine chisel ; the nerve is drawn
forward with a tenaculum, and cut off with scissors at its place of ejitrance
into the orbit, as far back as possible.
OPERATIONS OX THE HEAD
497
4. At its place of exit in the infra-orbital foramen \.\\q. pes anserimis viinor
is exposed, if necessary, by a small additional external incision in a down-
ward direction (Fig. 917, a). From this place the already severed end of the
nerve is drawn from the infra-orbital canal with a tenaculum or with forceps,
and cut off or torn from its ramifications in the skin.
Fig. 919. Wagner's Reflecting
Hollow Refractor
Fig, 920. Neurectomy of the Infra-orbital
Nerve, b, Liicke-Braun-Lossen's resection of
the malar bone; a, Thiersch's method of ex-
posing infra-orbital nerve for extraction
For extracting the nerve on this branch it is sufficient to expose its place
of exit at the infra-orbital foramen (Fig. 920, a). The forceps are introduced
under the nerve transversely to its axis, and, by slowly rolling it up, twist
out the central part (as far as its place of entrance into the orbit) and its
peripheral extensions {alveolar and dental branches).
For dividing the superior alveolar nerves, von Lajigenbeck detached with
raised upper lip the duplicature of the mucous membrane from the bone by
a long incision ; and with the metacarpal saw or chisel he divided the
anterior wall of the antrum of Highmore from the nose as far as the ptery-
goid process.
If it appears desirable to make the supramaxillary nerA-e accessible as
far as its exit from tJie cavity of the sktill {^foramen rotiDidnni), the surgeon
■performs : —
49S SURGICAL TECHXIC
NEURECTOMY OF THE SUPRAMAXILLARY NERVE WITH TE>rPORARY RESECTION
OF THE MALAR BONE {Liickc-Braiin-Losscn)
1. The external incision is in tJie form of an angle. TJie first incision
begins i centimeter above the external angle of the eye, and 2 to 3 milli-
meters from the external orbital margin ; in an anterior direction it descends
obliquely as far as the region of the third upper molar, where the zygomatic
process of the upper jaw can be felt as a sharp angular projection.
2. With a small pointed knife, always kept close to the bone, the soft
parts on the internal surface of the malar bone are detached from below
upward, and the latter is sazvcd tJirongh with a metacarpal saw or with a
chain saw obliqttely toward the viedian line.
3. The scco)id incision is made at a right angle to the first incision from
its upper end, in a posterior direction along the icpper margin of the zygo-
matic arch as far as the zygomatic process of the temporal bone, dividing
the skin and the temporal fascia.
4. At its connection with the temporal bone the zygomatic arch is then
divided with a saw or chisel (or merely nicked, Braun), and the skin flap,
together with the zygomatic arch and the masseteric insertion, is turned in a
downward direction (Fig. 920).
5. After the anterior fibres of the temporal muscle, if necessary, have
been divided, the masses of fat bulging from the sphenomaxillary fossa,
together with the venous plexus and the internal maxillary artery, are pushed
backward with broad retractors ; if necessary, the fatty tissue lying below
may be cut away.
6. The nerve is now sought for with a strabismus hook introduced into
the infra-orbital groove, and an attempt is made to separate the ntrxQ. from
the infra-orbital artery ; the artery, a branch of the internal maxillary, takes
its course from ivithout backwaj'd 2cnd dowjiward ; the nerve take its course
from behind inward and upivard, obliquely fori^'ard, downward, and out-
ward, and may be traced centrally as far as the foramen roticnduni.
7. While the nerve is vigorously drawn forward with a tenaculum, it is
divided with pointed curved scissors (" Hohlscheej-e") as near the foramen
rotundum as possible; its peripheral branches, together with the severed
pieces, are evulsed.
Kocher reaches the foramen rotundum by avoiding the facial branches
by turning the malar bone in an outward direction.
I. External incision, beginning i centimeter towards the median line
at the palpable infra-orbital foramen, takes its course forward and in an
OPERATIONS ON THE HEAD
499
external direction, somewhiat obliquely downward as far as the zygomatic
arch (Fig. 921); ligation of the angular artery, avoiding Steno's duct;
division of the orbicular muscle of the eye, which together with the peri-
osteum is raised as far as the orbit. The musculus quadratus of the upper
lip is detached subperiosteally, and the infra-orbital nerve thereby exposed
is grasped with a strabismus hook at the place of its exit. The insertions of
the zygomatic muscles and of the anterior portion of the masseter are
detached from the malar bone.
Fig. 921 Fig. 922
Kocher's Method of exposing the Supramaxillary Nerve
AT the Foramen Rotundum
2. The zygomatic arch is freed internally and externally, and chiselled
through obliquely; the union with the upper jaw is divided so that the
incision from the infra-orbital canal, which is opened lengthwise, extends as
far as the anterior insertion of the masseter through the superior wall of the
antrum of Highmore. The nasal process is chiselled through obliquely in
an inward direction,
3. The malar bone is then turned upward and outward by means of a
bone hook (Fig. 922), and the fatty orbital layer is raised with a blunt hook.
The infra-orbital nerve may then be inspected with ease as far as the foramen
rotundum, and may be grasped, divided, or extracted behind the spheno-
palatine nerve coursing downward.
4. The turned-up malar bone is then replaced in its former position ;
bone sutures are usually superfluous. The external wound is sutured
throughout its whole extent.
THE INFRAMAXILLARY NERVE
The third branch of the trigeminus, or inframaxillary nerve, makes its
exit from the cavity of the skull through the foramen ovale, and at once
500
SURGICAL TECH NIC
divides into several branches, of which the most important sensory are :
the auriculotemporal nerve, which ascends around the articular process of
the lower jaw in front of the ear; the lijigiial nci've atid the viaxillary nerve,
both of which course downward and forward behind the internal pterygoid
muscle and the inner surface of the lower jaw. TJie lijigjial nerve then
takes its course along the floor of the cavity of the mouth and in a lateral
direction to the tongue ; tJie maxillary nerve enters, together with the
accompanying artery, into the maxillary canal at the lijigula and together
with the artery courses along the canal, and, as the mental nerve, leaves it
through the foramen mentale below the depressor anguli oris muscle where
it ramifies in the skin of the chin (Fig. 914, ///).
Sonnciibcrg and Liicke obtained access to this nerve on the i)itcr)ial
surface of the lozverjazv in the following manner : —
The operation is made with the Jiead in Roses position, to afford a
more satisfactory view of the parts of the lower jaw, situated on its inner
surface.
I. An incision in 'Cuo.form of an angle — botJi sides of ivhicJi are equal —
from 5 to 6 centimeters long, through the skin and the periosteum, running
clo.sely around the ajigle of the lower jaw
(Fig. 923).
2. The periosteum on the internal surface
of the lower jaw, together with the insertion
of the internal pterygoid muscle, is detached
with an elevator and pushed upward and back-
ward until the projecting bony lamina of the
canal is felt ( Fig. 909).
3. Guided by the finger, a tenaculum is
now introduced upward and inward as far as
the canal ; with a tenaculum, the nerve is sepa-
rated from the accompanying artery, drawn
strongly forward, and held firmly with torsion
forceps.
4. Either the nerve can then be resected
by dividing it first close to the opening of the canal and then as far toward
the central portion as possible (centrally), or, according to Thiersch, it can
be torn out with the Thiersch forceps instead of with the torsion forceps.
Around these forceps, the whole peripheral part, as it issues from the dental
canal, and also the central portion of the nerve as far as the base of the
skull are twisted and forcibly extracted.
Fig. 923. SOXNEXBERG - LiJCKE'S
Method of exposixg Ixfra-
MAXILLARY NeRA'E
OPERATIONS ON THE HEAD
501
KiiJin and B runs removed portions of the angle of the lower jaw in order
io expose the dental canal.
Briins made a curved exterjial incision along the posterior margin of the
lower jaw from the ear downward as far as the anterior insertion of the
masseter. The parotid gland is pushed backward ; the detached masseter
upward. From the angle of the jaw, now easily accessible, a rhomboid piece
from I to li centimeters wide and from 3 to 3|^ centimeters long is sawed
out from its posterior margin and detached from the internal pterygoid
muscle (Fig. 924, ^) ; the nerv^e, lying in the open canal, can then be easily
drawn forward with a tenaculum.
Velpeau and Linhart chiselled an opening in the anterior surface of the
lozuerjaw, through which the canal is opened (Fig. 925).
For. oval.
A err \ x \\ ■»/
inframax
N. Ungualis
mt.
Fig. 924. Internal Half of Left Lower
Jaw. a, a, saw incisions according to Bruns
Fig. 925. External Half of Right Lower
Jaw with Velpeau-Linhart Fenestra
1. External incision from 3 to 4 centimeters long in the median line of
the ascending ramus of the lower jaw.
2. After the masseteric fascia has been split and Steno's duct exposed,
the latter is drawn upward together with the transverse facial artery ; the
fibres of the masseter are divided IcngtJizvise.
3. The periosteum is split in the same direction, and pushed back with
a raspatory until a sufficient portion of the jaw has been exposed.
4. With chisel and hammer, a rectangular piece is chiselled off from the
anterior wall, layer by layer (Fig. 925), until the canal has beoi opened and the
nerve, together with the artery, can be seen coursing through it ; here it may
be grasped with facility.
502
SURGICAL TECHNIC
Fig. 926. Kronlein's Retrobuccal Method
The foramen ovale may be reached as follows : —
(a) By the retrobuccal method of Kronlcin (Fig. 926).
I. Transverse incision of the c/ieek, beginning I centimeter from the
angle of the mouth and ending i centimeter in front of the lobule of
the ear ; division of the fatty tissue.
The buccinator muscle and the mucous
membrane of the cheek remain unin-
jured. Division of the anterior two-
thirds of the masseter with careful
avoidance of the parotid gland and
Steno's duct.
2. The coronoid process of the
lower jaw is freed with an elevator
from the masseter and the internal
pterygoid muscle covering it ; it is then
divided as low down as possible in an oblique direction with bone-cutting
forceps, and drawn upward together with the temporal muscle.
3. The nerves are made accessible bj blnnt dissection. Through the
fatty layer of the cheek and through the internal and the external pterygoid
muscles, the operator advances as far as the canal, where the inferior alveo-
lar nerve and also the lingual nerve can be easily palpated and brought into
view; farther upward lie the chorda tympani and the internal maxillary
artery. If the external pterygoid muscle is drawn forcibly nfizuard, the
auriculotemporal nerve is reached, encompassing the middle meningeal artery
behind the lingual nerve and the inferior alveolar nerve. Thus the base of
the skull is reached, where the nerves can be extensively resected, or where,
according to TJiierscJi, they can be removed by extraction.
By this method, also, single twigs of the third branch of the artery can
be removed if desired : the buccinator nerve, the inferior alveolar, the lin-
gual, and the auriculotemporal.
{b) Mien lie: makes a temporary resection of the lower jaw: —
1. External incision along the sternocleidomastoid from the mastoid
process as far as the level of the great cornu of the hyoid bone ; thence in
a short curve upward to the anterior margin of the masseter and \\ centi-
meters beyond the margin of the lower jaw (Fig. 927).
2. The bone and the cervical portion of the parotid gland are exposed ;
the ligament extending from the lower jaw to the fascia of the sternocleido-
mastoid is divided.
OPERATIONS OX THE HEAD
503
3. The jaw is sazued through by the step inetJiod. Along the anterior
margin of the masseter, the most anterior insertions of which must in most
cases be also removed, the periosteum at the external and the internal sur-
face of the lower jaw as far as and behind the last molar is exposed without
injuring the mucous membrane of the mouth. With a chain or wire saw,
the bone is divided perpendicularly half through from behind the molar ;
I centimeter farther toward the front, the bone, from the outside, is also
sawed half through with a metacarpal saw, and the middle portion is chis-
elled through horizontally (Fig. 927 , ).
Fig. 92S
MicuLicz's Method of exposing Inframaxillary Nera'e
4. The portions of bone are forcibly drawn apart with hooks, the inser-
tion of the internal pterygoid muscle is detached, the inframaxillary nerve
behind the canal is drawn out, and the lingual nerve, running immediately
below the mucous membrane of the mouth along the molar teeth, is sought
for. By advancing bluntly upward along these trunks of ner^'es, during
which procedure the external pterygoid muscle must be forcibly drawn
inward and upward, the foramen ovale is reached (Fig. 928).
5. The nerves having been resected, the lower jaw is united by a bone
suture of silver wire (the step form of the fracture prevents a displacement