artery), and the corresponding veins.
Next the muscles are cut off from the larynx. The same is extirpated,
and the surrounding parts are cleared of diseased glands lying along the
inner margin of the sternocleidomastoid muscle on the sheath of the large
vessels and below the submaxillary bone. The unilateral extirpation of the
larynx is confined to the diseased side. In all other respects, however, it is
made essentially according to the rules given for total extirpation.
It is less dangerous, and the patient can speak distinctly even without
a canula.
The lateral incisions are sutured; the median incision is only tamponed.
The wound of the pharynx is not sutured ; from it an oesophageal tube
is introduced into the stomach, and the wound cavity is tamponed with iodo-
form gauze. The patient remains in bed on his back; the dressings are
changed daily. Even on the next day, an ordinary canula {Ha/ui) may be
substituted for the tampon canula ; the wound above the canula is tamponed
with antiseptic gauze.
The cavity of the wound rapidly decreases in size if the case runs a
favorable course ; patients are able to speak audibly in a whispering tone of
voice. If it is desirable to
wear a phonetic canula, an
^^ artificial larynx'' {Bruns-
Beyerlc s, Gusscnbauer s, or
Jnlins Wolff's) is to be
recommended (Figs. 1194,
1 195).
The patient can speak
through these apparatuses
with a loud voice. On
account of the irritation
produced by the canula,
Fig.
1 194
Fig. 1 195
Phonetic Canula (Artificial Farynx). a, according to
Gussenbauer; /', according to von Bruns
however, many content
themselves with whispering
speech.
Aside from recurrence,
most patients that have been subjected to this operation have died from
aspiration of secretions; the greatest care, therefore, must be bestowed
upon the after treatment.
OPERATIONS ON THE NECK 625
Bardenheiier obtained very good success by forming a septum between the
oral cavity and the cavity of tJie wound after removal of the larynx. The
anterior wall of the oesophagus is sutured to the margin of the mucous
membrane (which is preserved as much as possible) below the epiglottis, or
with the vivified free margin of the epiglottis. The cavity of the wound is
tamponed. The patient is placed with his head lowered backward in such
a position that the tracheal stump forms the highest point of the wound and
no secretions can flow into the tracheal wound. Since the patient can
swallow, he does not insert any oesophageal tube for the introduction of food,
and thus the first tampon can remain in position as long as eight days with-
out irritating the wound.
J. Wolff employs the oesophageal tube, but removes the tampon canula
directly after the operation, and sutures the tracheotomy wound. The
superior margin of the tracheal stump is sutured all around to the skin, and
a common canula is introduced into the trachea from above.
Rotter closed the pharyngeal defect by a double row of sutures including
the mucous membrane, sewed over it the muscles detached from the larynx
in a second layer, and the skin as far as the angles in a third layer. The
patient could swallow very well immediately after the operation.
OPERATIONS FOR GOITRE
(struma)
I. Parenchymatous injections.
Injections of tincture of iodine or of LngoVs solution (or alcohol, osmic acid,
iodoform oil) may sometimes effect a decrease in simple, not too large, goitres
(parenchymatous) (after a preceding inflammatory reaction) ; sometimes,
however, they meet with no success.
They are administered in intervals of from two to three days, in doses
beginning with half a Pravaz's syringeful, but gradually increasing to a full
syringe. Whether the syringe has been properly inserted into the tumor is
recognized from the movements of the canula in an upward and downward
direction during deglutition. It is dangerous to inject the solution into a
vein, because sudden death (embolism) may ensue. Hence, it is necessary
first to draw the needle a little before making the injection.
The injection must be made vciy slozuly.
II. Puncture with subsequent injection of tincture of iodine or LngoV s
solution is of some value in struma cystica, only when the walls of the cyst
626 SURGICAL TECHNIC
are rather thin and have not too many pouch-like distensions of the cyst
wall.
The puncture is made with a trocar under most careful aseptic precau-
tions with the skin drawn tense. The trocar must not be too small, because
the contents of the cyst are often composed of a thick (colloid) fluid. The
evacuation must be made slowly, because by relieving the pressure too
rapidly, hemorrhages are easily caused in the interior of the cyst. For
dressing, iodoform-coUodion and a light compressive bandage are used.
(Parenchymatous injections are useless in adenomata of the thyroid gland
and seldom of signal value in cystic goitre. In miasmatic goitre paren-
chymatous injections of a 5% solution of carbolic acid repeated at
intervals of a week and combined with the internal and external use of
iodine seldom fails in reducing the swelling.)
III. Incision with suturing of cyst wall to skin (C/ie/n/s). In stninia
cystica and abscesses.
1. Exte^nial incision over the most prominent part of the swelling with
avoidance or double ligation of the larger veins.
2. Cutting through the superficial cervical fascia.
3. Stitching the exposed wall of the cyst and fascia to the margins of
the skin by a continnoiis quilt suture.
4. Incision of the cyst in the line of the external incision, cleansing,
tamponing. In larger cysts, if necessary, the exposed portion of the
anterior wall is I'csected ; under some circumstances, thorough drainage
without free incision proves successful in very large cysts.
Profuse parenchymatous hemorrhage {in struma cystica parenchymatosa —
Stronieyer) is arrested by firm packing with iodoform gauze, peroxide of
hydrogen gauze, or zinc chloride gauze.
If the extirpation of isolated cysts can be made easily, it is to be pre-
ferred to incision {Miiller).
IV. Extirpation of Struma (Strumectomy) {Billroth, Rose, 1878). The
total extirpation of the thyroid gland, according to present experience,
is no longer permissible, since, in consequence of the operation, epileptic
fits, paralysis of the muscles of the larynx, cachexia, myxoedema, fatal tetany,
and idiocy are caused or threatened (cachexia thyreopriva — Kocher).
It should be considered only in the surgical treatment of malignant
disease (sarcoma, carcinoma); and then the implantation of fresh glandular
substance into the abdominal walls may prevent cachexia after complete
extirpation, as well as the administration of the fresh gland or its extracts
fthyroidin, iodothyrin — Banmann).
OPERATIONS ON THE NECK
627
Hence, in all other cases, only the
Unilateral extirpation is considered, and this only when still sufficient
healthy glandular substance is present on tJie other side.
KocJier proceeds as follows : —
I. External incision according to the seat and the size of the tumor in the
median line of the neck along the inner margin of the sternocleidomastoid ;
Fig. 1 196 Fig. 1197
Kocher's Extirpation of Struma (Strumectomy). a, transverse incision;
b, angular incision
in very large strumas, angular ijieision or trap-door incision. A simple trans-
verse incision, " Kragenschnitt,'' ascending more on the diseased
side than on the healthy side, is followed by the slightest cicatrix
(Figs. 1 196, 1 197).
(A curved transverse incision with the convexity directed down-
ward and following the lower border of the swelling is the one
which is now generally resorted to in performing partial and com-
plete strumectomy.)
2. After division of the platysma and the superficial fascia,
and after a careful double ligation and division of all visible blood
vessels, the sternohyoid, the sternothyroid, and the omohyoid mus-
cles, if necessary, are separated in the median line close to their
insertion into the larynx. If possible, they are divided only partly
and in a transverse manner. The sternocleidomastoid, freed suffi-
ciently at its anterior margin, is drawn aside with blunt retractors.
The external capsule of the goitre now exposed as a thin layer of Fig. 1198
. . Kocher's
connective tissue is incised. It is separated with the goitre c^.n-RE
probe (Fig. 1198) from the struma (ligation of the veins), so Probe
628
SURGICAL TECHNIC
that its posterior surface can be reached by passing one finger along the
external margin of the goitre.
3. The goitre is turned out toward the median line (luxated) very care-
fully and cautiously, in order not to lacerate the blood vessels, which are
exposed to great tension.
4. TJie inferior tJiyn'oid artery, lying behind the turned-out goitre in the
form of a curve from the outer side to its place of insertion on the trachea,
is carefully freed (recurrent nerve) and ligated, but not divided ; likewise the
accompanying vein. At the inferior margin, the very large thyroid vein is
divided after a double ligation.
Fig. 1 199. RioHf-biDLD Struma, showing
THE Ramification of Superficial Veins
(Kocher)
Fig. 1200. Diagram showing Ligation
of Large Veins Necessary in Extir-
pation of Struma (Kocher)
I, A. and V. thyreoidea sup.; 2, V. thyroid, sup. access; 3, V. thyroid, inf. access; 4, V,
thyroid, inf.; 5, V. thyr. ima princeps and access.
5. Entering with Kocher's director above the isthmus at the medial
border of the upper horn, the surgeon, after a double ligation, divides an
ascending ramus of the superior thyroid vein in the median line, and draws
the upper horn forcibly upward with the fingers until the siiperior tJiyroid
vessels become very tense. He then isolates them with the director, and
ligates them ; he divides the superior thyroid artery and vein.
6. On the superior and inferior borders of the isthmus, the superior and
inferior communicating veins are ligated and divided ; the director is slowly
OPERATIONS OX THE NECK
629
inserted between the isthmus and the trachea ; the isthmus is secured with
two strong Hgatures, and divided between them.
7. The goitre is then raised with the left hand from the trachea and its
posterior margin, still adhering to the trachea, and is detached from it, care
being exercised not to injure the recurrent nerve ascending at this place.
Since this nerve can be injured in spite of all precaution, it is more practical,
by a vertical incision made
parallel to the trachea, but a
little distant from it, to leave
in position a portion of the
posterior portion of the cap-
sule for its protection.
Fig. 1 201, Posterior View of Larynx
AND Trachea with Neighboring
Trunks of Vessels (Course of re-
current nerve)
Fig. 1202. Recurrent Nerve and Inferior Thy-
roid Artery (Wolfler).
The recurrent nerve of the pneumogastric nerve, or tnfenor laryngeal
nerve, arises from the vagus, on the right beneath the subclavian artery, on
the left beneath the arch of the aorta, ascends behind these vessels, in the
groove between the trachea and the oesophagus behind and toward the
median line from the common carotid, upw-ard to the lower margin of
the cricopharyngeiis muscle. Below this it enters the interior of the larynx
from behind, across the upper margin of the lateral cricothyroid ligament,
accompanied by the inferior thyroid artery (Figs. 1201. 1202).
630 SURGICAL TECHXIC
8. The external wound is sutured, leaving a space at the most dependent
part for free drainage. Under a compressive bandage, the healing can take
place in one to two weeks.
V. Resection of Goitre {Micnlics) is made in diffuse colloid degeneration
on both sides, for the purpose of avoiding the serious complications produced
by total extirpation (recurrent paralysis), by allowing to remain a portion of
healthv glandular substance in connection with the point of entrance of the
inferior thyroid artery, whereby the recurrent nerve is most securely pro-
tected, and remains uninjured. This procedure, however, can be modified
variously, leavmg at times the inferior, at times the superior pole, at others
the isthmus of the glands.
After division of the skin, muscles, and fascia, one-half of the goitre is
isolated bluntly ; next, at the superior cornu, the snpciior thyroid artcjy and
vein are ligated ; at the inferior cornu only the superficial vessels are ligated.
The isthmus, bluntly detached from the trachea, is divided after double
ligation " en masse," while an assistant laterally compresses with his fingers
the blood vessels entering into it. The lateral flap to be resected is detached
with the scissors from the anterior and lateral surface of the trachea. The
poj-tion situated at the angle between the traeJiea and the ccsopliagus is alioiced
to remain. With the aid of strong clamp forceps, which squeeze out the
parenchyma, it is ligated with strong catgut ligatures, and in several sec-
tions tied off Uke a pedicle by ligatures " en massed The latter contracts
to a nodule of the size of a chestnut in the angle between trachea and
oesophagus.
To avoid the separation of the tumor y>vw tJie lateral suifaee of the trachea,
and also the contusion of the recurrent nerve, by the ligature " en masse,'" risks
which are always to be apprehended, Kocher, w ith the knife, circumscribed the
capsule of the gland near the isthmus (hilus) by a circular incision perpen-
dicular to it (sagittal). The upper section of the circle, however, must lie
completely above the cricoid cartilage. By this means, injuiy to the reeuj-rent
lurvc is excluded almost with certainty. Finally, a small flap of the thyroid
gland, similar to the normal one, is formed from the remaining stump. Next
the pedicle of the detached half of the goitre is divided longitudinally in
several sections with probe-pointed scissors ; each part is grasped with
strong clamp forceps and ligated, and then the whole tied-off mass is divided
with the scissors.
VI. Enucleation or intraglandular extirpation ( Porta, Socin) in cysts and
in well-circumscribed adenomatous nodules and in bilateral goitres. After
cutting through the shin, fascia, capsule {capsula externa sivc fasciosa, deep
OPERATIOiNS ON THE NECK 63 1
cervical fascia), and the overlying (healthy) attenuated glandular tissue
{glandulaj' capsule), the several glandular nodules are enucleated bluntly.
Sometimes the operator can proceed still more rapidly if, by a deep
incision, the adenoma is at once divided into tzvo equal parts, and each half
is enucleated with the fingers and the sharp spoon (evacuation, KocJicr) ;
often, however, a very violent hemorrhage ensues.
Hence it seems to be more advisable, according to Bose, by means of an
elastic tube as thick as the little finger, to constrict the tumor behind its
greatest diameter, whereby the hemorrhage is prevented ; at the same time,
after the division of the capsule, the glandular tissue is squeezed out of the
wound. Of course, in suitable cases, the methods of resection and enucleation
just described can be practically combined.
ENUCLEATION RESECTION (yKocher)
which is to be employed for the removal of all isolated nodules.
After the goitre has been luxated from a transverse or angular incision,
as described on page 627, without ligating the large blood vessels, the isthmus
is first divided after a double ligation. From this incision the internal cir-
cumference of the goitrous nodule is separated. The veil of glandular tissue
is undermined in an upward and downward direction with Kocher's director,
and a double ligature applied in a horizontal line. Next, from this place, the
nodule is enucleated with the finger first above and below, then also at its
posterior surface from the glandular substance. The latter is then vertically
divided with the scissors at its posterior surface as far as the ligatures on the
anterior surface between the inferior and superior cornua. The nodule is
then removed, together with the tissue covering it.
VII. Ligation of the Afferent Arteries {yon IValther, Wolfler). In
vasciilar goitre and Basedozv s disease.
(a) Ligation of the superior thyroid artery.
1. External incision 4 centimeters long along the internal margin of the
sternocleidomastoid across the great cornu of the hyoid bone as far as
the thyroid cartilage.
2. Division of the platysma. The artery is fo2ind in front of the great
cormi of the hyoid bone in the triangle between the omohyoid, digastric, and
sternocleidomastoid muscles.
Kocher and Rydygier searched for the artery from a transverse incision
extending from the margin of the sternocleidomastoid to the body of the
hyoid bone. The anterior branch of the artery is always to be felt on the
6^2
SURGICAL TECHNIC
lar.sup.
thy r. sup.
median upper side of the superior cornu of the (enlarged) thyroid gland,
passing downward at the side of the larynx.
(d) Ligation of the inferior thyroid artery.
Von Lajigcubcck made the cxtcrjial incision 6 centimeters long in the
groove between t/ie tzuo heads of the sternocleidomastoid muscle.
1. Division of the platysma, ligation of the tj'ansverse cervical vein, the
transverse vein of the scapula, the external jugular vein. Division of the deep
cervical fascia, splitting the sternocleidomastoid muscle in an upward direc-
tion.
2. The tendinous part of the omohyoid muscle appears in the middle of
the wound, and is drawn outward or divided. The internal jugular vein,
which is now exposed, is drawn toward
the median line. The carotid, the
pneumogastric nerve, and the anterior
scalenus muscle covered by cellular
tissue and fascia can be inspected.
3. After blunt division of the lat-
ter, the phrenic nerve becomes visible
and is pushed outward. Along the
internal margin of the anterior scale-
nus muscle, which is drawn a little
toward the outer side, the arch of
the inferior tJiyroid artery {sympathetic
nerve !) is seen. (See also Fig. 1202.)
To avoid the danger of injuring the
sympathetic nerve, Wdlfler draws the
large blood vessels and the pneumogastric nerve inward. Rydygier in
ligating this artery proceeds as follows : —
1. TJie external incisioji 6-7 centimeters long extends 2 centimeters
above and paj'allel to the clavicle, transversely across the clavicular portion of
the sternocleidomastoid muscle and the supraclavicular fossa.
2. After incising the platysma and the superfcial ccj'vical fascia, both
forefingers penetrate in a perforating manner through the loose cellular and
adipose tissue behind the sternocleidomastoid as far as the margin of the
anterior scalenus muscle. The lymphatic glands are removed.
3. The sternocleidomastoid with the large blood vessels of the neck and
the pneumogastric nerve are lifted with long blunt \iOo\i^ forward and inward,
so that the wound gapes widely. Then there appears on the internal margin
of the anterior scalenus muscle the thyrocervical trunk, from which tJie
cricoihyr.
r. inf.
ihyr. inf.
Fig. 1203. Diagram of Arteries supplying
Larynx and Thyroid Gland
OPERATIONS ON THE NECK 633
inferior thyroid artery branches off in an inzuard direction. This vessel is
secured by a double ligature.
Kocher ligates the artery at a place where, behind the carotid, it curves
toivard the thyi'oid gland inwardly.
1. External incision transversely across the clavicle (jugulum; in a curve
obliquely upward and outward across the sternocleidomastoid.
2. Platysma and sternocleidomastoid are forcibly retracted outwardly,
the omohyoid and the sternohyoid muscles are drawn downward and in-
ward ; the jugular vein, the common carotid, and the pneumogastric nerve
are isolated on the internal margin, and drawn outward. Then between the
latter and the margin of the thyroid gland (or the sternothyroid muscle),
the operator advances toward the vertebral column.
3. The thyroid gland is raised inwardly, and the convex arch of the
artery is then seen lying upon the longus colli muscle beneath the recurrent
nerve, which crosses it.
If the extirpation of the diseased thyroid gland appears impossible or
impractical, the following palliative operations may be attempted : —
Jaboiilay raised the goitre from its natural position and lifted it, so to say,
by his exothyreopexia. From a median incision, the goitre is carefully
separated bluntly with the fingers from its connections, and the loosened
lobes are luxated outward and surrounded with sterilized gauze. After the
gauze is removed on the fourth day, the skin contracts over the goitre of its
own accord, while the latter gradually contracts, because the distortion of the
large vessels has impaired its nutrition. Since this procedure, however, may
cause thrombosis, Wblflcr makes a dislocation of the goitre in a similar man-
ner by drawing it out from its bed, where it causes functional disturbances
(for instance, between trachea and sternum), and by fixating it under the
skin and the sternocleidomastoid, mostly at a higher level. As a substitute
for extirpation, which can no longer be performed, owing to the extent or
location of the disease, he also recommends pimctiiring with the needle point
of the thermo-cautery.
LIGATION OF THE ISTHMUS OF THE THYROID GLAND
was recommended by Gipp and Jones for the relief of dyspnoea and other
pressure symptoms.
The external incision extends in the median line from the tJiyroid cartilage
downward. The isthmus is detached bluntly from the trachea, constricted
by ligatures " en masse " on both sides of the trachea, and divided between
them (or the whole portion pressing upon the trachea is resected).
634
SURGICAL TECHNIC
Asphyxia is especially to be feared as a serious accident in operations for
(goitre.
It may be caused : —
1. By ancEsthesia.
2. ^y paralysis of the recurrent laryngeal nerves.
3. By a complete compression of the scabbard-shaped compressed trachea
(when the head is turned laterally and the goitre is turned out; (Figs. 1204,
1205, 1206).
^
Fig. 1204
Fig. 1205 Fig. 1206
Scabbard-shaped Compressed Tkache.e (Demme)
To prevent this compression-stenosis, either the lateral tracheal ivalls may,
during the operation, be drazvn apart with sharp hooks, or the lumen of the
trachea may be kept patent by simple pressure of tJie finger upon the anterior
wall. For the more permanent removal of the stenosis, a strong catgut liga-
ture with a curved needle is passed at two places through the lateral walls of
the trachea and drawn together over the angular anterior margin in such a
manner that the lateral walls are separated {Kocher).
In dyspnoea of a high degree, chloroform anaesthesia must be avoided
(not ether, on account of the aspiration of profuse tracheal secretions), and
a moderate morphine anaesthesia or local anaesthesia must be attempted.
The latter is to be recommended also for all operations for goitre of short
duration.
(At the present time, Kocher performs all his operations on goitres
under Schleich's infiltration method.)
OPERATIONS ON THE NECK
635
Tracheotomy should be avoided as viuck as possible in all these opera-
tions, since it renders asepsis almost impossible {pJdeginonous mediastinitis ;
aspiration).
Fig. 1207. KdxiG's Flexible Canula for Tr.\cheotomy in Struma
If, in substernal and firvily adherent goitres, the surgeon is compelled
previously to the operation to perform tracheotomy above the seat of com-
pression, on account of threatening asphyxia, a long flexible cannla must be
introduced extending beyond the stenosis {Konig, Fig. 1207).
OPERATIONS ON THE (ESOPHAGUS
The introduction of the oesophageal tube is made for relieving the stomach
of any injurious contents, or for conveying food into it. For this purpose,
the oesophageal tube is connected by a rubber tube with a
reservoir (douche, funnel, stomach pump) (Fig. 1208).
The reservoir is filled with fluid ; the fluid flows into
the stomach when the reservoir is lifted sufficiently ; the
fluid and the contents of the stomach are siphoned out,
when the reservoir is lozuered sufficiently.
If the oesophageal tube is to remain in position for
some time, or if, on account of the resistance of the
patient, it cannot be introduced through the mouth, it
must be introduced through the lower meatus of the nose
and the pharynx into the oesophagus. It can remain in
position for a long time without causing any especial
inconvenience.
The patient sits on a chair in front of the surgeon
with his head extended, his mouth wide open, and his
tongue projected. The surgeon depresses with his left