'm THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES Santa on.ijA ri\'i: srij(ii:ijv Nosi:. 'I'liijoA r. AM) i:ak* *anta mon Ol'KIIATIVK SIKMiKKV AOSi:. TIIK'OAT. AM) KAK' I'OIJ I.AK'VXCOI.OCISTS, lv'lll\nl,(t(;iS'rs, OTOlJXIlSTS, AND srHCKdXS M.WAI W. I.(i|-;i"., A.M., .M.I). PROFESSOR OF i:.\U, XOSi; AND TIlRc).\r lJlSi:.\Si:S IN Sr. LOIKS l-NUERSITY IX COLLABORATION WITH Joseph C. Heck. M.I)., George \V. Crilc. M.D., William II. Ilaskin. M.n.. Robert Levy. M.D.. Harris P. Moslicr, M.D., George L. Richards. M.U, Gcarge H. Shainb.niRh. .M.D., and George H. Wood, M.D. l.\ TWii \n|,r,MES VOL. I Foi i; III \ni;i:i> wn mm: ii.i.t stumioss f \\()i-l< was uiiiliTlaki'ii ;il \\\r .-im^ot ion of m:iii\' (■()ll(';ij::iies, with nil little iiii>-i\ iiii;- (in tiir iiai1 (if tln' antlnir. 'I'n li.u'lilt'ii tlio liurdi'ii and to iiiakc tlic imlilicatiuii moiv cl'lVrl i\ r. it \\ a> ili\ idcd ainoufr collaliovntors wlio were ^pi'cially (|ualifi('il fm- the a>^ii;ncil topics. Till' (•ndi'avoi- lias liccn to |iicM'nt tin- (i|ii'rat i\c sni-.i;cr\' (if tlic iiosi', throat and i-ar, uuacconipauicd liy an\' discussidn (iT patliolo.i;}', etioloe. thidat and ear. the extci-nal sni'ffcry of the throat, the direct e\aiiiinatidii (if the lai-ynx, ti'acliea, lirondii, esopln\ here made In I lie many w lin have liy Iheii- elTiirt-, ad\ice and eiicunraucmeiil reiidere(| this pultlication possible, to .Mr. .\. Schwilalla, S. .1.. w Im \\a,- (if L^reat assistance in reviewing tlie text, to the cdllalidraldrs, and Id the pulilishers. whose ]iatie!ici^ lias been mo.-t cdinniendable. II. W. I.. coNiHii'.r i()i:s I'o \{)\.. I. JOSKIMl C. HKCK, M. I).. Cuk aco. Profossor of Otulo-y, Khincln^v mihI L;ir\ ii^'iiln- v, friiviTsilv (if Illinois. GEORGE W. CHILE. M. D., Cleveland. Professor of Snri;(My, Wcstoni Rosorvp Tniversity H.^NAU W. I.OKH. M. 1).. St. I.oits. Profi'S.sor of K:ir, Xo,-ii> ;iiiil Tliriiat JJiscii.scs, St. l>oMis I'liivorsity. HARRIS F. MOSHER, M. D.. Boston. Assistaiil PnilVssor of r,nr.vimoloi.Ty. Ilurvard Mrdiciil Sc-lio.il. GEORGE E. SHAMiiAUGM. M. I)., (hk aco. Associate Professor of Laryiijioloj^y and Ololo^^y, Kiisli Moillral ('ollooc. GEORGE 15. WOOD, .M. I).. I'liii.Anii riiiA. CON I K.N I >. oil A I'T i: H T. TIIK Sri{<;Ff.\F- .WA'in.MV i.l' 'IIIK N'nsi;. PAGE Externnl Xosf 1 Xasal Cavities 3 Floor of the Nose— Septum Xasi — Roof of tli(! Xoso — Kxteriial Wall of tlic Xobc — Tlie Clioana;. Accessorv Sinuses of the Xo.se T Frontal Sinus — Maxillary Sinus — Etlirnoii] Cells — Spliciioiil Sinus. Variations of the Sinuses in Size and Shape '■'''* Frontal Sinus — Maxillary Sinus — Etlimoid Cells — Ethmoid Labyrinth — Anterior Ethmoid Cells — Posterior Ethmoid Cell.s — Sphenoid Sinus. Supcrfieial Area and Cubical Capacity of the Sinuses. . . .• 36 Optic Chiasm and Xerve 40 Xa.«olaprimal Duct — 50 Hypophysis (Pituitary Body) 52 Vascular Supply '- Arteries — Veins. Innervation " ' SjTnpathetic System. C II A P T F. H II. BT'ROirAL AXAT0:MY of TJIE PHARYXX, LAHY.XX, AXn XECK. THK PHARVX.X. Xasopharynx 5;j Pharpigeal Tonsil. Oropharynx 59 Palatal or Faueial Tonsil — Pillars and Lateral and Posterior Walls. Laryngopharynx "-"^ L^TTiphatics of the Phai-j'nx 64 Xen-es of the Pharynx 65 Structures of the Pharj-ngeal Wall 66 Superior Constrictor Muscle — Middle Constrictor Mu.scle — Inferior Constrictor Muscle — Palatophar>Ti{feal Muscle — Stylopharyngeus Muscle — Palatoglossus Muscle — Azygos XJ\-ulse Muscle — Levator Palati Muscle — Tensor Palati Muscle. THK LARVX.X. Superior Division "" Ventricular Bands. Middle Division "'' Inferior Division "1 Cartilages of the Lar>-nx "1 Cricoid Cartilage — Arytenoid Cartilages — Thyroid Cartilage — Epiglottic Cartilage — Lesser Cartilages. (Xi) Xll COXTEIfTS. PAGE Articulations niiil Ligament* of the Larynx ~'i Joints — Ci'icotliyroid Membiaue — Thvroliyoiil Meniliranr — I n I'cricir Tli.vroarytcndiil Ligament — Superior Thyroarytenoid Ligament— Ligaments of tlio Epiglottis. Muselcs of the Lar^^lx 75 Cricothyroid Muscle — Posterior Cricoarytenoid Muscle — Arytenoid Muscle — Lateral Cricoarytenoid Muscle — Thyroarytenoid Muscle — Kxtenial ThNToar^-tcnoid Muscle — Thyroepiglottic Muscle — Internal Thyroarytenoid Muscle — Action of the Muscles. Nerve Supply of the Larynx 70- Superior Laryngeal Nerve — Internal Lai-yngeal Sei-v — External Laiyngeal Nerve — Recurrent or Inferior Larj-ngeal NeiTe. THE LYMPHATIC SYSTEM OF THE NECK. LjTnphatic System of the Neck 70' Suboccipital Group of Glands — Mastoid Group — Parotid (iroup — Suliparotid (ilamls — Submaxillary Group — Facial Glands — Submental Group — Retrophar\nigeal Group — Descending Cervical Chain of Lymph Nodes — AcI'V. TU'At'llKdSi (H'^', I'.lv'oM I K iS( ol'V. |-;s( tl'1 1A( ;(»S corv. AND CASTUoSCdl'V THE DIRECT K.\ AMI.NATION OF TJIK LAKYXX. General Considerations 155 Historical — Contraindications — Cliciice of tlie .\nestheti( — Cocainization — Difficulties iif the Examination. Metliod of Making the Direct Examin:itii>n l.jS Passing the Speculum from the Conu-r of tlie Mouth — Direct Examination with Counter Pressure — Direct Examinati(pn Fndev Ether — Instruments for Direct Ex- amination — Inhalation of Oxygen. Suspension Laryngos-copy 1G7 TKAfllEOI'.RO.VCIIOSCOPY Lower Tracheobronchoscopy 170 Contraindications to Lower Traclieolironchoscopy — Anesthesia — I'usition of the Pa- tient — Method of the Examination — Tlie Endoscopic Picture — Interpretation of the Endoscopic Picture — Choice of the IJpiiei or Lower Route — Dangers of Rronchoscojiy _Ase].si^— Size nf the Tul.es. I'.KOXCJIOSCOPV. Lower Bronchoscopy ISO T'ppcr Bronchosco]iy 1S7 Anesthesia — Method of Performing Upper Bronchosco])y- — Tntroases of Trachea and Bromlii '2(H) Stenosis of the Trachea — Treatment. CONTEXTS. RK.MOVAL OF FOREIGX BODIES FROM THE LARYNX, TRACHEA AND THE BRONCHI. F(iroii;ii Hoilics in tlio Larynx 202 Removal of Foroign Bodies from Trachea and Bronclii 203 Choice of the LTppe,- or Lower Routx- — Indications — Dangers — Danger frnrn Leav- ing Foreign Body Alone — Results — Symptoms — Diagnosis — Pliysical Signs — Loca- tion — Teclmic of Removing Foieign Bodies— After-effects of Removal of Foreigii Bodies. ESOPHAGOSCOPV. Esophagoscopy o-[q History — Anatomy — Structnre — Lymphatics — Position — Direction — Diameter — Length of Esojdiagns— Distensibility — Subphrenic Portion of the Esophagus — Move- ments of the Esophagus — Measurements of the Esophagus — Contraindications to Esophagoscopy — Anesthesia — Instruments — G<>neral Examination of the Patient — ■ Technic of Esophagoscopy Under Cocain Anesthesia — Position of the Patient Introduction of the Esophagoseope by Sight — Introduction of the Esophagoscope by Means of a Flexible Mandrin or Bongie — Introduction of the Esophagoseope Under General Anesthesia — Use of the Adjustable Speculum for Introduction of Esophagoseope — Passing the Jackson Esophagoscope by Sight — Passing the Oval Tube by Sight — Passing the Esophagoscope by Aid of a Mandrin or Flexible IViugie — Appearance of the Normal Esophagus. THE DISEASES OF THE ESOPHAGUS. Acute Intlaniniation 030 Stenosis of Esophagus Due to Cicatrices ... 232 Location of Strictures — Diagnosis and Trcntmcnf of Eso|iliiigeal Strict\irps— Cases of Stricture — Use of a Thread as a Guide in Esophageal Strictures — .\fter-care of Strictures of the Esophagus. Spastic Stenosis of the Esophagus 240 Esophagospasm — Cardiospasm— Phrenospasm. Benign New Growths of the Esopliagnis 247 Treatment of Benign New Growths. Malignant New Growths of the Esophagus 248 Symptoms of Cancer of the Esophagus — Diagnosis of Cauc<'r of the Es(i]ihagiis— Diagnosis and Treatment of Cancer of the Esophagus. Compression Stenosis of the Esophagus 254 Inflammation and Ulceration of the Esophagus 2.54 Chronic Inflammation of the Esophagus— Ulceration of the Esophagus. Neurosis of the Esophagus 0.5,3 Sensory Neurosis of the Esophag-iis— Paralysis and Paresis of tlie Esojijiagns, Congenital Anomalies of the Esophagus 2.57 Congenital Stricture of the Esophagus— Divcrticnhini. Dilation of the Esophagus ogp Foreign Bodies in the Esophagus 261 Places Wliere the Foreign Bodies Lodge— Procedure to be Followed in Cases of Foreign Bodies— Choice of the Anesthetic— Coins ahd Buttons in the Esophagus— The Bristle Probang— Pins in the Esophagus— Safety Pins in the Esopliagus. COXTEXTS. NV OASTROSf'OI'V. PAfiK Gastioscopy 271 History — Uscfuliioss — Inslnimoiits — Tocliiiic of Gaslroscopv — I'ositioii of llio Pa- tient — Passing the Gastroscopp — Area of tlio Stoniacli Wliii-li Can lio Kxploied — Contraindications — Dangers — Uiflficulties. Tlio Stomach as 8e<'n Tlirongli the Ciastroscope 270 Xnniial StoMKii'h— irovonients of the Stoniaeli—C.astritis— Peptic Ulcer— Malignant IMseasi's «f the StoniacIi— Gastroiitosis and (iastrectasia. ClI A I'T K R \- T. PLASTIC srKdEHV (»F TIIK XOSK AM) EAR. ( ieneral Considerations 27f> History — Important Factors — Covering Defects — Recording Cases Before. During and After Correction. HHIXOI'I^ASTV. Rhinoplasty 28S Classification of Xasal Deformities— Jiethod of PrnciMlnres in Xasal Deformities and Malformations. Correction of Unilateral and IMutial l)efi<-ieiicies of the Xose 29t Legg's Ojieration — Koenig's Operation — A'on Ksmarch's Operation — Von Langen- heck's Operation — DietTenliach's Operation — Von Esmarch 's Operation — Busch 's Operation for Partial Loss of Tip and One Side of Nose — Nelaton 's Operation — Sonne's Operation. Correction of Total Loss 295 Helferich's Operation (French Method^. Correction of Sunken Bridge, Upturned Loliule or Tip, and Sadill(> Imck 29S Roljerts' Operation for Sunken Bridge with U]itiniic,l Lohnli- or Tiji of Xose — Roberts' Operation for Sunken Saddle-back Xose. Formation of a Xew Colnmella 301 Dieflfenliach 's Operation — From the Dnrsiim of X'os<' (Hindoo ^re1Ilo(^ — Lexer's Operation for Formation of Columella (from Mucous Membrane uf the U]i|ier Lip). Dalian or Tagliacozzi 's Method .■!0,> Isracd's Operation — DietfVnbacli's Operation — Xclaton "s Operation. Hindoo or 1 mliau Method 31 f) Thiersch's Operation for Total Loss Tnpanicum and mastoid cells along tho upper posterior wall of the extcrrnal canal 104 78. Horizontal section through the tempor.-d bone viewed from above 105 79. Section through mastoid process and oxteriial canal 1 0.0 80. Section through temporal bone, showing the relation of the facijtl canal to the fenestra vestibuli and of the horizontal («inal to the antnini 106 81. Section through te^mporal Imne, exposing the fa/-ial canal 107 82. .Vdult temporal bone, showing anatomic relations after a complete tjTiipanomastoid exenteration 107 83. Adult temporal bone, -showing the t>7)ical relation of the linea tcmjjei'alis ex- tending in a liori/ontul direction back from the external canal 108 84. Adult temporal bone, showing the linea temporalis making a marked curve down along the posterior ?)order of the external meatus before turning backward. . . . 100 85. Adult temporal bone showing the linea temporalis making a curve upward !it the posterior margin of the extciTial meatus 110 86. Section through mastoid process, antmm tympanicurn, .-ini] external canal Ill 87. Pneumatic type of mjustoid. Larger «dl.s arranged along the jieriphory 112 88-89. Section through temporal bone. Section passes through antrum, veslilnilf arjil interaal meatus 112 90. Section through U-m^'n-A bone, showing lelntion of the lioriz.intal caiKil ;.im1 facial canal tn Ihi' midille ear chambers; also rcliitioii of llie carotid and Imlba?- jiigularis to the I'avnm t\'mpani 11 ■'5 91. Section through the mastoid [irocess, showing but pmti-il |piiciirriatizatioii 114 92. Diplretic tj'pe of mastoid. ('iiT]i|iletc !il(>cni-c of ipniMinr.-it ir- s[rafes. Anirinn tyiii- panicuni c^ntract/cd 114 9."). Section through adult temporal bone, showing persistence (jf infantile t.v|ie with absence of pneumatic sjiaces in the mast-oid 1 1o 94. Section through adult tx'mporal bone, showing the relations of the carotid to the cavum tympani and the structures in the tloor of the recessus epityinjjanicus. ... 116 95. Section through mastoid, cavum tympani, tuba auditiva, showing a large tubal cell 117 96. Sr-clioii tinougl] tlir> ni;istoid and tympanic cavity, sliowirig the relation of the Ijori- zoiital aJid sii|ierior (■aMal>* to tlic aatniMi 1 Ti !i7. Ifoiizoiital section thr(jii;;h the trniporal bone scon fj.uri Im-Iow 119 ILLVSTRATIOXS. XIX PAGE Section through temporal V)ono, shonin<; rplation of the bulbus jiigularis to cavuiu tympani and relations of the cochlea and facial canal to the ca^^lnl tympani 120 Horizontal section through the temporal lione seen from aliove 122 View of the posterior aspect of the temporal bono, showing bulbus jugularis ex- tending to the upper margin of the fietrous l>one 123 Tracheotomy under local anesthesia : novocainizing the skin 132 Tracheotomy. Incision through thjnoid gland and trachea 133 Tracheotomy. Xovocainizing the trachea from within 134 Tracheotomy. After the operation 135 LarjTigectomy. Preliminary tracheotomy witli iodoform gauze packing 141 Larj-ngectomy. Five days after preliminary tracheotomy. Arrangement of tube for anesthesia 142 107. LarjTigectoniy. Separation of the larynx from the esophagus 143 108. Laryngectomy. Closure of pharyngeal ojiening 144 109. Laryngectomy. Closure of wound with iodoform gauze packing 14o 110. Esophagostomy. Ample incision of skin along the anterior border of storiiomas- toid mviscle . . , 152 111. Esophagostomy. Exposure of esophagus 153 1 12. Esophagostx)my. Esophagus stitched to skin 154 113. Jackson 's tubular sjieculum 159 114. Diagrammatic representation of direct laryngoscopy ICO 115. Position of second assistant and patient for endoscoi>y per os 161 111). Bronchoscopy room at Massachu.setts General Hospital 102 117. Mosher 's adjustable speculum 1 63 118. llosher's adjustable speculum 164 119. Forceps for direct work upon the larynx 166 120. Killian's suspension apparatus 16S 121. Mosher 's folding frame for suspension apparatus, closeil 169 122. Moslier's folding frame for susi^nsion ajiparatus, open 169 123. Urethroscope used as a tracheoscope 170 124. Urethroscope used as a tracheoscope, showing individual parts 171 125. Jackson 's bronchoscope 1 "3 1 26. Jackson 's bronchoscope, with Ijcveled end 173 111". Ca.st of the interior of the trachea and bronchi, with their chief raniitications within the lung 1 74 128. Cast of the interior of the trachea and brom-hi. witli their i-hicf raniitications within the lung 1 75 120. The arch of the aorta, with the pnlnion;iry aitery and iliief l.r:in
  • 240 IS.l. Cardiospasm. Retouclipd tracing from an X-ray plati- 211 lS(i. Apparatus for ililating the oardia 24:'. 1S7. Cunliospasm. Print of an X-ray platt- showing a .lilatocl csupliafjiis 24(; ISS. Section of normal csophaf^is (Low power') 248 1 SO. Carcinoma of the esophagus 2;j0 1!)0. Sect ion of carcinomatous area (Low power) 2.-)l I'M. Scctimi of carcinomatous area (High jiower) 2.'il! 1112. Carcinomatous stricture of the esophagus 2o2 Ifi;!. Cancer of the esophagus. Rotoueheil tracing from .\' ray plate 253 I'.it. Korc-cps with iiuncli tiji 255 l2-2.'i;!. Von Esmarch 's operation 202 2:!4-2.'!5. Von Langenbeck 's operation 202 2:Mi-2.'!7. DielTenbach 's operation 20.1 2.''.S. V(m Esmarch "s operation 20.'? 280. Busch's operation for partial loss of tip and one side of noratioii for iK?rf(iniliim of m'|iIiiiii 364 361. Hazpltiiip's operation for pei-forn(ii>n of .scpliini 365 364. Usual operation for nmorotia 367 366. Parkliill 's operation for niaerotisi 368 365. Clievne ami Bnrylianl 's operal ion for niacrot ia 369 372. Goldstein "s operation for macrotiu 370 376. Goldstein 's o]>eration for projeclinj; ear 372 379. Beck's ojieration for roll ear or soealled do7() 388. Simple operation for colobomata .'(77 390. Green 's operation for colobomatji .'{77 Monk 's operation for prominent ear ."."S 393. KoUe 's operation for projectini; car 37S 397. Trautmann operation for closure of posterior deficiencies 380 401. The von MosetisjMoorholT operation for posterior deficiencies 381 403. Goldstein 's retro-auricular jdasl ic 382 Celluloid artificial ear 382 Incision for spino-facial anastomosis 384 Spino-facial and peripherospinal to descendens hy|io};lossi anastomosis 385 Beek 's nerve tracing forceps 386 Facial-hypoglossal end to side anastomosis 388 Facialhyi>oglossal end to end anastomosis 389 \()L. I. OPERATIVH SI Rl.liRV OF I IIH NOSH, TIIROA l\ AM) HAK. (IIAPTFH I. TIIH SIKI.ICAI. AWIOMV OF I III'; NOSH/ liv ilA.X.U W. Lul.K, .M.l,). External Nose. Tlip external nose (iiasus) wliicli projects dow nwaril ami forward from the forehead, between the eyes, presents two lateral and one iiifci-idi- surface, all t I'ian.iiular in >liapc, and a siiiiriidr -urlaci- which vai-Jes considerably in size and cniitiiui-. .\> mhmi in l-"i;;>. 1 and '2 the root of the nose (radix nasi) is that portion i)rojeetinf;- for a sliort distance downward fT-oni tlic forehead, and tlic liridiic of the nose (dorsum nasi) is the superior ^ui-i'ace e\lenilin:;- fnini the inot \n the tip of the nose (aj)ex nasi). The supporting;' framework of the n(i>e is c(ini|iosed of bones and cartilages, united li> cnunective tissues. It 1^ lined with mucous mem- brane and covered hy tnuscles and inteL':nnient. The nasal bones ami the frontal |iro<'esses (pi-ocessus frontales nia\ilhc) of the inaxilhc which constitute the hoiiy framework of tlie external no>e are attached hy -iron.n i-onni'cti\e ti>,-ne fiher- to the lateral cartilages (cartilaiiines nasi lateiales) at the apertura ]iiri- formis (Fif^s. 1, 2, 9 a)id 11). Kach of these cartilasos is triangular in shape with the apex downwaiil, and is attached to the cartilage of the .septum (cartilago septi nasi), ami to its fellow on the oppo- *For the convenience of readers, structures arc designated by their usual English names. However, the B.N. A. nomenclature is given in the text and exclusively in the figures in order to follow recogniied authority in terminolog>'. The figures .iccompanying this chai)ter have been made from drawings of Mr. Tom Jones, with the exception of Figs. 20 to 3A, inclusive. Acknowledgment is gratefully made to Or. D. M. Schoemaker for the dissections illustrated by Figs. 1, 2 and 3. The remaining preparations, except those illustrated by Figs. 9, II and 12, were made by the author. Ol'EllATlVli Sl'RGERY OF THE NOSE, THROAT, AND EAR. DIX NASI PROCESSUS OS NASAl_E /'V Fig. 2. The cartilages of tlie nose; anterior view. TlIK sniCICAl. ANATOMY HI' ■|IIK XnSl'.. sill' >\t\v. A \;iri;ililc iiiiiiilii'i- of si-^niiKtiil cjtrl il;i,L;i'> ( i';irtil;i'_:iiH'S sesaiuiiiilca') ai'c round lirt \\ ecu \\\r latci'al iia>al cartilaui- ami llif .U'l'calci' alar i-aiiila.L;i' ( i-ai'lila^n alari- iiiajoi'). The N'.-mt alai' car- tila,i;c's I carlila^incs alans niiimrrs) ;!i'i' small c-ail il,-iL;imius jilaU'S. \arialili' in iiumluT, wliirli Iji' liclwi'mi llic i;rcnliT alar carlilavt' aii in sliape and cxtcal, coiisl ituli's in lai-.L^c nifasurc tlic I'lamcwovk of till' lower lateral poiti f tlir i^xlcnial nosr. and Uial of llic ala (cnis lalcralc). T\\r niiMlial portion (c-rns mcdialc) li-'ii;-. .".) \vi)ids around the antcfior infciioi- poitioii uixini:' to tlie nari- its roundi-d appearance. It is loosely conneeted with tlie carlila.ue of llie . ala (tela snlicntanoa). CRUS MEDIALE The orifices of the no.se sliouiii; the cartilagines alaies niajoros. (lissortioii (if the cniia iiu'dialia of Nasal Cavities. Tlie anlei-i(i|- |iorlion oT tlie nasal cavities, lietwceii tlic .-da and Ilie septum, is called (lie \cslilinle ( l''i.i;s. '.]. (i ami 7). it i> coxcred with squamous ei)itlielium and contains numei'oiis stiff liairs known as vil)rissa\ 1'lie nasal ca\-ities. rii^ht and left, are liollow spaces ttetweeii tlie liones of tile head and face, extemlinu' hackwaid fidin the vestilinle (o the naso])haryn\, and from the IIimh- of tli<' cranial ca\ity aliove to the I'oof of the mouth lielow. Floor of the Nose. The Imuix lloor. narrowest at its anlciaor extremity, hecoiniui;- wider po-leriorl\ and tlnMi narrower at tlie choana?, is formed iiy the palatal |ii-oces> of the maxilla ('])rocessus palatinus ossis mavijlaris) and the pal.alal pioce^,^ i,|' the palate l)0lie (processus ]ioi-i/,ontali> o>si- p.alatini). The .-iilure helweeii these hones divides the lloor into two niMMpial portions, the anterior three- foiirtlis ap])roxiiiiately heint; maxilla and the po-leiior oneTourth 4 (i|'i:i:aii\ K sritcKiiv of thk xosk, ■riii'.nAi', axu kai;. palate lioiic ( Fi.i;'. 4.) 'I'hc caii.-ilis inci.-ivus which (jjioiis (ni tlio septum .jii.-t alioxt'. ju'iicfralcs Ihc lldor in its aiitci'ior iiorlion coiivcy- iiip' till' iiasoiiahitinc ihma'c ami arli'iy lo llic rooT of llic mouth. Tiie sinus inaxillaris may 1»(^ seen I'xtcnial to the latci'al wall of the nose oxlcudiui;- liclow llic level of the lloor. (See also l-'if;-. 1?,.) Septum Nasi. -The sejitum nasi tornis the inner wall of each nasal cavity, ai)proximately in tlie median line, it may be .'^tvais'ht, but more often it is ])ont to one side or the other or irre^'ularly deviated in one or both nares. It is divided into three ]iar(s, tlie bony (se)iluni nasi oss(Mim). cartilaginous (cartilagineum) and membranous (mem- OR1ZONTALIS '// "'"'' CANALIS INCISIVUS SPINA NASALIS ANTERIOR Fig. 4. Floor of tlie nose. l)ranaceum) septum (F\p;. 5). Tlie memliranoir- jiortion (septum mobile nasi) separates the vestibule from its fellow, and is made up of tlie crura medial ia of the two greater alar cartilages, Avith tlieir attach- ments to the septum nasi, covered by a mucocutaneous investment. The cartilaginous portion (septum cartilagineum) is formed by tlie car- tilage of the septum and the cartilage of .Tacobson. The cartilage of the septum is more or less qiiadrilateral in form and is attached posterosuperioi-ly to the perpendicular jilale of tiie ethmoid (lamina perpendiciilaris ossis ethmoidalis), ]iost<'roinferiorly to the groove of the vomer, inferiorly to the anterior ])art of the crista nasalis maxillfe and to Jacobson's cartilage, and superiorly to the nasal bones and tlie lateral cartilages. From the posterior angle a projection extends back- ward often for some distance, known as the processus sphenoidalis septi cai-tilaginei. Jacobson's cartilage (cartilage vomeronasalis Till", SflMMCAI, AXATOMV (H IIIK XOSIC. .laculisuiii) lies Ix'lwet'ii lla- cartila;;i' ami the voiir'I-, ;iik1 Hjc nasal crest ol' the maxilla. Till' l)oiiy ])(ir(io7i is eoniposed (if tlie periu'iidicular ])lat(> of llie ctliiiiniil. lln' in>liuiii 1)1' tile s|iliciii)it I (crista s]ilieii()i(lalis), the vomer, llie maxillary crest (crista iia.-alis niaxilhc), ami flic iialaliiic crest (crista iiasalis ossis ])alatiiii). The ])er])eii(licular phitc of the ethmoid extemls downward and I'oiwaiil from the criiiiiloriii ]ihile ol' the ethmoid (lamina crihrosa ossis LAMINA PERPENDlCUl LAMINA _ CRIBROSA ^^ CRISTA ^^^H SPHENOIDALIS ^^^^S SINUS jtf^^^^B^^I SPHENOIDAL! ' ' 1 "iJM^B OS FRONTALE v -^^ >S NASALE •••nTILACO NASI LATERALIS -RTILAOO LPTI NASI CARTILAOO ALARIS MAJOR >^ CARTILAGO VOMERONASALIS (JACOBSONIt Fig. 5. Tlie si'iitmii nasi. ■ethmoidalis) liavinp; attachmeni- with (lie nasal spine (spina iiasalis) of the frontal, tlie nasal bones, llie cartilafres of the septum, the vomer and (lie lostrum of the splienoid. The vomer constitutes ])racl icallv llie wlmle nf the |M)>(ei-ior ami inferior ])art of the sej)tiim, articiilatini^ helow with the nasal crest of tlie maxillary and palate l)ones. anteriorly and superiorly with the cartilaf,^e of the sc|ituiii. .lacuhson's carlilaye and the pei-pendicular I)late of the ethiiKiid, ami suiii'rioilv with the rostrum and hodv of the b (il'KKATIVK sriKiKKV (iK Tl I K MISK. 'niKoA-l'. AND KAi;. spliciioiil. Its sii|irri()i' in;ii-.i;iii d'niih's into two wiim's, al;i' \'(jiii('ris,, liy w liicli it is attnclicd to the sphenoid. The jiostcrior liordcr t'oniis the di\idin,u' lioumlary of tlic two clioaiia' (if iiostcrioi' iiarcs. (I^'i.i;'. 8.) 'I'lic nislriiiii of the sjiliciioid lakes part in the Torniation ol" tho- SINUS FRONTALIS ' AGGER NASI MEATUS NASI INFERIOR Fig. 6. T'hi' (lutcr wall of the risht iias:il oavitv septum. In the specimen illustrated (Fiii'. .")) it is trianf;iilai- and eon- sideral)ly larger than u.=;uaL The maxilla' furnislies hut a small part of the nasal septum, the crista nasalis, whicli by its articulation witli the vomer, Jacobson's cartilage, and tlie cartilage of tlie septum, comprises the inferior por- tion of the septum, corresponding to tlie extent of tlie maxillary portion of the floor. In its anterior half it presents the eanalis incisivus for the passage of the nasopalatine nerve and artery. Its most anterior pro- liii: srucTfAT. AXATfnrv oi- -I'liK xnsK. I .■jection is tlic Miili'iior ii;i>;il -|iiiii' (-pliKi ii,-i>;ili> nnji'rinr) . (I-'Ili's. 4 and ').) Corrospoiidiim' wifli I lie luisal crc-t of lln' nin\illai"y is a similar pro jection n]nvanl i'ioim Hie lioi'ix.onlal jilale nf the ])alalo ))()iic. If lie> lieliiiiil the iia-al (•i'e>| ,)\' tile iiia\illai-\- ami art iriil;,tes willi i) at the >utui'a jialaliiia tran.-\-ei-.-a. I'd-leiinily it |ire>ents the pn^lci-iiir s])iiie (spina nasalis juistcrior). Roof of the Nose. 'i'he roof df Ihe mi>e is constituted iVoMI herciiv liacl<\vai-d l.y tlie rollowiii- hoiie>: the ii;i>al, tli.' frontal, the ethmoid and sjilicnoid. The lamina crilno^a of the ethmoid ( l''ij;-s. 5, 12, 4."), 4(1. 4S, .lO, ')'.], 7)4 and o.") ) w hich cnii\ey> the lilam<'n(- of the olfactory novvo (Fi.iis. 44 and 47 ) I'rom the ci'aiiial ca\ il> info t he nasal cavity is almost horizontal. If is cumpo.-ed i>\' \ciy hartl lioni' which is easily vooo.c;- nized liy the operafm- on aeeonnf of it> resistance fo the in^f runiont. The si)]u'noi luMAveon it and the ellinioid. tllere is a >pace culled the recessns ^|i]|eUoef hmoid- alis, which recei\es the openiii,i;' of the sjihenoid sinus. A prolie with its end ti|)])od slightly downwaid will reaiiily enter th.e sjilienoid if it is passed ha(4 infeiior), lacrimal. I'fhmoid and sphenoid, eonsfitule the outer wall of the nose. The inferior furhimili' and the middle tur- binate (concha nasalis media) ( Fiizs. (i, 7, l-'i. Hi. 17 ami IS) are attached to the crista I'onchali^ ami ci-ista furhinalis of the maxilla and of the iialafi' hone. The >u|ierior tnihinate (concha nasalis snpei'ior) anhorf di>tance. The infei'im- turhinate and middle turliinafe extend ahout the same dis- tances forward, constifnf Iiil; Ii\ far the uiealei- portion of the pro.jeclion from the external wall. .\ line diawn idonu Hie su])erior border of llie middle turhinate and exP^ideil lo (he nnterior wall di\ides the nose into two uueipml part>. ;i .-uperior compri-iim' about oiie-liffh and an inferior about fourdiffhs. 'V]\v superior and su|u-eme turbinates are much sniidler and shorter than the other turbinates. Tiiey sjnin.u: from 8 OPERATIVE SURGERY OF THE NOSE, THROAT, AXD EAR. t]ie lateral mass of the ethmoid in tlie posterior third of the nasal wall. However, all of the turbinates extend about the same distance backward. The choanje therefore are in relation with the posterior ends of the inferior and middle turbinates. (See Fig. 8.) The superior and supreme turl)inate lie just above the superior choanal level. Upon examination through the anterior nares, the inferior is visible for from one-lialf to its Avhole length, tlie middle ordinarily at its anterior end, ilNUS FRONTALi! NASALIS SUPERtO RECESSUS SPHENOETHMOIDALIS ', ^PeRTURA SINUS SPHENOtOALIS SINUS SPHENOIDALIS CONCHA NASALIS MEDIA SALIS INFERIOR The outer wall iif tlio left nasal cavitv with the oinu'ha lue.lia removed. and the superior and su))iem(' are not visible unless extensive atrophy is present or unless the middle lurbinate has been removed. The inferior turbinate is attached to the lacrimal, constituting a portion of the M-all of the nasolaci'inial canal, and. to the ethmoid; it serves to decrease the size of tlie oi'ifice of the maxillary sinus. The turbinates are covered with nmcous membrane, continuous with tlio mucous memlivaite of the external wall of the nose. It is THE SURGICAL AXATOMY OF THE NOSE. J liiickest over the infevior and niitldlc turbinates, made so by the large number of venous radicals Avhicli aie present. These have been vari- ously designated as turbinate bodies, Sclnvellkorper (by Znekerkandl) (plexus cavernosi concharum) ; they are of great importance in the APERTURA SINUS SPHENOIDAUIS OCULOMOTORIUS =tS H0RI20NTAL1S The choauffi ami anteriur wall of the siiheiioid sinus vicwea from liehiiul. physiologic action of the nose, more particularly in connection Avith respiration. There is a small elevation on the outer Avail just anterior to the middle turljinate knoAvn as the agger nasi. It is sometimes the seat of an anterior ethmoid cell. Tt is by entering through the outer wall at the agger nasi that Moslier reconnnends that the ethmoid cells be curetted Avithout distui-l)ing or necessarilv removing the middle tur- 10 OPEKATIVE SURGERY OF THE XOSE, THROAT, AXD EAR. biiiate lione. Below lliis is a s]if;'lit dopression kiioAvn as atrium meatus medii, which exteuds l)ac'kwaTd aud downward into the iiiiddh> meatus. By virtue of tlie turbinate ledges on the external wall, the nasal cavity is divided into three meatuses, the inferior, middle and superior (Figs. 6, 13, 17 and 18). The inferior meatus, below and lateral to the inferior turbinate bone, receives the lacrimal secretion through the orifice of the naso- lacrimal duct, in its anterosuperior poi'tion. None of the accessory sinuses opens into it. The middle Tueatus contains the orifices of the frontal and max- illary sinuses, and of the anterior ethmoid cells. These orifices in the main open into the infundibulum, a liollowed out space below tlio maxillary attachment of the middle turbinate and between the bulla ethmoidalis and the uncinate process of the ethmoid bone (Figs. 7 and 13). The frontal and one or more of the anterior ethmoidal cells open usually through its anterior and upper portion. The maxillary sinus op(^ns as a rule posterior to the orifice of the frontal sinus. It not infr(>quently lies in such a position that discharge from the frontal and ethmoid cells passes directly throiigh the in- fundibulum into the maxillary sinus. The opening of the maxillaiy is not ah\ays single; one or more* accessory orifices may be present, but they ojien into the middle meatus. The infundiliulum communi- cates Avitli the middle meatus through the hiatus semilunaris. The superior meatus contains the openings of most of the posterior ethmoid cells. Occasionally one is found above the superior turbinate. Behind and above this is the opening of the sphenoid in the spheno- ethmoidal recess. The Choanse or posterior nares which are the openings of the nose into the nasojiharynx are oval shaped and fairly synnnetrical. They are foi'med by the vomer internally, the horizontal plate of the l)alate inferiorly, the vomer and s])henoid superioi'ly, aud externally by the processus pterygoideus. Fig. 8 is an illustration of the choana^ from lKd]ind with the infe- rior portion of the anterior wall of the sphenoid sinus cut aAvay so as to show the nasal cavity projecting al)ove the upper level of the choanje. It also serves to show the relation of the sphenoid sinuses to the choanal', the nasal cavities, and the optic nerve. Posterior to the choana- on each lateral Avail of the ])harynx is the opening of the Eustachian tube. Tn children the nasal cavities are relatively smaller than in adults for the reason that the turlnnates are far larger in proportion. THE SrnciCAL AXATll.MY OF TIIK XOSK. 11 Accessory Sinuses of the Nose. The accessory sinuses of llie ikisc are eavilirs in llie itiaxilhxry. frontah etlimoid and siiliciioid Ixnics. wliieli ai'c liinnl with a iinieosa conthuious -witli tliat oT tlic nose; lliey conununieatc^ Aviili the nasal cavities in ])hrces more or h>ss (h^finite. In order to understand llicir different rehrtions. it is advisable to stnclv the hones -which form their walls. OS FRONTALE SUtURA INTERNASALIS FORAMEM OP PERTURA PIRIFORMIS CRISTA LACRIMAL POSTERIOR FORAMEN INFRAORBITALS ; SULCUS INFRAORBITALIS SINUS SPHENOIDALIS CELLULA ETHMOIDALIS POSTERIOR Fi,-. 1'. The left oihit: Ijone relations. The two nasal hones united at the sutura iuternasalis and the two maxillary bones united at the sutura intermaxillaris, to,a,'ether with the corresponding nasal bones at the sutura nasomaxillaris form the apertura piriformis, or the entrance to the bony nose to which the soft parts of the external nose are attached (Figs. 9 and 11). The nasal bones above form the ])ortion of the roof of the nose which lies anterior 12 OPERATIVE SUEGEEY OF THE KOSE, THROAT, AJvD EAR. to the frontal Avitli Avliicli tliey articulate at tlie nasofrontal suture. Tlie maxilla constitutes the anterior, external and posterior Avails of the sinus maxillaris Avhicli it encloses. It articulates externally Avith the malar (os zygomaticmn) at the sutura zygomaticomaxillaiis. It is extended into the orbit and assists in forming its floor by articulating Avith the lacrimal, ethmoid and sphenoid bones. In the orbit, as shoAA'n SINUS FRONTALIS { / -.ERVUS OPTICUS SINUS SPHENOIDALIS OS ZYCOMATICUM SINUS MAXILLARIS Fii;. 10. Left orbit with bone lemovod exposing tlie mucosa of tlie accessory sinuses. in Fig. 9, the sinuses are Aisilde where the bone has been cut aAvay, the ethmoid in the lacrimal and ethmoid bones, the frontal in the frontal bone, and the siDhcnoid in the sphenoid bone. A realistic A'ieAV of the sinuses is seen in Fig. 10, in Avhicli the decalcified bone in the specimen illustrated has been remoA'ed leaAdng the mucosa of the sinuses intact, the frontal, anterior and posterior ethmoid and the sphenoid, from before bachwavd, and the maxillary beloAv. From these THE SURGICAL AXATOMY OF THE XOSE. 13 ligures it is easy to ol)servo liow an iiifhuninaiioii oi' the otlnuoid cells may result in a iieriorbital abscess. In Fig. 11, the outer plate and cancellous tissue over the frontal sinuses have been cut away leaving the sinuses free with a thin cover- ing of bone. The sinuses are somewhat larger than the average, but their relation to the adjacent bone structure is well shown. OS NASALE ;INUS FRONTALIS ^EN SUPRAOR PIRIFORMIS OSSEUM ANTERIOR CONCHA NASALIS INFERIOR Fiy. 11. Bones of the nose luid orbits; external pkite over frontal sinuses removed. The roof of the nose and of the orl)its from the endoeraiiial side is presented in Fig. 12. The relations of sinuses to the lesser wing of the sphenoid bone, the pituitary fossa (fossa hypophyseos), the optic chiasm, the frontal, and the cribriform plate of the ethmoid bone are shown. The frontal sinuses, anterior and posterior ethmoid cells and sphenoid sinuses are shown in succession. 14 OPEKATIVE SUKGERY OF THE XOSE, THROAT, AND EAR. A clearer understanding' of tlie cells from this aspect may be secured from Fig. 52, Avliicli is made from a specimen which Avas pre- pared after decalcification by removing the endocranial bone covering from the sinuses, leaving the mucosa intact. The relation of the optic nerve to the two sphenoid sinuses and to the last posterior ethmoid cell is Avell brought out in this illustration. Frontal Sinus. — The frontal sinus is the most anteriorly placed of -RISTA GA FORAMEN C/eCU^ SINUS FRONTALIS SINUS FRONTALIS PROCESSL ' CLINOIDEU ANTERIOR SINUS SPHENOIDALIS FOSSA HVPOPHVSEOS Fig. 12. Floor of tlie niitcrior craiiial fossa; lioiiy roof of accessory sinus removcil in part. all the accessory sinuses of tiie nose. It varies greatly in size, but conforms in some measure to a uniform plan in that the size laterally depends upon how many recesses more or less resembling one another are present. Thus tlici'e may W one, two, three or even four of these recesses present. The frontal sinus lies between the two plates of the frontal bone. Its ant(nior wall forms the prominence of the forehead THE SURGU'AI, AXATO.MV OF THE XOSE. 15 al)Ove tlio eyolirows. (Sec Fi.i;-. 11.) 'I'ln' ])ost(.'rior and superior wall separates it from the frontal loi)c of the ))i-aiii, the inferior from the orbit. The irre,i;ularities in the anterior wall are well shoA\n in tliis figure, as well as the relation in the oi'hil and the foramen supraor- CR'STA GALLI JS FRONTALIS CELLULA STHMOIDALIS ANTERIOR CONCHA NASALIS MEDIA Fig. l.l. Coronal soption tlirouLili tlie nose ami mliit. Iiitale. Ea(liof;ra])hs sliow the extent and sliape of this Avail and are therefore required before radii-al o])('rative ]n'oeedures are undertaken. Tlie relation of tlie ])osterior and suiicrim- wall to the brain has been studied extensively 1)V Onodi, who found (hat this wall of the 16 OPERATIVE SURGERY OF THE XOSE, THROAT, AND EAR. frontal sinus may extend over tlie gyrus frontalis superior, gyrus frontalis medius and gyrus frontalis inferior. Tlie inferior Avail is in relation Avith the orbit (Fig. 13) and reaches often far back into the ethmoid labyrinth. As a rule it extends but a short distance pos- teriorly over the orbit Avhile laterally it is usually limited to the inner and middle thirds, although in some instances it may reach the outer third. The septum between the two frontals is seldom directly in the median line, on Avhich account either sinus may extend beyond it. The cavity is often subdivided by more or less complete septa Avhich have the effect of establishing pockets in Avhat Avould be otherAvise a smooth caAdty. Fig. 11 shoAvs hovr irregular it may be. The sinus opens into the middle meatus by Avay of the infundibulum through an elongated canal (Figs. 7, 15, 16, 17 and IS) or simply as a foramen directly into the infundibuhnn. A A^ery characteristic formation of the uiDper portion of the infundiltulum is shoAvn in Figs. 15 and 16, in Avhicli it lies behind an anterior ethmoidal cell, quite similar in appearance. In Fig. 16, the frontal is seen opening into the infundiliulum through a canal. Theie has been considerable confusion in the application of the terms infundibulum and hiatus semilunaris. Onodi includes under the term hiatus semilunaris, the entire space betAveen the uncinate process and the b\illa ethmoidalis of the ethmoid bone, and accepts the designation of Killian, recessus frontalis, for the sharply outlined fossa into Avhich the frontal often opens. "\^'liere a canal is present, he terms it ductus nasofrontalis. It is quite conmion for one or more ethmoid cells to open Avith the frontal through the infundilndum, furthermore the orifice of the maxillary sinus may lie in sucli a position that it receiA'es the pus Avliich floAvs from the frontal sinus and ethmoid cells, giAdng the impression that suppuration of the maxillary siniis is present. Maxillary Sinus. — The maxillary sinus as Avill be seen in Fig. 14, is a cavity in the maxilla interposed between the alveolar process and tlie OTbit and the external Avail of the nose and the malar_process. A portion of the anterior Avalt has been cut aAvay bringing Tlie cavity into view. That portion of the alveolar process coA^ering the roots of the teeth has been cut aAvay, to shoAv their relation to the floor of the sinus. In the specimen illustrated the roots of the three molars and tAvo bicuspids are in close relation Avitli the sinus, Iavo of the roots of the second molar making imlcntations into the floor. The cuspid lies anterior to the sinus, Init it oxtonds above the floor. The floor of the sinus is by no means smooth or regular; as a rule there are bony septa present A\hicli divide it into pockets. Hence puncture through the alveolus Avill not necessarily result in satis- factory drainage. The floor of the nose is generally on a higher level than tliat of the sinus. (See Figs. 4 and 1.3). THE StTRGTCAL A^\\TOMY OF THE NOSE. 17 Tlie postevior limit of llie maxilla scparalcs llio maxillary sinus from the zygomatic fossa (fossa iiil'ra(('iii]ioralis). Tlio lloor of llio orbit in part constitutes the roof of the sinus and the extei'nal Avail of the nose, its internal wall. The cana! for the infraorbital nerve forms in most instances a ridge on the roof of the sinus; however, tiie ridge may not be Avell marked and may he even absent. (Fig. 13.) Tlie opening of the sinus into the middle meatus is on the internal wall, generally in its upper part ; at times there are accessory openings. ZYGOMATI CO FRONTALIS OS ZYGOMATICUM / Higlit lateral view of l)oncs (if tin of the teeth exposed. 14. ! fac witlL iiiaxilhirv sinus and roots Hence it is that pus in this sinus is evacuated through its opening more readily in the recumbent i^osition; jjus coming from the middle meatus may be determined to come from the maxillary sinus if it appears or increases Avhen the head is lowered and the face is turned towards the side examined. This brings the oriiicc into the most dependent position and thus permits pus to How out more readily. The position is not conducive to the How of i)us fi-oni the frontal sinus or the anterior ethmoid cells. 18 OPEEATIVE SI'RGEKY OF THE XOSE, THKOAT, AND EAR. The maxillary sinus may be opened surgically: 1. Through the alveolar process by removing a tooth or in some instances without the removal of a tooth. 2. Through the anterior wall (in the fossa canina) in the mouth. 3. In the middle or inferior meatus, Avith or without resecting a part of the inferior turbinate. 4. By cutting away a pait of the margin of the apertura piri- formis through the nose and continuing the excision bv removing a SINUS - -.^^H FRONTALIS '^?^H CELLULA i ETHMOIDALIS MEATUS -' "' NASI MEDIUS ^,- ■ CANALIS ' NASOLACRIMALIS MEATUS NASI INFERIOR \^:/ FOSSA PTERYGOIDEA Sagittal sect ion througli tlie riglit side of ncise and maxillary sinus. External portion. part of the external wall of the nose below the attachment of the infe- rior turbinate (Canfield's operation). Ethmoid Cells.— The ethmoid cells are divided into two groups, the anterior which open into the middle meatus and the posterior which open above the middle turbinate, generally in the superior meatus. There is no uniformity as to the number, position or size of the cells in either group. They lie in the bony wall between the nasal cavities and the orbit, the frontal and sphenoid sinuses, and between the floor of the cranial cavitv and the middle turbinate. THE SflUITCAI. ANATOMY OK THE XOSE. 19 / SoinoliiiK^s an (>lliinoiil cell may cxIimh] into tin* middle 1url)inate formiiiij,- Avlial is kiidwn as a (•(nu-lia liullosa. Such a cell as a rule lias its o]XMiiii,u- in its upper ])ai-l, and lliereloi-e draiiia^-e is unsatis- ractoiy -when any alVeclion is jn-eseiii wliicli causes it 1o fill u]) with lluid. The bulla ellimoidalis ( (''ius. 7 and ]'■'<) ((Uilaius one or more ethmoid cells, ,i;-enei'ally helouiiinu- to the anterior ,t;roup, althouii,-li occa- sionally one is found opiuiin.i;- into the su])erior meatus. In the specimens illustrated in l-'i;;s. lo and !(!, a sagittal section has been made, so as to cut thfou^h the anterior attaclnnent of the INFUNDI8ULUM E7 HOiDALIS ANTERIOn CELLUL/E ETHMOIDALES POSTERIORES PROCESSUS UNCINATUS CONCHA NASALIS rNFEB Fi-. ii;. Sagittal section tliroush tlie riyht side (if tlie imsi'. Intciual portion. inferior turbinate to the maxilla, which is shown free except for its attachment to the palate bone. The middle turbinate is shown articu- lated with both the maxilla and palate bone. The uiu-inate ]n-ocess which assists in closing; up the inner wall oF the maxillary sinus projects downward from the lateral nutss of the ethmoid. As will be noted it ]>ai'takes in jiart of the j;-eneral cellular arran.nement of the bone in this ])osition. The frontal openinii; into th(> iid'undiluduni ethmoidale is M'oII shown 20 OPERATIVE SritGERY OF THE XOSE, THROAT, AND EAR. while adjacent aiitei'ior ethmoidal cells are quite typical. I'ehiiid these are the posterior etlinioid cells, and posterior to them, the sphenoid. The specimen shows the pterygomaxillary canal throughout its entire extent. It will be observed that the upper part of the canal, where the s])henopalatine ganglion lies, may he entered l)y iDlunging NTERIOR SALIS INFERIOR MEATUS NASI MEDtUS Fig. 17. Sagittal seetidii tlnoiigli tlie left side of the nose internal to that of Figs. 15 and Ki. Inner portion. a needle into the outer wall of the nose just above the posterior extremity of the middle turbinate. An ethmoid cell lies anterior to the infundibulum running par- allel to it and resembling it in shape and size. As has been already reported by the writer, a probe is likely to enter this particular type of cell, giving the surgeon the impression that he is in the frontal sinus. Sometimes this cell or another anterior ethmoid cell may project far into the frontal sinus. con.«tituting what is known as a bulla frontalis. TTTK sri;i;i(Ai. .\^'.\To^^v ni- tiik xosk. 21 Tlu' ;in:ui,i;ciiii'ii( of tlio i-tlmioiil laliyriiitli i.s sliowii in F\<^s. 17 ;iiul IS, wliifli illustrato llic two sidos oL' a sagittal sfctioii dI" the nasal cavity made internal to the one in the speeiinen illustrated in tlie last tAvo figures. On one side the ]tosteri()r ^tortious of the turl)inate are left Avith their articulation with the ]i;dalc lioiic. and on olliei- their maxillary attachments are preserved. Sphenoid Sinus. — The figures show two very large sphenoid sinuses, tlie light extending nnterioHv lo 1h(> loft side far Inn-ond the CONCHA ,. - ^^ ^ NASALIS - A SUPERIOR J^B m '^'% w-/ meatus' " nasi superior CONCHA NASALIS MEDIA y MEATUS NASI MEOIUS cor NASALIS JCHA INFERIOR CELLUL/e ETHMOIDALES NTERIORES /lEATUS NASI INFERIOR Fig. 18. Sagittal section tliroiit;li the left siilo of flic nose iiitein:il to tluit of Figs, l.j ami l(i. ExteniiiJ portion. median line, and the left posteriorly almost as far. The s]ihenoid sinuses occupy a greater or less amount of the body of the f^phenoid. 'i'he two sinuses are not uiiirnnn in size, shape or velalinn. A sphenoid sinus ina.v exleiid liuf slightly to the oj)])osite side, and sometimes it may grow In such an extent on the opposite side, that the other sphenoid is reduced to an exceedingly small size. On the other hand the last posterior etlinidid may almost entirely replace it. It may extend almost, as far liaek as lh(> Classerian ganglion, and 22 OPERATIVK sri:in;i;v (ik tiik nose, throat, axd ear. to tlie hasilhu- ])vooess of the occipital, and as far forward as the canalis opticus. Sphenoid sinuses of various shapes and sizes are illus- trated in Figs. 35 to 55. The walls of tlie si^heiioid sinus vary in thickness not only in different individuals, but also in the two sinuses of the same head. This statement pertains more especially to the superior Avail, the effect of which is to bring the pituitary body and optic nerves raucli NERVUS TROCHLEARIS PHTHALMICA Coronal section through nose and orliit throe mm. anterior to the anterior wall of the sphenoid sinuses. closer to one sinus than to the other. The external Avail, generally the thickest, lies betAveen the sinus and the middle cranial fossa, and adjoins the sinus cavernosus and the carotid artery. The folloAving nerves in addition to the optic are found in relation Avith the external wall, abdu- cens, oculqmotor, trochlear, oijhthalmic and maxillary (Fig. 8). The posterijir Avail articulates Avith the basillar process of the occipital. The inner Avall or septum simiuni s])luMio!(lalium is frequently ; THE SlMUiU-AI, AXATD.MV (IF TIIK XOSK. 23 ill tlio iiu'dinii liiii'. lull fi-oiii wlial lias alivatly Ix'cii slated, i( may be I'XfOiMliiiu'iy iiTc^ular in its jKisitioii. (Fi.e,'. HT.) Tlio aiilciiov A\all is in ivlalioii witli tlic nasal cavity (rooossus s|iluMin('tlnn()irior ollmioidal i-cll. Tii tlio soction (V\iX. 1i') llio -walls of tlie nasal cavitios liavc Ihmmi ciil away :; iiini. aiiti'i-ior to the sinus, showing tin' i-elatioii of llu' autciior wall tn the nasal cavities and the posterior ethmoid cells. I'lu' turbinates, four in nuniher on each side are ent elose to their jiosteiior extremity. The choaTia^ are A'isible in the depths. Thi'ir |Hisiti(in with I'espect to the sphenoid sinus and to the jiosterior portion of the nasal cavity is well shown. It will be observed that much of the nasal cavity lies al)ove the clioana>, quite as gi-eat in size from below upward as the choaufc themselves. This (inure shows how the s])heiioid may be opened with or without the destruction of the posterioi- ethmoid cell. Compare this with P^'if;-. 8, Avhich ^ives a view of the sjihenoid anteriorly from the ]iharynx. The orifice of the s])henoid sinus, while always opening' into the nose above the superior turbinate, varies considerably in its jiosition. The follow-in^' table shows the distance between the inferior marf;-in of the opening-, and the lowest level of the lloor, and the highest level of tiie roof respectively, in fifteen heads measured by the writei-: DISTAXCK BKTWKKX THK IXFKI.'TOi; .MAIiClX OF TllK X.\.SAL OrKXING OF THE SPJIKXOII) SlXrs AXD TIIK FLOOR AXI) HOOF OF THE SIXL'S (In Millimotors) HEADS KIGIIT LEKT FLOOR ROOP FLOOR i;ooK VI. 17 13 13 11 VII. 7 15 20 14 vni. i;! 14 11 16 IX. 10 13 4 13 X. ];} 9 8 12 XI. 12 14 11 15 XII. ■I 4 14 12 XIII. ir, 21 17 19 XIV. If) 22 8 10 XV. 2 2 14 13 XVI. 7 14 3 7 XVII. 12 12 7 12 XVIII. 6 4 5 14 XIX. 21 7 9 8 XX. lit 2 17 10 24 OPF.r.ATIVE SI'RGKnV OF THE XOSE, THROAT. AND EAR. Tliose fifi-ures show a \vi(l(' variation, and yet it may be said that tlic (irifieo, as a rnlo, is midway between the roof and the floor. This is true for twenty out of thiriy sinuses. In XIX, XX, right, the orifice is in the u]i|iei- Uiii-d; in vii and xvi, right, and ix. xvr and xvni. left, it is in the lower thiid: in thf dthcr twenty-three instances it is in the middle third. It is relatively highest in head xx, right, where its distance from the roof is one-tenth of that between the roof and the floor. It is rela- tively loAvest in ix, left, where it opens in the lower quarter of the anterior Avail. The relation of the cavernous sinus and of the third foculoniotoi'- ius), fourth (trochlearis), fifth (trigeminus), sixth (abdueens) and the vidian nerves to the spher(oid sinus has been carefully studied by Sluder. He found that the body of the sphenoid is covered altove and laterally by the dura mater with the cavernous sinus between its ex- ternal and internal surfaces, occupying a position for the most part above and lateral to the body. Within the cavernous sinus are found the internal carotid artery, and the third, fourth and sixth cranial nerves, the first division of the fifth lying in the lower part of its lateral wall. The sixth and third division of the fifth are the only ones of these nerves that are not at times in close association with this cell, that is, separated from it by a very thin layer of bone, and even the third division of the fifth is sometimes also in close association with it. The sixth is uniformly placed on the lateral aspect of the carotid while within the cavernous sinus and is ahvays removed from this bony wall. The fact Avhich determines the relations of these nerve trunks to the sphenoid sinus is the size of the cavei'nous sinus rather than the size of the sphenoid sinus. A large sphenoid sinus prolonged back- Avard and outward may closely approach the third division of the fifth in the foramen OA^ale or even the Gasserian ganglion. (See Fig. 47.) The second division of the fifth is in close association with the sphenoid sinus when it extends laterally to the foramen rotundum. The first division of tiie fifth comes into close association Avitli the sphenoid sinus anteriorly when the cavernous sinus is small in either direction. The third and fourth nerves may be in relation with the sphenoid sinus when it is prolonged outward into the anterior clinoid process or lesser Aving of the sphenoid. The sixth nerve comes into these relations in the sphenoidal fissure (fissura orbitalis superior) AA'hen the sinus is prolonged into the great Aving of the sphenoid (ala magna). This close association of the sphenoid sinus Avith the second di- TIIK SriKIICAI. AXATllMV dl' ■lllK XOSK 25 Fijr. :;n. (Iload A'l.) Fig. 121. I II.M.l VII.) Fig. •.'•.'. (Urad VIII.) Lateral and »ii[ii>iior ioo4iiistmirtii>iis of the accessory siiui<rior ree^nstxurf ions of the awossorv sinuses of tlic nose. 30 OTKltATIVK sri:iiKi;V (tK THE XOSE, TIIIIOAT, AXL) EAR. visidii t>r tlic lillli ill llic roianieu rotunduin may be estalilishod as cai'ly as llic Ihiid year of lire, and witli tlie vidian nerve in its canal as early as the si.\lli year. Variations of the Sinuses in Size and Shape. Tlie reeonstriu'lion nietliud is perliaps the best for ilhistratina,' the variations in size and shape of the sinuses. Eeconstructions of the simises in fifteen heads are shown, riglit, k^ft and snperioi". In Figs. 20 to 34 inclusive, the central illustration is the superior view, tlie right shows the left set of sinuses, and the left the right set (so placed in order to make orientation easy). The anterior ethmoid cells are repre- sented by dotted lines and tlie posterior by broken lines. The other sinuses are drawn with solid lines, as they are ol)vious, viz., in the central illustration the maxillary are the most external, the frontal an- terior, and the sphenoid ])osterior; in the lateral, the frontal is supe- rioi-, the sphenoid posterior, and the maxillary infi'rior. The ethmoid cells of each group are drawn as if they constituted a single sinus, excei^t Avhere the cells were too far distant from the group. As the figures are reduced to one-half the natural size, it is easy to estimate the extent of the sinuses. In the central figures the extent of the sinuses anteroiiosteriorly and laterally is shown, and in the right and left figures, superoin- ■feriorly and anteropostei-iorly. The corresi)onding diameters may be thr;s determined. Frontal Sinus.— AVhile there is a great diversity of shapes to be found in the different fi'ontal sinuses, there is rather more imiformity of shape and size in the two fi-ontals of the same head. The dimen- .sions in millimeters are as follows: DIAMETERS OF THE FRONTAL SINUS (In Millimptcrs) irEAD ANTEROPOSTERIOR SUI'KROINFERIOR LATERAL R. L. R. L. R. L. vt. 15 18 24 30 20 32 VII. 32 33 28 26 22 26 A'lII. 22 Ifi 51 28 25 11 IX. 17 21 27 36 21 37 X. 17 17 40 37 27 22 XL 22 16 38 38 22 15 XII. 16 22 34 45 10 27 XIIL 17 13 25 22 21 18 XIV. 2(1 21 45 37 42 37 XV. 9 12 14 24 7 11 XVI. 12 13 35 30 26 21 XVIL 2() 30 35 43 17 23 XIX. 28 21 39 41 25 30 XVIII. 12 17 30 31 28 20 XX. 2G 31 46 45 32 24 THE srruiU'Ar, axatiimy oi' thk xosk. 31 The varintidiis in llic size of llir iVmilnls iii;iy lie siiniincil u)) as I'lilldw s: Ran.u'f. aiilri-()|)()stcri(ir !• to .'!.'!. siiiicrninfciici- 14 to ."il. ladTal 7 to 42. I'siial. Icaviim- lUil live liiuiicsl ami lowest, aiili'i-oposlcrior l.'j to ll(i. supcidiurciior iM (o -10. lalrral 17 lo '-'A). Avcranc aiitcro- ])oslci'ior iM. suiM'i'oiiircrior .■)4. laliTal '_')'>. 'i'lii' larui'sl .-iiius is lliat of \i\ ( I^'Il;-. L'S ) riL^iit. in wliii-h the (lianic'ti'i-s ai-r I'l;. 4."). 4l'. and llir sinallcsl llial of w ( l^'it;-. I'll) rii;-h(, liaxini;- tlir ilianicliTs 1'. 14. 7. Maxillary Sinus. As a r\ilc the maxillary sinuses in a .uivcn lioad arc I'airly uiiil'orMi in size and sliai^'; the dimensions of the maxillary siniise.«J arc sliowii in tlio following' table: DIA.METKRS OF THK .MAMLLAKV SIM.S AM) IJISTA-NCK OF TJIK OlMiMXC FROM THE FLOOR OF THE CAVITY (In ^nilimrtrrs^ — DISTANCE OF ANTLi;u I'OSTKIUOK INFERIOR I,.\TKRAL OPKXINO FROM FLOOR OF CAVITY IlKAIl R. L. E. L. R. L. R. L. VI. 39 40 42 32 30 25 36 28 VII. 40 42 41 47 28 29 32 39 VIII. .32 30 28 29 19 IS 24 25 IX. 17 20 17 21 S 11 15 14 .\. 39 37 37 40 3."! 30 36 38 XI. 40 40 37 39 31 29 33 34 XII. 34 29 28 28 28 25 21 23 XIII. 37 40 45 43 29 32 32 32 .\IV. 37 42 38 40 25 25 23 21 XV. 40 33 38 34 24 20 33 30 XVI. 25 26 23 26 15 17 18 24 XVII. ?,r, 37 31 33 32 23 22 25 XVIII. :\r, 2C 38 26 26 19 33 21 XIX. 3() 42 45 42 27 32 40 38 XX. 3fi 35 39 36 25 21 36 28 The \a rial ions are as follows: Ran,u:o, antcroposteiior diameter 17 to 4l', snperoiiifcrior 17 to 47, lateral 8 to .'^:>, oi-ificf to lln,,r 14 lo 4(1. Isiial. h a\ing- off liighost and lowest five, anteroposterior '2'J to 40. snperoinferior 28 to 42, lateral 111 to oO. oritk-c to lloor 21 to oli. .\\i'iag< . anlero|iost('ri()r IW, snpero- inferior 38, lateral 23.8, orifice to floor 2!). The largest is vii (Fig. 21) left. 42. 47. 2!). the smallest is ix ( Fig. 2:;) riglit. 17. 17. S. If will be Moled ilijil leaxiiiL:' (Mil a few- of the extremes, tln' inaxillary sinuses are mure unifoi-m than anv of the other sinuses. 32 nPKIIATIVK SXTUIKUV OK TITE XOSK, THROAT, AM) KAK Ethmoid Cells. — To show Ww nivat coinplcxity of tlic I'llimoid cells aii ."i7. lateral 7 to l'!). I'siial. l<>a\iiiL;- nut li\r liiuln-st ami lowi'st. anti'i(i|iosterior 14 to 127, suporoiiifcriDr 17 In '.U. laliial It In IS. Avcv- agc, anteroposterior 21, siiperoiiil'erid:- lTi.Ti. latiial 14. The largest is that ol' xiv ( l''i-. i:S) left, ;;(). .Id. I'i), and the small- est that of XVII (Fi-. 'M) rigiit, !). \\K 7. Posterior Etlunoid. — Range, anlcioiMJstcriDr K! to '.]'.], snpero- iuL'erior G to 38, lateral 8 to 28. Usual, leavinii' nut live highest and lowest, anteroposterior 17 to 26, superoinferioi- 17 to .■!1, lateral 11 to 18. Average, anteroposterior, 22.3, superointerior 23.3, lateral 14.7. The largest is that ol" vii (Fig. 2(5) left, 30, 3G, 20, and (he smallest that of XII (Fig. 20) right, 15, 6, 8. Sphenoid Sinus.- 'riier(> is a Iremeiidnns variation in 1h(> dimen- sions ol' the thirty sphenoid sinuses, as sliowii iu the rollnwiui;- tahle: DIAMICTKKS OF TIIK Sl'llK.NOlU SINUSES (In Millimeters) HEAD ANTEROPOSTERIOR SUPEROINFERIOR LATERAL R. L. R. L. R. L. VI. 35 15 30 24 31 12 Vll. 42 36 22 34 34 25 VIII. 25 20 27 25 16 12 IX. 21 14 23 17 17 13 X. 17 14 22 20 17 11 XI. .•51 27 26 2() 14 19 XII. 9 .•J9 8 26 7 24 XIII. 1(5 ?,?, 36 36 14 27 XIV. 24 10 38 IS 35 10 XV. 2 2;! 4 27 2 21 X \' I . •20 21 ni 14 S XVll. 24 14 21 ni 17 17 XVIII. 9 19 10 I'.i ii 24 XIX. 32 20 28 17 27 12 XX. 29 30 21 27 28 34 The anteroposteri casts of tliciii and sulijcct these Fig-. 37. (Head XIV.) Plaster easts of sphenoid sinu.ses, jilaced iu situ. to some standard of measurements. Branne and Clasen found the cubical capacity by volumetric measurements of metallic casts of the sinuses. The writer presented a method at tlie International Laryngo- THE srr.tilCAL ANATOMY OK THE NOSE. 37 niiinolosieal Cougross in Berlin in l!»ll. by wiiidi l>ntli IIh' ciil.icMl capacity and tlio siiporlicial area ( Tor tlic lirsl tinn') wnr (l.'lcrniiiialili' from iilastcM- casts made of llic sinuses (r\cc|il the rtlnnnidal) in serial sections, and tlien properly united according;' In the iiieijinds used by Fig. 38. (Head XXIII.) Pliistor cnsts of splionoid sinuses, jilaccd in situ. dentists. A number of illustrations of such casts of the sphenoids are hero presented, the casts beina; placed in jirojier position in the lowest section. A far lictter understandinii' nl' (1 \leiit and varial)ility of llie sphenoid sinuses is s(!cured liy this nieiiied than by any other. 38 ()n:i;.\TivK srncKiiv ok the nose, throat, axd eau. It will bo observed that the splienoid sinuses although sliowing little resemblance to one another in the different heads, are fairly uniform in sliape and size in vii (Fig. o.")), xxiii (Fig. 38) and xxxv (Fig. 40). Fig. .-ii). (HL'.-ia XXVI.) Plaster casts of s|ilionoiil sinuses, plareil in situ. These are all large except xxiii. The greatest difference is to be seen in XII (Fig. 36) in which tlie riglit sphenoid is reduced to a cavity 2 by 2 by 4 mm. xiv (Fig. 37) and xxvi (Fig. 39) show considerable difference in the size of the two splienoids. TlIK srivdlCAI, ANATOMY Ol' TIIU NOSK. 3!) Tlio results of till' iiirasiiii'iiii'iits iiia\' lif suiiimaii/<'e ETHMOIDALES ^. POSTERIORES SPHENOIDALIS SINISTER iRIA CAROTIS INTEF aTERIA CAROTI! Fig. 42. (Head YII.) Preparation slunvini,' relation of optic nerve to acc-essory sinuses of the nose. TIIK SllUMCAl, ANATOMY (H IIIK NOSE. 41 'I'lic autlior lias inado a study ol" this in the liftccn heads ilhist rated in Fiiis. 41 to 55 inclusive. These are the same heads of which recon- slruclicns were made as shown in Fiij-s. 20 to 114 inclusive. SINUS FHONTALIS SINISTER SINUS FRONTALIS DEXTER ', -=^5^ g- r ?' m ARTERIA CAROTIS INTERNA ARTERIA CAROTIS INTERNA Fig. 43. (llciid VHI.i l*r«'|i:ii;itiiJii sliowiii;,' lel.'Vtion of ojilie nerve tn aci rssiiiy sinusps ol' llio ikisc. SINUS FRONTALIS SINISTER SINUS FRONTALIS DEXTEF NERVUS OCULOMOTORIUS SPHENOIOALIS DEXTER ARTERIA •. CAROTIS INTERNA NERVUS OCULOMOTORIUS sella' TURCICA Fi;;. 14. (llca.1 I.\.) ^liow-ing rt'l:itio!i '■' ....<;.• iirrvc to accessory suiuscs of thi.' nose. 42 oPKitATivK s^■|!(;I••,l;^■ ok tiik nose, -I'liitoAT, .\m> kai;. The o]itif c'l)iasiii in llicsc lic-ids is in llic main in i-clation with one or botli p])hen()i(l simiscs. it is diicctly n|Min ihc roof in heads vi {Fis;. 41 ) lidlli sides: VII ( Ki- 41') : xii ( Ki^. 47) lioth sides: xiii (Fin-. 4s^) left: CELLULA ETHMOIDALIS POSTERIOR ^RTERIA CAROTIS INTERNA ARTERIA CAROTIS INTERNA Fi--. 4.5. (Head X.) Preparation slnnviii;L;' reljitioii of optie nervo to nf'C^ssoiy sinuses of tlie nose. MUS FRONTALIS SINISTER SINUS FRONTALIS DEXTER V ' LAMINA CRIBROSA CAROTIS INTER NERVUS OCULOMOTORIL NERVUS OCULOMOTOR I US Fig. A6. (Hea.l XI.) Prpjt;i.i:itinn showiii;^- lelution of ojitic nerve to accessory sinuses of tiie nose. THE srr.cicAi. ANAiti.\n m tiik xosk. 43 XV ( Kiy. :)()) left: xvii ( Fiii'. 'y2) riulit ; win (Vi>x. 'il]) Idl; mx {Fi'j;. ')4) liotli sulos. It lies coiisiil('ral)ly iihovr tlic iimiI' in \iii ( I-'Il;-. 43) left: xiv (Fig. 40) loft: XVI (Fig. 51) loft. It lies postoriov to the si)iiciioi(l simis in via (Fig. 43) both sides; IX (Fig. 44) both sides: x (Fig. 45) both sides; xi (Fig. 46) both sides: xiii (F^ig. 48) right: xiv (Fig. 49) both sides; xvi (Fig. 51) both sides: XVII (Fig. 52) left: xx (Fig. .55) both sides. It is thus seen llial in more than half nf tlie instances the chiasm lies posterior to th(> sphcndid cavitx. Sjirrial attention is called to VI, VII. XII. xiii. XVII. xi\. wlicri' a coiisidcraliic portion of the sphenoid cavity lies beyond tin^ anterior margin i>\' the optic chiasm. Xo other cells among tliese specimens come into iclatinn with the optic chiasm. Tlie optic nerve may be described as ))assing externally from' the ehiasm along the roof or lateral wall of the sphenoid sinns in slight relation, usually with the last ])osterioi' itlnnoiil cell, .ind iVoiii tlience to the ])ulbns opticus through tlie perioiliita. Tt may be divided into a sinus iioitimi ami a \'r('o portion, riidei- the former term, I include that jiart of tlic m rve in iiiunediate relation with the accessory cavities of ll:e nose or ( arliit i-aiily ) \\itliin o timi. of the simis wall. The following nieasuremenls show (he length of tlie nerve in the ililTei-eiit heads : I.KXGTH OF Dl'TlC XERVK (In Millimeters) The following variations are olitained: Optic nerve: range, 34 to 55; usual, heaving off highest and lowest live, 40 to 48; average 44. 44 oi'i:i;.\ri\ K snuiKnv or tiik xose. tiitoat. axo kak. Free portions: raiig-o, ll^ to 38: Tisual, Icavinii- off liiulicst and low- est five. 1") to 23: average 20. Sinus portion: rang-e. 17 to 32: nsual. lca\iiiL;- off liiuliest and low- est five. 21 to 28 : average 24. It is therefore clear tliat. a( least in these heads, the sinns iiortion of the optic nerve is a trille greater tlian the free portion. There does not apju'ar to be any correspondence between the leiigtli of the optic nerve and the extei\t of accessory cavities. "Where the sinus is very large, the optic nerve has its origin in the chiasm on the roof of the sphenoid, some distance anterior to th(> posterior wall of the sinus, as for instance in vi (Fig. 41) right: vii (Fig. 42) both sides; xii (Fig. 47) left: xiii (Fig. 48) both sides; xx (Fig. 55) both sides. AVhore the sinus is small, the o]itic nerve leaves the chiasm gen- erally behind the sinns. as seen in viii (Fig. 43): ix (Fig. 44) lioth sides: x (Fig. 45) both sides; xvi (Fig. 51) both sides. Head xvrn (Fig. 53) is somewhat at variance witli this rule, but, u.iulei- any circum- stances, it does not appear possible to assign the variation of thi^ sinus as an explanation for the varying size of the optic nerve, nor for the relation which the sphenoid opening bears to the optic nerve. The following table of measurements shows this difference. DISTAXCK BETWEEN LOWER SURFACE OF OPTIC XERVE AXD XASAL OPEXIXG OF SPHENOID (In Millimeters) HEAD RIGHT LEFT VI. 9 6 ni. 6 6 VIII. 2 6 IX. 6 7 X. .S 2 XI. 9 12 XII. 9 3 XIII. 5 XIV. 14 14 XV. S 5 XVI. 12 11 XAII. 5 5 XVIII. 1 above 2 above XIX. 1 above 1 XX. S 12 Range, 2 above to 14; usual, leaving off highest and lowest five, 2 below and 11 ; average 6. In two instances xviii (Fig. 53) l>oth sides, and xix (Fig. 54) right. THE SrRGICAI. ANATOMY OK TMK NOSE. 45 the orifice i.s aljuve the Iuwit sui lace oT tlic optic, and in xiii (Fi.ir. 48) left, it reaches the same level. In nine instances out of the thirty, the SINUS FRONTALIS SINISTER SINUS FRONTALIS DEXTER .' NERVUS OLFACTORIUS CAROTIS INTERNA kRTERIA CAROTIS INTERNA ^' NERVUS OCULOMOTORIUS NERVUS OCULOMOTOHIUS Fife'. 47. (Uead Xll.j Preparation showing relation of optic nerve to accessory sinuses of the nose. SINUS SPHENOIOALIS DEXTEI ARTERIA CAROTIS INTERNA NERVUS TRIGEMINUS NERVUS OCULOMOTOHIUS Fig. 48. (Head XIII.) Prppaiatinn showin:; r..l:,i;,,i^ ..f <.|.ii<- ii..rv.. ti, ■ M„1W,.« Ui ll... 46 OPKIIATIVK srHGERY Ol' TIIK XCISK, TlfKOAT, AXD KAR. optic nerve lies witliin 'A iiiiii. of I lie level u\' the (ii-ilice of tlie sinus. When the optic nerve lies sd near the level of the orifice of the sphe- ARTERIA CAROTIS INTERNA ARTERIA CAROTIS INTERNA Fig. iii. (Head XIV.) I'lepaifitiiiii sliiiwing' leUitiou of opiir- iiCTVc to acc^ssoiy sinuses of tlie nose. CAVUM NAS ETMMOIOALIS POSTERrOR ARTERIA CAROTIS INTERNA ARTERIA CAROTIS INTERNA Fig. 50. (Head XV.) Preparation showing- relation of optic nerve to acc«ssoiy sinuses of tlie nose. THK sriUllrAI, .\NAlu\n UK TIIK XOSK. 4( nnitl. it is in a far nioi*r vuliit-ralili' iH.^iti.ui than when ils dislancL* is uTcatt'i", fur t!if uritir^' n'j.irv,.iiis i In- iMtssilili' liriu'lit ^)[' jais in si>lM'imid cniiiN'ciiia witli an oucti ni-illci'. SPMENOIDALIS DEXTER ARTERIA CAROTIS INTERNA ARTERIA CAROTIS INTERNA Fi^i'. 51. (,Hea(l XVI.) Preparation showing relation of optic nerve to accessory sinuses of the nose. SINUS FRONTALIS SINISTE SINUS FRONTALIS DEXTER CELLUL>E ETMMOIOALES ANTERIORES CELLUL>e HMOIDALES ■.TERIORES SPHENOIOALIS SINISTE if X ^v SINUS SPHENOtDALIS DEXTER ARTERIA CAROTIS INTERNA NERVUS OCULOMOTORIU8 Fiji. 5l\ (Hrn.i \\ I I. . Preparation slmwinj; relation* of nplic lu-rvr to ac.'4'ssoiy -inuses of' \ho nose. 48 OPERATIVE SUKGEltY OF THE NOSE, TIIKOAT, AND EAR. The optic nerve as a rule eonies into I'clation Avitli the iiostero- external ang'le of the last posterior etlunoid cell at its roof, and from this i)oint It passes in an (>xternal direction lliroun-li (lie periorbita to SINUS FRONTALIS SINISTER LAMINA CRIBROSA SINUS FRONTALIS DEXTER ARTERIA CAROTIS INTERNA ARTERIA CAROTIS INTERNA Fig. .J?,. (Head XVIII.) Preparation showing relation of optie nerve to aeeessory sinuses of the nose. SINUS FRONTALIS SINISTER SPHENOID Fig. 54. (Head XIX.) Preparation showing relation of optic nerve to accessory sinuses of the nose. TtlE srr.C.ICAT. AXATO.MY OK THE XOSE. 49 llic bnllius. The space bctwcMMi the iicivi' nml 1l Iliinoid laliyriiitli iiuToasos in almost diroct iiroiioiiioii as thr imiac aiipi'oaclics tlio litilhus, and its .junrdun with IIh' luilluis is ^I'lhTallx tlic imsilioii n[" liToatest distance betwi'cii llic in'rw ami lln' rllnuniil lali\rintli. In only one case, xii (Fig. 47) does tlic aiiti ridi- iilnnoidal cell come in close relation with the o]i1ic iici-vc icplaciiii;' a posterior ethmoid cell wliirh lies liclow it. The iflarKni whirli tlic iifrvr liears io the last iinstfi'inr clliiiiiiid, wlidi thai i-i'll n'lih-iccs llic sphenoid. DUCTUi NASOLACRIMAL DUCTUS NASOLACRIMALIS SINUS SPMENOIOALIS SINISTER CEREDRALIS AN CELLULA ETHMOIOALIS POSTERIOR LAMINA CRIBROSA CEREBRALIS AN-'ERIOR Fig. no. (Head XX.) Prciniration .showing lolutioii of oplie nerve to aecessoi.v simisos of tlie nose. is very characteristic. I'nr in tlic twd instances in wliicli tliis re[)lace- inent is present in tin' heads (•xainiind. xvi {F\'j:. 51) and xviii (Fig. 53), the nerve is I'oiind tu run aldu.i; tlie external wall of the cavity. This increases the ethmoid poi-tion very considerably, dianging it from a course along an angle to one along a wall which it follows in an almost surprising manner. This ]ii-obably exjilains the cases of optic iicnrilis which complicate an ethmoiditis without an accom])aiiy- ing sphenoiditis, as in the Avriter's ca.se of l)lindness cured by ethmoid exenteration. :>() (iim;i;a'I'1vf. snuiEi;^' oi' 'niK xosk, •imikoat. anh kai:. The frontal sinus is n'lati\cl>' dislant I'l-oiu tin- i)|itii' iin-vr. the nearest ])oint Ix'inn-. as a rule, at tlic iiiiifr side of tlic orhil, and hi^re it is nuich riirthcr away than tiic O()rresj)onding anterior ethmoid cells, "wliieli ordinarily lie anterior to it at the level of the optic nerve. In some instances, however, the frontal sinus may extend for a con- siderable distance backward: for example vii. x, xi, xii, xv. xvii, XVIII, XX. In all the cases the siinis is much closer to the optic nerve than where the sinus remains anterior. In all the specimens the periorbital fat makes a close relation with the maxillary sinus ini|i(issilile, altliiiii!;ii, in some instances, the distance is less than 10 mm. Nasolacrimal Duct. The increasini;- disposition to treat stenosis of the nasolacrimal duct by operation thrcninh the nose justifies a study of its topoii'raphic Rifilit hitoral wall of tlu> nose with pxiiosure of the and ilin-tus iiasnlacrimalis. saccus nasuhu'rinialis THE SURGICAL .\X.\T(iM\ nv TlIK XOSK. 51 relations in tlio iioso. Tin- superior and inferior canalienltp lacrimalos, wiiicli start at tlio pnncta lacrinialis. convey the tears into an expanded pdUi-li railed the saeeus hicriiiialis closed ahove ami Ix'inn' continuous lielow witii the ductus nasolacrinialis wiiich itsell' opens just below the niaxillar\ attachment ot" the concha inferioi-. Tile saccus Incriinnlis lies in the fossa laci-ininlis hetween the crista lacrinialis aiiteiini- and tlie crista lacrinialis |Misieriiir ( Kiii's. !). ROTrs INTERN CHIASMA OPTICUM SEPTUM SINUUU - SPHENOIOALtU FOSSA MEDIA - TORUS TU8ARIUS C Fig. 57. Coronal section tlirougli the .sphenoid sinuses, leniovitl of so|>tiini sinmini sphenoidaliiim and exposure of the hypophysis by cutting awn.v tlic l>one of tlie posterior wall of the left sphenoid sinus. III. It exti'iids tu the canal icaiialis nasolacri'iialis I and iner,y:es into the tluctns nasolacrinialis wliidi runs lietwcen the lateral wall of the |«ose and the maxillary sinus. ' The illustralion I Ki-. ."iCi slmw,- tjic course of the sac (the upper expaiide.l |M,rtion) ,-ii|il ilic duct aloiiir the external wall of the nose. Ill the speciiiMii, III,. Ihum. 1,1 the external wall has lieen cut awav 52 OI'KRATIVE SriKiKKV OF THE XOSE, THROAT, AND EAR. leaving tlie sae and (hi' duct (roe as far as its opciiint;' i)ol()\v tlio in- forior turbinate. It is to he observed that they lie anterior to the middle turbinate and aiiti'i'ior and interior to the lirst cthiiioid cell which is here exposed. Hypophysis (Pituitary Body). The location of the jiitnilary Itody oi' hyj)oi)hysis behind the sphe- noid sinuses, makes it a factor in intranasal surgery. It lies in the fossa hypophyseos of the sphenoid bone (Fig. 56). It consists of an anterior grey portion, ectodermic in origin, and a posterior wliite portion, epider- mic in origin, connected by the infnndibnlnm -with the third ventricle. A reflection of the dura, diaphragma sell??, Avhich stretches from the an- terior to the posterior clinoid processes separates the hypophysis from the oi^tic chiasm and optic tracts, Avhich lie just above it. The in- fundibulum penetrates the dura beliind the optic chiasm and lietweeii the light and left optic tracts. Laterally the cavernous sinus surround- ing the internal carotid artery comes into relation with the pituitary body and the adjacent structures. Anteriorly and inferiorly it comes into relation with the sphenoidal sinus, as shown in Figs. 12 and 56. Figure 57 is an illustration of a preparation made by ci;tting away that part of the roof of the sjohenoid sinus forming the hypophyseal fossa and the dural investment, leaving the pituitary body free in the cavity. The septum Ijetween the two sinuses has also been removed. The specimen shows how the hypophysis may be safely exposed by an endonasal oiieration through the sphenoid sinuses. Vascular Supply. Arteries. — The arteries of tlie external nose have their origin mainly from the arteria maxillaris externa. Branches of the arteria oplithalmica and arteria septi comnmnicate with the network from the arteria maxillaris externa. The frontal I'egion is sujiplied by the arteria oplithalmica, the arteiia frontalis and the arteria supraorbitalis. The nasal cavities and the accessory cavities are supplied by the branches of the arteria opldludniica, arteria maxillaris interna and the arteria maxillaris externa. The arteria sphenopalatina, terniinal branch of the arteria maxil- laris interna passes from the fossa pterygopalatina through the for- amen siihenopalatinum into the nasal cavity, giving off the arteriae nasales posteriores and the arteria? nasales posteriores septi (nasopala- tine). The branches of these vessels supply the inferior, middle and THE SURr.U'Ar. AXATOMY Ol" THE XOSK. 53 superior turbinate?, the mucosa of the iiiferioi' and iniiMlc im-at us. Ilic s))honoi(l sinus, and also a i)ortion of tlie si']i1uim. Tli(^ arteria ctliinoiilalis autt'rioi- ami lln' arlei'ia ellinioidale ]iosl(M-ior leave lli(> oiliil llirou-li llh' rinaiiicn cdiinoidalis aulerius and the fciranien ctlniiDidali' |iii>tcriu^ i-r-|icc1i vch . cnlci- llic cianial cavity ])assiiii)er portion of the mucosa of the septum, the ramus lateralis, the middle turbinate and anterior portion of the inferior luiliiiiate and ]iosterolateral wall of the nose and the ramus anterioi- to that of the anterior portion of the roof. The neivns iurraorl)italis uives niT the nervi alveolares superiores which sn)i]ily the mucosa of tlie niaxillarv sinus and anterior part of llie lloor of llie nose. Tile pjiii:: I loll -|ilienii|i;ilalinniii j;-ives olV the nei-xi 54 OPEKATIVE riUKGERV OF THE XOSE, THROAT, AXD EAK. iiasales wliich supply the ujiiht aiul posterior portion of the lateral wall of the nose, the mucosa of the su})erior meatus, and the superior and middle turbinates and ethmoid cells. The nervi nasopalatini arc branches of the gangiicm sphcnopala- tinum which supply the posterosuperior portion of the septum. The nervus nasopalatinus is the largest branch of the sphenopalatine. It passes down the septum to the canalis incisivus and supplies the adja- cent portions of the septum. The nervus ethmoidalis anterior supijlies the mucosa of the an- terior ethmoid cells and frontal sinus; the nervi alveolares superiores the maxillary sinus; the nervus ethmoidalis posterior and the nervi nasales the posterior ethmoid cells; and the nervi nasales the sphenoid sinus. Sympathetic System. — Fibres fi-oin the plexus caraticus pass through the ganglion sjihcnopalatimnn which gives off fibres which are distributed to the posterior two-lhii-ds of the inferior and middle turbi- nate and nasal septum. ( ii.\|'ti;k II. SIRCICAL ANATOMY OF TIIK IMIARYNX, LARYNX. AND NKCK. P,v Ckoik;!-. 15. \V(M,!.. M.|). THE PHARYNX. Tlic ]iliaryiix. wliicli is a ruiiiicl-sliniH'd tiilic. is divided for ooii- vpiiience of dcsfri])tion into lliirc |ini.2;opliarynx. Diiiinu i|iiift insjiiinlion with tlio montli closed it presents anteriorly in (irdcr I'loiii nlin\c dowinvnrd the posterior nares or olioantp, the soft ]ial;itc willi i(s ;iii1ciii)r pillars attaclieil to the tongne and its postciim- |iillars to tlu' Inlcial wall of tlie pharynx, the e])i the Eustachian in-oiuinence with the oiieiiin? of the Eustachian tuhe. posteiior to tliis the fossa of Kosenmiiller and he- low, the lateral folds of the ]>liaryn\. The posterior wall is a smooth surface .^howinj;- small deposits of lymjihoid tissue and is continuons ahove with the vault, which arches forward to the upjier part of the (•lioan?(». Tn the vault is situated the iaruc mass of |yiii|i|ioid tissue which is desiu'iiated the ]iharyn,u-ea] toii-il. Tin' pliai-yn\ is f^'reater in its lateral than in its anlei-opo-teiini- diameter, the greatest hreadth lieill-- just aho\e the Soft palate. The Nasopharynx. The nasoiiharynx exteiidiui;- from the \ault to ilie lowi i- horder of the soft ])alal(' is an open eavity. thi' latei'al. -npeiaor and posterior walls of which are riuid. The choana' oi' po>tei-ioi- nai-es are two ohiong- siiaces takin-- the pla< f jirael ieall\- the w hoh' of the anterior wall. The vault or foinix of the pliarxnx forms tin' i-oof of the cavity and is oeeu])ied in part h\ the pliaryn;;-eal tonsil. The Pharyngeal Tonsil, composed of lymphoid tissue, varies ex- tremely in size and shai)e. Tt Tiiav consist simjjly of a few small eleva- tions si-;n-cely notieeahle to the naked eye, or it may he a, lare:e pendant mass fillin.i: tlie :;reater jiart of the iiasopharym:-ea] caxify. Tn sha)ie 5G OPKHATIVK ST'i;(lKi;V OK TIIK XOSK. 'I'llltOAT, AXD KAIt it may be a more or lesi^ distinct rounded elevation, 2)la('ed directly in tlie middle of tlie vault just behind the ii])per level of the clioanaj and the upper iiavt of the nasal sejjtum, or it may be dilTused, spi-eading from the vault out into the fossa oC Rosenmiiller, downward on the posterior pharyngeal wall, and latterly to the lateral folds. On each side of the jjluu-yngeal tonsil, and at about the level of the posterior end of the inferior lurliiual is the pharyngeal orifice of Fi"-. o.S. lal Median .soctimi Uimuyli face of an adult man, sliowing tin relations of the structures duiing quiet nasal respiration. 1, Frontal sinus; 2, Anterior palatal pillar; 3, Posteritu- palatal ]iLlIar; 4, Sphenoid sinus; 5, Posterior edge of nasal septum: 6, Fossa of Koseu- niiiller; 7, Pharjiigeal tonsil; 8, Ostium of i:iisi.Mlii:Mi tube; 9, Dotted line showing contour o,f the tong-ue; 10, Salpiiiu(i|ili;ii \ nyi-al fold; 11, Plie^ triangularis; 12, Palatal tonsil; 13, Lateial ].liai'viiL;enl fold; 14, Epi- glottis; 1."), Wnfric.ular liaiid; 16, 'Vocal c.-onl. the Eustachian tulie. The opening is quite large, funnel-.sliaped, with a small end of the funnel directed towards the tympanum. Above and behind the opening is the Eustachian prominence, consisting of a roniidcd ridge rorm. Tlic liranclics of tliis arlei'y aua.'^toiiiose with tlio ascending;' |)liaryuf;('al, and tlie ])liaryi>goal ))rancli of the pteryf^opahitiiie. "^I'hc pt(M-y<;-opalatine is a branch of tlie internal maxillary, wliile the aseendiiii;- ]iliaryng-eal comes directly from tlie external carotid. Tlie veins follow louglily the course of their cor- responding arteries and o]K'n into the ])teryg'oid plexus Avhich is situ- ated partly on the inner surface of tlic internal pterygoid muscle, and Fin'. 00. Transverse section Uirough the head of a eliild one muiitli old, just in front of the posterior phar\-ngeaJ wall. The neck has been twisted so that the lar^-nx is thrown somewhat to tho left. Illustration sliows the rela- tion of the epislotlis to the uvula. 1, l'h;nvni;c;il tonsil; 12. Xasal septum; :'., Uvula; 4, Epiglottis; .",, Trache;i. partly around the external pterygoid muscle. The pterygoid plexus empties posteriorly into the internal maxillary vein and anteriorly into the deep facial vein. The lymphatic drainage of the vault oL' the ])harynx is tluough a rather close mesh of lymijh vessels, which drain either into the retro- pharyngeal lymph gland, or into the posterior or external group of the deep lateral chain, the vess(>ls passing posteriorly to the large vessels of the neck, and behind the rectus capitis anticus muscle. The nerve supply of the pharyngeal vault is derived fi-om the pharyngeal branches of jVIeckel's ganglion. SL'lU;ir.\L AXATO.MV (i|- TIIK rilAllVNX, I.AliVXX, AND NIX'K. .>:' The Oropharynx. Tlio division licfwccii the nasoiiliarynx and ompliarv n\ is a vory movahlo oiio roiisistinp; of tlio free edge of tlip soft jialali'. The upper siirfaco of Iho soft ])alafo foniis an antoroinfovior wall to tho iiaso- ]ihar>iix. mIhIc llic iid'ciiin' siii I'ari' is diroctod towards llic moutli. Tii tho iid'aiit llio lowtM- liordci- of tlio soft palato roachos almost to tlie o]ii.£;lottis, l)\it in llic adiiK tlicro is nioro spaco betwooii the epic:lot1is and the ])alate Avliich is filled in l)y the dorsum of the tongue. The an- terior wall of th(> oroiiharynx is. tlierel'ore. made \\p of the uvula, jiha- rynneal ]iortion of the dorsiun of the lontiue and the eiuirlottis. The lateral diameter is about twiee the anlerojiosterior ' di\ided into three lobes by two lissui'cs, running from Ijolow and behind ui)ward aiit to the line where the plica merges into the tonsillar mass. Behind it terminates at the fxee edge of the posterior pillars, above it reaches to the supratonsillar margin, but below it does not come quite to the surface epitlieliuni, as lliei'c is \-ery a]it to l)e a thick lymphoid deposit Just below tiie tonsil. 'Phe ca]isule sends strong librous tral)ecid;e into the sulistance of the tonsil which carry the blood vessels, lymphatics and nerves. An im- ])ortant peculiarity of the operculum or ])lica triangularis is that in the fully developed tonsil it is attached firmly to tlie tonsillar mass only close to its very edge, and can be readily separated from the capsule which covers the front of the tonsil. The crypts are ingrowths of the surface epithelium, their lumina l)eing formed by the desquamation of a central core. These crjq^ts vary Itoth in number ami in size but they generally run deep into the ade- noid mass, terminating usually clo.«e to tlie capsule, and they may com- municate more or less with each other. They are as a rule larger and more numerous in the up])er part of the tonsil. In the usual type of tonsil the growtli of the two lower lobes forms a deep pocket close to the cai)sule. with its opening in the supratonsillar fossa. This pocket is not in the true sense of the word a ci\ pt. hut is rather an inclusion recess similar to that which I'oinis in the ]inlate from overgrowth of the supratonsillar margin. The tonsil is surrounded exteinally hy the |iliar_\ ngeal ajtoneu- rosis which is rather loosely associated with the capsule. Ex- ternal to this is the superior constrictor nniscle of the pharynx. Still further externally is the bucco])haryngeal fascia, a thin and in jilaces ill defined layer which surrounds the constrictors of the ]iharynx and the outer surface of the buccinator muscle, hnmediatdy beyond tliis rather thin covering, the tonsil is in relation \\ itli a space tilled with loose Fatty areolar tissue. The outer wall of this space is formed by the internal pterygoid muscle; its posterior wall by the prevertebral muscles ami the internal wall by the pharynx. This triangular space G2 OI'KIIATIVE snuiEKY Ol' THE XOSE, THROAT, AXl) EAl!. is iiTegTilavly dividi'd into two snuillcr 8])a('es by tlie stylopliaryiigens jnusc'le, and extenial 1o lliis l)y tlic styloglossus iiinsde. The faucial tonsil is in relation ^vitll tlic anterior of tlicse two divisions, Avliile the internal earolid artei-y is placed well hack in llic ])osterior division. The intei'uai earolid is never closer than 1.5 cm. IVoni the Avail and the pharynx is more or h'ss separated from il hy the interposition of the stylopharyngens nmscle. The external caidtid artery lies about 2 cm. from the iatei-al Avail of the pharynx, and has interposed between it and the tonsil a ])orlion of the jiarotid gland, and llie Avhole of the Fitc. (52. Dissection of tlio rpi;i()ii of the |Kilatal toifsil from the outside. 1, Capsule of palatal tonsil; 2, Facial aj'terv; 3, Hypoglossal nerve; ■i, Superior thyroid artery; 5, Tonsillar Inaueh of facial .artery; tj. Occipital artery; 7, Internal carotid artery; S, Liiig^ial artery; 9, External carotid artery; 10, Spinal accessory nerve; 11, Conunon ciirotid artery; 12, De- seeudens hypoglossi nerve ; 13, Pneumogastric nerve. musculature of the styhiid ])rocess. Tl must be remembered, however, that the outer surface of an enlarged and embcthh'd tonsil is not in the same plane as the pharyngeal wall, and it thus may come in much closer relation to the large blood ves.sels in the neck than the above description would lead one to suppose. Furthermore, the facial artery quite frequently, after branching from the external carotid, has a de- cided upward bend before it SAveeps outward to pass ai'ound the ramus of the jaw. AVhen this upper bending is marked, the loop of the artery thus formed conies in close relation to the inferior porticm of the t(Ui- SfndlCAI. AXATOMV OK Tl 1 K niAKVW. I.AIIVNX. AND NKCK. iV-') sil, iiiakiiiL;- it ]i(issil)l(> tn wouikI this artery diiriiii;- iipcratimis mi tlic tonsils. Tli(^ only nnisclo iiitorvoninir bchvocn it and llic tonsil is tlio superior coiisf riclor. Tlie two carotid arlorics. liowovor, arc separated from the tonsil liy llic stylopliaryniiciis and (lie slyloc^lossus. Till" Mood sujiply of (111' tonsil comes cliielly tlirnuft-li tlie tonsillar liranrli of tln' I'afial arter\. The lower jiarl ol' tlie tonsil, however, may he sni)])]ied from a hranch of the lin;;ual, sometimes cominf? from the dorsalis liniiiia'. and sonielimes from the main linirnal trunk. Oc- casionally the iialaline liranch of the asciMidin.n' ])haryn^eal sn])plies the posterior n])per ])art. "^Phe internal maxillary also contrihules to the hlood sn]i]ily of the tonsil thronnh a small hranch comine]iiii(l the peculiar histolo.cie characteristics. On the po.'Jterior i)haiyii,L;-eal wall we fmd a varyiiij; number of isolated patclies of lymphoid tissue, spoken of as lymi)hoid follicles, n'hese small lymiihoid structures are more numerous in the uppei' ]iai't of th(> thi'oat. and seem to lie an irree-ular downwai'd ex- tension of the pharyn^^eal tonsil. The Laryngopharynx. The laryiiueal portion ol' the jiliarynx, oi' the laryii,i;dpharynx. ex- fends fi'oin the epiglottis down behiinl the larynx lo the level of the sixth cervical vertebra. This corresponds about to the lower liorder 64 (iPKHATivK sn;i;Ei;Y of the nose, tiikoat, and ear. of ilio cricoid cartiliigf. Below tlie arytenoid cartilages the walls of tlie laryngopliarynx are in apposition except during the act of swal- lowing. In 'front of the epiglottis and on the base of the tongue is an accumulation of hanplioid tissue called the lingual tonsil. The varia- tion in size and shape of the lingual tonsil is very marked. Generally it is scarcely more than a rather close aggregation of separate nodes, giving simply a roughened appearance to the base of the tongue. Some- times, however, it develops in two lateral masses which may be so large as to be more or less pendulous. Below the lingual tonsil there are two depressions, the bottom of which represents the junction of the epiglottic nuicous membrane with that of the tongue. These depressions are called vallecula?. The val- leculse are separated by a distinct fold of mucous membrane, the median glossoepiglottic fold, or as it is sometimes called the frenuin of the epi- glottis. Each is bounded externally by another fold of mucous mem- brane, the lateral glossoepiglottic fold. The ijyriform sinuses are deep depressions somewhat boat-shaped, elongated in a vertical direction, placed on each side of the u^sper part of the larynx between the ala of the thyroid cartilage and tlie thyro- hyoid membrane on the outside, and the arytenoepiglottic fold on the inside. Tliey are bounded anteriorly by the lateral glossoepiglottic folds, and posteriorly^ l^ass gradually down into the laryngopharjmx. Tlie blood su])i)ly of the laryiigopharynx is derixcd soli ly from the external carotid, and chiefly through the ascending pharyngeal branch. Other contributory branches are the ascending palatine branch of the facial, and the tonsillar branch of the facial, also the posterior palatine and pterygopalatine branches of the internal maxillary, and sometimes a few twigs from the lingual. The smaller veins from the ])harynx pass into a pharyngeal plexus Avliich may be found between the buccopharyngeal aponeurosis and the constrictors. This plexus anastomoses with , the ptoiygoid plexus above, and empties below either into the internal jugular or into the facial vein. Lymphatics of the Pharynx. The lymphatics of the pharynx consist of a netW'Ork beneath the ]iharyngeal epithelium and the superficial layer of the mucous cutis. This network is probably most marked on the posterior surface of the larynx and in the pyriform sinuses; it is also very rich in the phalan- geal tonsil but very scanty near the esophageal opening. A less im- portant network is found in the muscular tissue. The superior collecting trunks generally pass first to the retro- ])liaryngeal lym|)h glands. They may, however, pass by these glands SlTvCICAL AXATOMV Ol' TIIK rilAltVNX, I.AIiVNX. ANU NECK. 05 and liTiiiiiiatc in 1 iic ilrc|' ccrN iral 1\ iii|i|iat ics, ;iiiil ari'iirdiiiii- (o I'oirrr, into the anterior ■ir(iu|i, luit aceonliuii- {a the irscaiclK's of tlic autluir, botl) anatomic and clinii-al, tlicy tcrminali' In the ixistcrior u:ron|). Tlie middle enlleeiiim- truidlands of the interna] jniiidar li'ron]! near the iiosterior lieily of the di.u'astrii- niusele. The inferior rulleetinu trnuks ilraiii the Inwcr part of the ))har>n\ ninnin.i;' nndei- the ninenu- nieinhrane, and tenil to e(mvers-e in the ]iyrifonn siinises. 'i'hey here iiniie wiili the snjjerioi' lyni]ilmties of the larynx and with them end in tin' ,i;lands of the internal jugular lironj) just Ix'low the diuastrie mnscle. The lymph vessels of the soft jialate are very nnmoroiis, forming- a fine network which is more or less continuous with that of the neiiih- boring stiiietnres. This network is richest in the \ivnla. There are separate colleetinii: trunks from the su]ieiioi- and iid'erior surfaces ami from the fancial pillars. The colleetinij' trunks from the superior sur- face are more or less nnited with the collectors from the nasal fossa> which may be divided into asiendinii trunks and descendiin;' trunks. The former pass aronn ni'ar the diuastric muscle. The co'deetor- of ilic anterior pillar unite with those from the inferior surface, anil the I'ollcetors from the postei'ior pillar with the descending trunks of the superior surface. Occasionally scnne of the lymphatic vessels from the po>terioi- pillars terminate in the glands of the intt'rnal Jugular griuip as high up as the hifurcaticm of the carotids. Nerves of the Pharynx. The nerves ol' the pharynx, hoth inotoi- and sensory, come mainly from the })haryngeal plexus. This I'lexus which lies just beiu'ath the mucous mend)rane is forniecl hy hrain'hes from the glossopharyngeal, from the pnc'Uino:;asli-ic and from the -nperioi- cervical ganglion of the s.vmpathi'tic. The pharyngeal hraiu'li of the pneumogastric is really derived from the accessoiy p\' Meckel's .lian.iiliiMi. 'I'lic \m\\{ lif till' pliarxiix and the slrucfnn's ardiiiid llic orilicc of llic l']u- stac'liiaii lulic arc su|i|ilic(i l>y the |iliaryngeal braiicli of Meckel's siaiiii'lioii. Tile nmedus iiKiiiliraiic nn the external posterior wall of llie larynx is supiilicd \)y the superior lar\'n,i;'eal ner\'e. The Structure of the Pharyngeal Wall. Surrounding' the nineons membrane of the pharynx is a distinct layer of connective tissue, the pharyngeal a]ioneurosis. This fascia xai'ii's in thickness being usually strongest wliere the nnisi-ular wall of Ihi' jiharynx is weakest; and it gradually thins out as the lower end of tlie ])h;irynx is approached. Abo\e it blends with the ])eriosteum at the base of the skull, and is attached to the Kustacliian tubes, the margins of the posterior iiares and to other jiortious of the skull from which the pharyngeal constrictors arise. At the sinuses of Morgagni, that creseentic space betAveen the base of the skull and the uiiper bor- der of the superior constrictor, the fascia is very strongly developed. Externally, the pharyngeal aponeurosis is intimately associated with the constrictors, and forms the capsule of the faucial tonsil. The muscular wall of the pharynx is made u]) of two strata, the internal or circular layer consisting of the three consti'ictors, and an external, or more jjrojierly longitudinal layer, consisting of fibres from the sty!oi)haryngeus and from the palatopharyngeus muscles. The three con.strictor nuiscles appear as modified cones, the middle overlapiMng the superior, and the inferior overlapping the middle. The Superior Constrictor Muscle arises from the lowei- half of the posterior border of the internal plei-ygoid plate, below this fioni the ptei'ygomandibular ligament and from the internal surface of the man- dible just back of the last molar tooth. Tt is also attached antei-ioiiy to the mucous membrane of the floor of the mouth. The u])per libei-s of the muscle curve u])war(l and are inseilcd into the jiharyngeal spine of the occipital hone. This arching of the u])|>er tihers forms a creseentic interval in the pharyngeal wail called the sinus of .Moigagni. Thi-ongh this opening pass the Eustachian tube and the levator and tensor ])alati muscles. The middle and inferior hbres of the supeiior constrictor j)ass posteriorly, radiating upward and (h)wnwar(l to be inserted into the median rai)he on the posterior wall of the ]ihai'ynx. Tlie lower iihi-es are oA-erla])ped by the middle constrictoi'. The Middle Constrictor Muscle, somewhat smaller than the su])e- rioi', arises fi'om the stylohyoid ligaments and from both tlu> small and great coi-nua of the hyoid Itone. Its lihres, radiating u])war(l and downwai'd, ])ass ])osteri()rly to be inserteil into the median I'aphe of Srr.CHAI. AN'ATOMV 111- llll'. I'll \m NX. I.Ai:\NX. ANIl XKCK. (u Ilic |iliar\ii\. The lower liluo iuc ox cil.-iiiiK'tl hv llir u|i|ic'i- lilin'^ ol' tlic iiil'ci'inr. 'I'lir iiilriiial lai\\iii;i'al ar1iT> ami in'ivi' pass llii-nimli the iiitci-\al liclwiTii the sii|iciii)r and niitlillc coiislrictoi-s. 'IMic Inferior Constrictor Muscle aiiscs fniiii tlic obli(|iu' liiif dl' the tliyroiil (.•artilayc and I'ldiii the sides nf tlic cricoid, lis lilircs radiat- iu.ii' mostly upward, pass poslciiorly to lie inserted into the median pharyiisjeal raphe. The lower lilucs Mend with the musculature of the uitpor cm] of llie csophauns. At I lie lower cdi^e of flu" muscle the exIiTiial laryimc'il artery and iicivccome iuln relation with the larynx. The longitudinal muscular lihi'es of the pharynx are m.-nle up of (wo distinct nnisch's. the jialatopharyn.n-eus and the slylo|iliaryiif;-<'Us. The PalatopharjTlgeus Muscle fornis tlu' posterior laucial pillai-. It is composed of two la\<'rs. a lliiii posl<'rior siiperioi- sheet spread- iiifi' tlirouiih the suhstaiicc of the soft ])alate. aiicl a thicker aiiteroiii ferior laver which arises from the jiostei'ior hor nueus (already de>crilied|, the palatoylossns, the azyii'os n\nhe. the lexator palali and 'he tensor palati. The Palatoglossus Muscle is |ilaced directly heiieatli the mucous niemhrane of the ton.iriu-. the anti'i'ior palatal pillai'. and the anterior surface of the palate. It is a thin sheet of mu.scular lihres which arise from the under surface of the soft palate, some of its lihi-es hlendimi with those of its fellow of the opposite, and passes downward to form 68 orEiiATivE sn;GEi;v of the xose, tiikoat, and eai; the anterior pillar of the fauces. It is iiisei'led info the sides of the tong'ue, ami lilciuls Avitl .lie stj'loglossns and (lcc|i iransv crsc lil)rcs of the toiiaiie. The Azygos Uvulae Muscle is rdimd ln'tweeii llu- layers of the l)alatoi)har\n,ii,eus and arises from the posterior nasal spine and the aponeurosis of the soft palate. The two narrow hundles unite as they proceed downward to tlie tip of the n^■nla. tensor ]>ahiti ami tlie lo\atiir ;■ tlie soft palate to be drawn Fig. ()?.. Dissectiou showing- tlie relation of tin palati muscles. The leva,tor is eut jierniitti forward. 1, Eustachian cartilage ; 2, Tensor palati muscle ; 3, Levator palati muscle ; 4, Hamular process ; 5, Internal pterygoid muscle ; 6, Middle constrictor of pharynx; 7, Posterior palatal pillar; S, Sphenoid sinus; 9, Middle turbinate; 10, Inferior turbinate; 11, Tendon of tensor palati mus- cle: 12, Insertion of levator palati muscle; 13, Cut edge of velum palati; 14, Palatal tonsil; 15, Section of tongue. The Levator Palati Muscle arises from the inferior surface of the apex of the petrous bone close to the carotid canal. Its fibres forming a rounded belly, run parallel to and in close ap]iroximation with the under surface of the p]ustachian tube, to which, however, it is not at- tached. It is inserted in a radiating manner into the soft palate beloAV SlT.CHAl. ANATHMV OF ■I'llK rilAKVW. I.AIIVNX. AM) XECK. Oi' till' o.stiuiii of the tulic. Till' arlion of this iiiusclr mi tlir Mustarliian tube is not exactly inuli'istiKid. 'flic contnu'tioii nf tlic imisclc by iii- uroasiiig" its fircMiiiifcicih't' tcmls to raise tbc floor ol' tlir tube wliicli, by deoroasiiii:' the |pci-i)(inliriilai- width of ihi' liinnMi nf the tube, iii- croasos tlic horizontal, and this prohaMy iiK'i'cascs the |iatu!iMii'y of tho tube. Tlu' Tensor Palati Muscle is the n-al alxbictor or dilator tiil>a'. It arises in part from the scaiihoii] fossa of the internal pterynoid jilatc and the alar spine of tho s])lu'noid bune, anil in part from the miter sur- face, or the hook-like border of the cartilauinons wall, and the meinbran- ous part of the lOustaobian cartilajie. liiinnin;;- downward so as to form an acute anji'le with the cartiL-miiious jiortimi of the tube, tlie inuselo descends between the internal ]iter> L;oid mn>elr and the internal jitery- H'oid plate. It terminates by a rounded ti'iidon which jiasses around the hook of tlie lianiular process and is inserted beneatli the levator jialati into the posterior border of the Iiard jialate, as well as the ajio- neurosis of the soft ]ialate. The action of this muscle, by iiuHino,- on the cartila.uinous hook of the Eustachian tnbi'. tend< to sliuiitly imfoM it, which action increases the lumen of the tube. The nerve supply to the miisenlature of the phar.vnx is chieHy through the spinal accessory by wa\ of the iiharynncal plexus. This jilexus supplies the constrictors of tiie pharynx, the palato,ij;lossus, the jialatoiiharyngeus, the azyuos uvula-, and the levator jpalati. The ten- sor palati is supplied from the otic si:an.itlioii. the st.\ lojiharynv'i'us by the glossopharyngeal nerve, and the inferior constrictors receive branches from the vagus through the external and recurrent laryngeal nerves. THE LARYNX. 'I'lie larynx should be looked npmi a> I lie upper part of the trachea, especially modified for the production of the \iiice smind. Us con- struction is such as to permit the instant ai)pro.\imation and ad.just- ment of two elastic ))ands, tln' \oeal emds. These may lie thrown into the recpiired vibrations by a column of air I'oreed up thmn-li the tra- chea. To accomplish this juirpose numerous Joints, li-ameiits and muscles are necessary. By reason of the beant\ and perfection of the ••irrangement of these A-arious structures the lar> n\ is one of the most interesting organs of the body to the aiialmnist. It is situated in the median line of tln' nec|< just in IVmil of the esophagus, and is very lo(>se|\- attached to the snrrmmding slriictnres. On each side poste- riorly are the large vessels of the neck, and above arc the hyoid bone and tongue. 70 orKiiATix T. si-i;i;ki;v ny tiik xose. tiii'.oat, and eak. 'I'lic iii1('i-i(ii- III' llic larynx opens into the iowi-r jioi-tion of tlio plinr^iix jnsf lim-k nf ami helow tlic base of tlii' ton,i;iU'. Tin- aditiis laryngis is oliliqucly ])laoL'(l facing upward and hackward. It is boi-- dorod above li> the epiglottis, on each side liy the arytonoepiglottic folds, and ]josteriorly by the mucons nienibrane covering, the cavti lages of "Wrisberg (cnneifonn cartilages) and of Santoi'ini (cornicnla Iai-\-ngis). These cartilages surmount the ai-ytciioid i-artilages and follow their niovenieiitp,. The interior of the larynx is divided into three ])arts by the false and true vocal cords (\-entricular and ^■0l•al bands). Superior Division. Tlie superior division of the larynge;d cavity is compressed later- ally where the ventricular Itands oi- false cords separate it from the middle division. The anterior wall is formed in greater part by the pos- terior surface of the epiglottis. The upper part of the posterior sur- face of the epiglottis is concave except the tip which is turned slightly forward. Below, the epiglottis shows a distinct swelling, the cushion of the epiglottis. This swelling corresponds in position to the thyro- epiglottic ligament. The lateral walls are smooth except for two slight vertical elevations, the anterior being due to the cuneiform cartilage and the ]iosterior to the anterior margin of the arytenoid cartilage and the cartilage of Santorini. The shallow grove between these eleva- tions is called the philtrum ventriculi of Merkel. The anterior of these elevations runs to the posterior end of the false vocal cords while the posterior passes doAvnward to the true cords. The narrow pos- terior wall is formed by the interarytenoid fold and varies in breadth according to the degree of ai)proximation of the arytenoid cartilages. The Ventricular Bands, or false cords, form a partial floor of the superior division of the larynx. In front they arise from the angle between the two wings of the thyroid cartilage, and they reach back- ward oid\ to the swelling on the h\teral wall caused by the cuneiform cartilages. They are never in apposition and they never ol)scure the margin of the true vocal cords from view. The chief su^tport of this fold of mucous membrane is the thin superior thyroarytenoid ligament and a few muscle fibres. The distance in the adult male larynx from the ventricular band to the summit of the arytenoid cartilages is about one-half inch and to the ti]i of the epiglottis one and a half inches. Middle Division. The middle division of the larynx is limited abo\e by the false cords and below bv the true. On each side and covered bv the ven- >;ri;(;icAi, axatomy hk thk i'iiaiivxx, i.aiivnx, axu xkck. 71 triciilnr liamls i~ ilu' lai-> im'i';il ^imis (u- xciitriflr nl Mdiu.ivni. Its oavity is sdiiicwlint Inriici- tliaii its (iix'niii'; and it rcaclii-s I'lnni tin' an fiTJor aiiiilo ot' the ahr of the lliyroiil cartilaiii' liai-k to the anlcridr liordcr of tlic arytenoid caitilaiie. Tliis vontriflo of ^ror.i!;a.u:iii is ox- tiviiu'ly xarialilc liolli in sliapc and size. It may ronsist simply of a sijiiiK' liroa with the oi)ening between them con- stitute the true glottis, or linia Lzlottidis which is liciierally designatc'l the glottis. Inferior Division. Tin- infei-ior division of the larynx is somewhat llalti'Ued laterally above and lielow wliei-e its walls slope outward and downward from the \'ocal c(jid~. Its walls are in greater jiait made up liy tlie inui^r surface of the cricothyroid ligament. Cartilages of the Larynx. The Cricoid Cartilage is the lowest and is placed directly on toji of the trachea. It is shaiied sonii'W hat like a siiiUct ring, witii the signet part or posterior lamina ])ro.jectin- from thr nppei- side and the ui)i)er edge slo])ing rather gradually downward and forward to form the ante- rior circle. The ring is circular below cori'espoudiug to tiu' shape of the trachea, but above it is somewhat laterally compressed. On top of the posterior lamina are two oval convex facets which look sonu'what out- I'J. OPERATIVE srR(;EHV OV THE KOSE, THROAT, AXD EAR. ward as well as \i]>\\ ani. They are the articiilatiui'- surl'aces for the aiyt- eiioid cartilages and arc sei)arated l)y a faint median notch. On the iwsterior surface are two de])ressed ai'eas for the attachnieiif of the posterior cricoarytenoid mnsck's. On tlie jiostcrior jiarl nf tlic lateral surface of the cricoid, a vertical ridi>e runs do\vii\varndrinm on the external border of the arytenoid cartilage. The apex is directed upward, but is curved sliglitly inward and backward. There are two important processes, one the external inferior angle called the processus muscularis, and the other the anterior inferior angle called the processus vocalis. The Thyroid Cartilage makes up tlu" greater part of the frame- work of the larynx. It consists essentially of two large alfe joined to- getlier in front, but separated posteriorly liy the interposition of the posterior lamina of the cricoid and of the two arytenoid cartilages. The anterior junction involves only the lower two-thirds of the whole height of the ate, leaving a well-marked notch in the median line. At the bottom of this notch, the thyroid cartilage forms the most anterior portion of the larynx, and the ]irorainence due to its projection is called the pomum Adami. There is great variation in the angle of the junction of the two cartilages. In infants it is more of a curve than an angle, while the average for the adult male is about 90° and for the adult female almost 120°. The superior border of the ala is convex ripward, while the lower border is almost straight. Tlie posterior free edge of each ala is prolonged upward almost to the hyoid bone, foiin- ing the superior cornu and downward to the articulation facet on the side of the cricoid forming the inferior cornu. On the exter- nal surface of each ala somewhat posterior to its middle is a ridge I'unning diagonally from above, behind, downward and fonvard. It is usually spoken of as the oblique line and begins above at a prom- inence just below the su])erior border of the ala called the sujierior SriUlU'AI, AXAIOMV (IK IIIK 1'1IA1:VNX. I.AKVXX. AN'D N'Kl'K. !■« tuliiTrlc. It I'lids (111 llic iiil'i'riiii- liiirtkT in ;ni(itlicr indnrniciicc i-allcd llic inrcrior tulicrclc Till' Epiglottic Cartilag'e is a tliin lamina '>\' yWnw d.-ivtic r.-nil hiiiv sliapfd sdnicwliat like a lirdad and s\ar|ic(l paddli'. willi it> liaiidl- lu'low toriuiiiatiii.i;- in liir -Iimii^- tliyroi'iii.iiltittif liuanidil. Its surfac'c is irroiiulavly iudoiitcd li> di|iri'ssioiis and tlunv arc niinnToiis iiorfo- rations ruiinin.u- throiii-li tlio cartilaiic Its upper end is I'lcc. risini: just l)oirnul the l)aso of the ton.i;ut\ Tlie Lesser Cartilages df the lar>n\ arc six in nunilicr. Tlie two i-artilaniiH's tiitiroa' arc small nodules situated Just aliove tla- suiiorior cornu of the thyroid cartilajie in the lateral thyrohyoid liuaniciit. The eartila.n'os of Saiitoriiii or the cornicnlatc cartilaucs, two in iimiilier, are jierched on the apices (it the ai>tcnoid caitilaL^cs and arc enclosed in the iiosterior jiart of the aryteiuH'pi.ylottic I'dld of imicous iiieinhraiie. hi this same fokl, iinmetliately external tn the .artilaucs of Saiitorini, ai-e the eartilages of Wrisheru' or the euiieiform caitihuics. They are ineonstant structures hut ueiierally iiresent. Articulations and Ligaments of the Larynx. The ]aryii,<;eal joints with their lii;amcnts form one of the iiidr-t interesting anatomic features of the larynx. Joints. — The cricothyroid joints are diarthiddial witji a pivotal and also a gliding movement. The circular facets on the internal sur- face of the inferior conm of the thyi-oid cartilage are boimd fast l>y a caiisnlar ligament to the corresixuidiiig slightly elevated circular facets on the sides of the cricoid eartila-c. The pdsteiidr part of the capsular ligament is strengthened hy a ligaineiitdus tliickeiiini;'. The cricoaryte- noid joints are more comiilicatcd hut are also diartlii-ddial. They, too, pos.sess a pivotal movemeut as well as a lateral glidiii;^- iiiiilidii, and. ac- ccirding to some aiithdrities, a slight aiiterdpdsterinr rdckiiig motion. 'i'lie ai-ticniar facet of the cricoitl is convex while that of the arytenoid is cdncaxc. Both articular surfaces are elli|)tical and they never accu- rately coincide with one another. Tlici-e is a distinct capsular ligament which is strengthened jiosteriorly liy a prominent liand, which limits the anterior rocking motion or dis])lacement of the ar\ teiioid cartilage. The lateral gliding motion of this joint, permits tiie two arvteiioid car- tilages to ajiproach one a not her or s( |i;ir,iie. tlnis closing or opening the jiosterior third of the glottic chink-. 'I'lie jiiNdtal luoxemeiit allows the vocal process to move toward or awa\ from the median line causing adduction or aliduction of tlie \iic;d cords. There are Iwu importanl nicmliranes in the l,-ii\ ii\. ilie ericothy- 74 OPEKATIVE SX'lUiEKY OF THE XOSE, THItOAT, AND EAR. roid and tlic tliyroliyoid. Those lie in the iiitefvals between the eai'ti- lages as their names desii^nate. The Cricothyroid Membrane is an important structure and con- sists of three poilidns; two hiteral divisions and a central. These di- visions are all attached below to the upper border of the arch of the cricoid eartilaije. Their u])per attachments, however, are very dif- ferent. Tile central iiortion whicli is somewhat trian,i>'ular in shape, is strong, tense, and elastic. The base is attached to the upi)er border of the anterior part of the cricoid arch and the narrowed top to the lower border of the thyroid cartilage. The latei'al portions form the side walls of the subglottic juirt of the larynx ;uid aic lined internally only with mucous membrane. They arise below from the upper border of the cricoid cartilage and passing internally to the alas of the thyroid find their upper termination in the whole of the length of the inferior thyroarytenoid ligaments, the supporting band of the true cords. In front, the thyrohyoid membrane is also attached to the inner surface of the thyroid alae near the notch, and behind to the vocal processes of the arytenoid cartilages. The lateral erieoarytenoid and thyroaryte- noid muscles lie directly on the outer surface of the lateral i)art of the cricothyroid membrane. The Tliyrohyoid Membrane is attached along the up])er liorder of the thyroid cartilage ami to the internal surface of the hyoid bone. Its central or anterior itortion is thick and elastic and forms the median thyrohyoid ligament. This ligament is attached below to the thyroid notch and above to the upper margin of the posterior surface of the hyoid bone. Where the ligament passes behind the bone a bursa is generally found separating the two. Posteriorly the hyoid membrane terminates in a strong cord-like ligament: the lateral thyrohyoid liga- ment. This ligament runs from the tip of the great cornu of the hyoid bone to the extremity of the su]>erior cornu of the thyroid cartilage. It contains the small cartilago triticea. The inner surface of the thyro- hyoid membrane is covered by the mucous membrane of the pharynx, while the epiglottis is sei)arated from tlie median thyrohyoid ligament by a cushion of fat. There are two thyroarytenoid ligaments, the inferior and sujjo- rior. The Inferior Thyroarytenoid Ligament is really the thick'ened up- per border of the lateral parts of the cricothyroid membrane. It is the supporting ligament of the true vocal cords and is attached ante- riorly to the njiddle of the thyroid angle close to its fellow, while pos- teriorly it blends with the vocal process of the arytenoid cartilage. sim;ii1( Ai. AXATdMV HI" iiu'. l'll\I;^^■\■. I.Al;^^•^■. wn niu'K. i.i 'I'liis liu.-inii'iil roiilaiiis muiirnnis yellow riastic liiurs and mhucI lim^ iH'ai- it- anlcrini- mil a small ikkIuIc ot" I'lastio cartilas'e. Till' Superior Thyroarytenoid Lis^ament is a iiiurli li'Ss imiMn lani structui'i> anil wliilr tliiiiin'i- ami Wfakcr is lnnL;r|- lliaii llir inriTini-. Il suiipnrts llii' M'litiiiMilai- liaiiil>. II is allarlu'il antiM-iurly In tin- lli\ I'niil anulc .jll>l aliiiNr lilr inl'i'l-inl- ami liiis1i'|-in|-|\ tn a -mall I IiIhTi-Ii' oil the anterior sui-l'ai'i' of tlif ai\\ ti'imiil Jnst aluivr llir proeessus vo- calis. There are a iVw rlastir lilni's in it Init it is miistl\ mniposetl of librons tissue, whieh is mnri' nr li'-s rnnlinuuus willi ihr sn|i|iiirtim;- lihres of tlie ai-ytcnociiiulnttir I'lijil. Ligaments of the Epiglottis. 'I'ln- cirmlottis is fasteiicil to the l)0(ly of the hyoiil Imni' Ky an inr-ular lnnail rla-tic haml, tlir liyoi-pi- sirlottic lis^'auient. Fnnn ihr inl'i'iior nannwi-il mil of thf rpinlnttis a Fig. (i4. The Ijitoial pxtenial surface of tl\o laivnx. 1. Siiperioi' coinu of thyroid; 2, Posterior lamina of cricoid; ."?, Inferior ciirnu of thvroid; 4, Strenfrthening band of capsular lifjament; 5, First rin^' of the trachea; fi, Alii of thyroid; 7, Superior tubercle of thyroid; 8, Olilique line of thyroid; !), Centiiil part of cricothyroid membrane; 10, Oblique portion of cricothyroid mu.scle; 11, Horizontal portion of the crico- thyroid muscle. strong' thick lii-anient, eoniijoscil nl' clastic tissue, the thyroejii.nlottie linaiiieiit, runs to the jiosterior surface nf the tliyroid anu'le just below llie note]]. Besides tliese twu trnc li.iiauiciits the ei)i.nloltis is fastened to tlie tongiie by three folds uj' imicous ineinbraue. tlie median and two i;iti'ial irlossoepi.L:!nitic I'ulds. These have already been described. The Muscles of the Larynx. rmliT this brad will be i loci'i bed iiniy thnse muscle- which li;ive )tli llieir urinin and insertiim in sniiie part of tiie larvnx itself. While 76 opETiATivE srr.r.EnY of the nose, tmhoat, aicd ear. some III' tliriii arc coutaincd entirely within the cavity Ixumdcd by the ala nt' tiie thyroid, tiic cricdthyioid, the arytenoid and tlic |i(istci-ior cricoarytenoid aic on the external surface of the larynx ]iro|)er. The Cricothyroid Muscle arises from the anterior surface of the cricoid arch and the lower adjoining border and radiating upward and backward usually sei^arates more or less distinctly into two divisions. The anterior of these divisions crosses the cricothyroid interval more perpendicularly than the i)osterior and is inserted into the lower edge and the neighboring inner surface of the ala of the thyroid. The pos- Fig. (i.j. The muscles of the hxryngeal wall on the posterior aspect. 1, Arytenoepiglottic muscle; 2, Cartilage of Santorini; 3, Aryteuoideus oliliquus muscle; 4, Arvtenoideus transversus muscle; 5, Cricoarytcuui.leus posticus muscle; (5, Epiglottis; 7, Retroliyoicl bursa; 8, Thyrohyoid muscle; 9. Thyroepiglottic muscle; 10, Thyroid cartilage; 11, ThyroarA-tenoideus muscle; 12, Cricoarytenoideus lateralis muscle; 13, Articular facet for inferior cornua of thyroid; 14, Cricoid cartilage. terior division is inserted into the anterior aspect of the inferior cornu of the thyroid. The cricothyroid is sometimes rather closely asso- ciated with the inferior constrictor of tlie pharynx. The Posterior Cricoarytenoid Muscle arises by a broad base from a depression which covers almost the entire half of the posterior sur- face of the cricoid lamina. Its fibres, converging as they ascend in a slightly latei-al direction, are inserted into the posterior surface of the muscular ])idcess of the arytenoid. The Arytenoid Muscle consists of two parts, a superficial oblique laver and a deep transverse layer. sri;i;icAT. axaiomy di' iiii: riiAinxx. i.akvnx. axu nkck. ii The oliliiiui' •■irvlriioid is a iiairrd iiuisclc. one imisdc ci-ossiiisj: tlie ollioi' ill tlio median liin' nn ilic iMiNtciinr aspect df tiir larynx. I'^ael: iniisele consists ol' a narinw Ijiindli' wliieli arises rrmii liie jKisterior side of the imiseiilar jM-oeess ol' liie arvteimid and, nniniim- nl)li(|U('ly ujnvanl, passes arnniiij the outer side i<\' the summit nl' tlu' ojijiosito arytenoid ear1ihi,i;e. Sun f the lilues are here inserted intd the aryt- enoid hut uian>' ciintiuue upwaiil iutu the arytenoepij;"h)ttie fold, as tlie aryteniiepii;hittie muside. and are juined neai' tlie c^pi.u'lottis V)y lihres IVuni the th\ ine|iii:liilt ie nnisch'. 'I'lie traus\ersi> aryleiniid i.- a lraus\'erse sheet of muscle Iteneatli the oblique, stretching heiween the posterior aspect of the outer bor- der of each, arytenoid cartih-iu'e. Soni(> of the lihres are apparently cniitinuuus with the lihi-es (if the t hv rua ry t ein lid. The Lateral Cricoarytenoid is somewhat smaller than the i>oste- rior. It s|irinL;s hy a rather lnnad base from about the middle third of the upper herder nf the lat<'ral part nf the ericnid arch and also from the neiyhhcirinn' part uf the cricotliyroid niemhrane. Its filires nmuin.y backward ami upward eiiu\-ei-i;c to i>e inserted into tiie fimit of the muscular process n\' the ai'ytenoid cartiia.iAC The Thyroarytenoid Muscle coiisist.s of two jiarls. an external and an internal, which, however, are (dosely blended. .\ lar^ic jiart of the lower bordei' of this muscle is clusely associated with the upjier l>()rder of tile lateral cricoarytemiid. The External Thyroarytenoid Muscle is a hinad slu'et just within the ala of the thyroiil cartiiaue and spreads from tiie upper snrfa<-e of the lateral ci-icoaryteuoid to ahoxc the lexi'l of the xncal eoi-d. It arises in front from the lower half of the tliyioid ala (dose to the auule and also from a ixntion of the lateral cricot liNfoid meiidu-aue. Its fibres rminin.u- l)ackwai'd parallel with the \deal cord are in>ei-ted for the fjreater ])art into the muscular jn'ocess of the arytenoid cartilai-e. A few fibres pass around this caililau'e and are continuous with the trans- verse liiires of the arytenoid. The Thyroepiglottic Muscle is reall>- an oil-shoot from the np|>er border of the exteinal thyroarytenoid which turns upward to lie in- serteil into tlu' upper part of the arylenoepiulottic fold and the free mar.iiin of the epi.ulottis. 1'he Internal Thyroarytenoid Muscle is triamzniar in cross sec tion and (dosely associated with the vocal cord, it arises from the thyroid anule in front and is inserted first by several niiiscnlar slips into the vocal cord itself and second into the outer side of the vocal process and adj(iinin<; outer surface of the arytenoid cartila,i,'e. iH OPERATIVE ST'nOEKY OF THE XOSE. THIIOAT. AXD EAR. The portion dt' tlic inusi-lc wlik-li is iuscrlcd into tlic cord is some- times spoken of as the aryvocalis iimsele. The Action of the Muscles of the larynx is conct'rned ))oth with the movement of the \oeal eords and the eh)snre of the upper hiryn,n-eal aperture. The cricothyroid acts as a tensor of the vocal curds Ijy tilting the thyroid cartilage downward and forw^ard (oblique fibres) and by pull- ing the cartilage as a Avhole slightly forward (transverse fi.bres). As the arytenoids are prevented from riding forward on the top of the cricoid lamina, this forward tilting of the thyroid cartilage must put tension on the vocal cords. In opposition to this action of the crico- thyroid, the thyroarytenoid relaxes the vocal cords by approximating the angle of the thyroid cartilage with the arytenoid cartilage. While Fig. 66. Diagrams illustrating closed iuid open glottis. 1, Thyroid cartilage; '2, Thyroarrtenoideus internus; .'3, Cricoar^-tenoi- deus lateralis; 4, Ai-ytenoid cartilage; 5, Crieoaiytenoideus posticus; 6, Arytenoideus transversus; 7, Cricoid cartilage; 8, Thyroid cartilage; 9, Th_yroaiyt.pnoideus internus; 10, Cricoarrtenoideus lateralis; 11, Aryte- noid caitilage; 12, Cricoarytcnoidous posticus; 13, Arytenoideus trans- versus; 14; ('ricoid cartilage. the thyroarytenoid, as a whole, relaxes the whole vocal cord, it is prob- able that the falsetto voice results from a partial contraction of the in- ternal thyroarytenoid by relaxing only a ])ortion of the cord while the cricothyroid makes the remaining part of the cord tense, the tense ])ortion only being capable of vibration. The posterior cricoarytenoid muscle by rotating the arytenoid cartilage so that the vocal process turns outward, is the abductor of the cords while the lateral cricoaryte- noid niuscle by rotating it in the oi)posite direction liecomes the ad- ductor of the cords. The transverse arytennid muscles bi'ing the central sides of the arytenoid cartilages together and thus complete the closure of the sruciCAr, axatomv or tiik piiai:vn-x. i.ai;vnx. ani> nkck. ?!• lilottic rlliiil< ;irti'i- tllc \nr;il ccililv |il-ii|ic|- llllVc Iiith ;i ) i| H'i i\ i lli;it cd liV till' iiiwnrd i-ol,-ili(>ii iif ihr ;ii-\ li'iiiiiil rnrlilimi'. 'I'lu' <-l(iMiii' (if tllc su|HTiur lar\ iiiii'iil ;i|ici'tiUT diiriiii;' swallow inu: is nceoiniilislicil cliitllv liy tlic ol)li(|iU' itortioii of tlio arytenoid net- inn- in oonccii witli tlir arytcnociii^lollic iinisrlc-. Tlic transverse arytenoid with the tliyroarx Iciidicl miisidis pnihaldx aiil in the closure by appi'oxiniatiii.u' the ai\tciu)id cartihiiics and c(iniiiics>inL;' the sides of tlie larynx at almut the position of the false \ncal cords. The sn- l>erior aperture when c|(i>ci| |.ri'teni runniui;' helween the two arytenoid bodies. The nius(des therelnre which affeet this closure nuist be looked upon in elTeet as true s])hincters. The Nerve Supply of the Larynx. The nerves siippl\ in:.; the lar\nx are two in nnniher, and bnth are branches of the ))ncnni thi' \a.nus hii:h nji in the neck, and jiasses obli(pudy downwarecretory lilires, which it supplies to the whole of the laryu.neal mucous nieud)rane. The External Larjmgeal Nerve runs downward on the external surface of the inferior constrictor, endiui;- at the ei-icolhyroid muscle which it sniiplies. liranches aie sent to the iid'erior constrictoi- nmscle and probably, a I'ew motor twius iia>> to the ar\t<-uoid. The Recurrent or Inferior Laryngeal Nerve leaves the jiueuuio- i;'astric in the lower part of the ue. Parotid and snhparotid gron]). 4. Submaxillary grou]) witli llic I'acial glands as an off-shoot. 5. Submental group. (). Retropharyngeal gron]). The Suboccipital Group of glands aic rather inconstant struc- tures var\ ing fVom one to three in nnmher ani\ immIcs situ- ated nlon-- the leiiulli i<\'. aii.l imiiiediately lieneatli. tlie luwei- Imr.ler of the iiuuulil)le. The iai'nest of the urniip is generally fouml near tiic facial artery. These glands ai'e Just lieiiealli tlie fascia ami are inure or less intinn»tely associated with the n]i|H'r Imrder nf the snlnnaxil hiry salivary inland. Theii- afreieiit \ i'>^e|- cduic frcini the external uose, the cheek. iVoni the npiier and liie external part <<[' the Iciwer lip, front practically the whtih' nf the i;nnis and fruiii the anterior third of the sides of the Inni^ne. The efferent \essfls ruuuinii' o\er the surfaci' of the snhniaxillar_\ sali\ai-y izlands empty o-cuerally into tin i;-lands of the deep eei\ieal chain near the hifnrcatidii uf the cdnnnon cai'otid. .They nniy at tinu'> pass [n ^lamls farther dnwu the chain. The Facial Glands are small inconstant structures found in the course of the afferent \-essels leading- to the snlimaxillary nodes. They gXMicrally form thrive i^ronps. The inferior or supramaxillai'v rest on the jaw just in front of the massetei- mnsde. ( )ccasioinUly there is a gland immediately on the edi;.' of the jaw at this ])osition called the iuframaxillary gland. .\ less ficipn'nt uroup of glands is the middle or l)ucoinator group on the external snrface of the Iniccinator mus- cle. All of these hnccinator glands lie ijutside of the buccal fascia. There may, however, he a snM'as ial inland or a snlnnncous s>iaud. The third gronj) is >till less constant and is situated jnsf to one side of the uose. The Submental Group consisting of fi-om one to fonr glands are found in the triam^le hounded hy the anterior heilies of the two xterual ))ortion of the alveola-. iVom the lloor of the month and from the li]) ol' tlie longne. The efferent \-essels iMin either t with the >heath of the givat \e»el.- ol' the neck. Snppurati\e intlanmial ion of the mides leads to ret I'ophai'yngeal ab- scess. In this case the ai)scess starts laterally but bt'ing limited ex- teniall) h\ the fascia covering the vessels enlai'ges medianward. < tc- casionally theie aic small inconstant nodes l)aek of the pharyngeal wall ahnost in the median line. The I'etropharyimc al glands receive 812 0PEI;ATIVE SnUiEItY of the XOSE, TirROAT. AND EAR. tliciv ;ilTci-ci)ts ri-diu the luucous iH('iii1)i';nic of the nasal tossiP and i\c-- <-('ss(ii-y sinuses, JVoin tin.' iiasdjiliarynx iiicliHlin^i' tlic |ilLaryii,'4cal ton- sil, rniiu tile region of tile Kustaeliian tube and possibly from a part of tile tyiiipanic cavity. It must be said, however, that the retrophar- yngeal h'mi)]iati(! glauds are only interrupting- nodes plaeed on the col- lecting lymphatics as they pass from the ui)per ^jart of the back of the tliTdat to the posterior group of the deep cervical chain. The att'erent lymph vessels of the retropiharyngeal lymph glands follow the same general course as those efferents which come directly from the i)oste- ricn- ])hai'yngeal wall and ]iass behind the great vessels of the neck to reach tJie ]iosterioi- vdtxi' of the stei'nomastoid muscle, and em]>ty into the ujipcr nodes of the ])osterior grouj) of the doe]i cervical chain. Fig. G7. Dissection sliowiug the upper deep cervical lympli nodes. 1, Masseter muscle; 2, Facial artery; 3, Submaxillary gland; 4, H-ypo- glossal nerve; 5, Digastric (posterior belly) and stylohyoid muscles; 6, Anterior group of the deep cervical lymph nodes; 7, Facial nerve; S, Kxternal jugiilar lymph node ; 9, Sternomastoid muscle ; 10, Posterior group of the deep cervical l^inph nodes; 11, tSpiual accessory nerve; 12, Sterno- iiKistoid artery; 1?., Iiitcinal jugular vein. The Descending- Cervical chain of lymph nodes consists of two sets of glands, the deei> cervical chain and several more or less important secondary and more superficial chains. The deep glands situated on each side of the neck comprise from fifteen to thirty nodes on an aver- age, although these figures do not represent tlie extremes of variation. This group of glands is variously termed the <'ai'otid chain, the sub- SlT.dHAr. AXATiiMV dl' I'llK I'llAKVNX. I.AIIVNX, ANH NKCK. 8ii stcnicHiiasldiil -nmji, (H- llic ilcc)! hiliTjil ul;iii ;ii-f rliisrlx asMK-iatcd. Tlicv cxtcrul rnnii jusl liciiratli llic car ildwiiw aid iiiidcr tlic stoiidclciddiiiastdid iiuiscK'. i;('iifrall\' only as far as llic pdint wlicrc the diiidlivdid crus-cs llic vessels and nci'\-c<, lull dccasidiially icachin^' as i'ar as llic jiiih-lidii i>\' the internal jniiiilar and >iiiHda\iaii \ciii. The nidre siiiici-lieial di\i-idn nf the deeii lateral chain lies |idstci-idrly and is called tlie cxtenial m-diip. 'I'he external lilands arc generally small, and |ilaced in part ln'iieath the I'dsteridi- hdrder df the sli'rndclciddinastdid. and dcca>idnall\ extend so far ddwn the anterior hdrder of the trapezius niiisi-le as td cdinc into rather eldse relatidii with the siipraela\"icnlar glands. They rest rather 'irroii'niarly disli ilniied, dii the external -nrface of the -pleiiiii^. levator aiiii'nli scapnki'. ecrxieal plexus ami the spinal accessdi\ nerve The anterior dr deep dixisidii iA' the main L;rdiip is jilaccd directly over tlie groat vessels of tin- neck, and is termed tiie internal jugular group. These nodes are situated beneath the anterior border of the stenidcleiddinastdid mn df the >tenidmastdiil just below the pai'dtiil -land. ( )ccasidiially diie nr 1wd iidde> are fdiind rnrlher down along the course of the xcins. Their alTerent vessels come from the auricle and parotid i-egioii and their clTerent vessels terminate in the u|i]icr nodes of the deej) cervical chain. It is claimed that some- linics an efferent vessel from these glands may follow along the course of the exteiMial jugular M'iii and i-nipty into the Mipraclavicular glands. The Si'i'KKnciAi. Axtkukik ('kuvuai. Chain eonsi^ts of two or three inconstant nodes on the anterior jugular vein. The Deep AxTEiuoR Cekvic.\l Ciiaix may be .lixideil inld ihrce dis- tinct groups: the ])relaryngeal, the prethyroid and pretracheal. The prelaryngeal grou]) consists of one, two or three inconstant glands most frequently found in the triangular space bounded by tlio 84 (U'i:i;.\TivK snjdKKv of the xose, tiihoat. axd ear. two cricotliN mill imiscles. A\'liou ]irost'nt tlicir al'IVreiils coino from the iiiiililli' l\ iiijiliatic pedicle of the larynx. Tlioir elTereiits may run I'illicr to tlic pri't laclical nodes or to the lower nodes of the deep lateral- (;haiii. 'l\\r prctliyroid .<;laiids are usually absent. The pret laclieal urou]) is usually present and consists of one or more \('i-\- small nodes. Their afferents come from the thyroicl body and the i)relaryngeal nodes and their eiTerents terminate in the lower nodes of the deep lateral chain. Tiie Recurrent Chain consists of from three to six minute nodes along- the course of the recurrent laryngeal nerves. Their atlerent ves- sels come from the inferior pedicle of the larynx, from the neighbor- ing- region of the trachea and esophagus and a part of the thyroid body. It is im])oi'tant to remember that the efferent vessels of this cliain terminate in tlie inferior nodes of the deep lateral chain instead of pro- ceeding dowiiwai'd to the mediastinal glands. It is, however, possible that occasionally an efferent Fi'din these nodes passes directly to the superclavicular glands. The Supraclavicular Group of lymph glands occupies the supra- clavicular or sTdiclavian triangle. These glands are generally very numerous and are imbedded in the adipose tissue found in this triangle the so-called "fettpolster" of Merkle. In the upper part of the triangle they are just beneath the superficial cervical fascia and rest on the splenius, levator anguli scapulae and scalenus muscles. Also they hold important surgical relations with some of the lower branches of the cen'ical plexus which supply the trapezius and with the ascending cer^■ical arteiy. The more inferior glands of this group are in greater part placed in front of the middle layer of cervical fascia lying very close to the tenninal subfascial portion of the external jugular and descending branches of the ceivical plexus. Some nodes more deeply placed are found behind the omohyoid and the middle layer of cervical of the subclavian. The majority of authors place this chain of glands as an auxiliary fascia being just in front of the brachial plexus and the third portion group of the deep cervical chain, but my own researches have led me to believe that the supraclavicular nodes rarely show any anastomosis with any of the cervical lymph nodes. This is a most important ana- tomic feature because a direct coimection between these nodes and the cervical lymph glands would establish the necessary link in the hon- phatic chain fi'om the tonsils to the apex of the lung. The afferents of the supraclavicular glands come, first from the posterior part of the scalp and fi'om the muscles of tlie neck, second srr.cu'Ai. ANAiiiNn oi' iiii'. l•ll.\K^^■\, i.akvnx. anh nikk. ^^ from tlic sUiii of llic iicclm-.-il ii'L;inii. iliiid riniii tln' skin of the ;ii-iii owv till' (■(■|il:;ilic M-iii. rouilli rinin tlic liiiiiicfjil cli.-iiii n\' ilic .-ixillMry group of lA'lands, and lil'll: idouliti'd li\ sonic aiillior> i iVnin tlic pai'lctal pleura covoriiii;- llic apex of (•;icli Iuml;. The I'lTniMit \rssi'l of llie supraclavicular yiands generally empties inlo llic jni^ular Iruuk. The ju?;ular lymphatic trunk, tiic terminal vessel of the deep lateral chain, usually tcnuiuatcs on the rij>ht side in the anj-le of junction of the internal jugular and suliclavian veins. On the left side it nH)st tVeipientl>" tei-iniuates in the thoracic duct. TOPOGRAPHIC ANATOMY OF THE ANTERIOR CERVICAL TRIANGLE. Viewed fi'om the side, ilie m^ek is divlilecl hy tln' >ici imcdeido- mastoid muscle into two triangles, an anterior, and a posterior triani,de. The antiM-ior cei-vical triaui^-le is sididi\ideil into a diiiastric (suhuuixil- lary), a carotid (suiterior carotid) and a muscular (inferior carotid) triauule iiy the disi'astric and onu)hyiiid mn-ch'^. while the ])Osterior triauiide is divided by the jjosterior ludly nf the (iniohyoid Into *he occipital and supraclavicular triauiiles. The skin of the neck is loosely attached and tlic cicases and folds formed by the flexion of the head as a nde run from above and behind obliquely forward and downward. It is important to remember the direction of these foLls as incisions hi-al with less deformity when made either in the fold it-elf oi- iiarallel with its course. In the lower part of the neck the folds run moic trausx'erse, and the incision should then be less oblique followiui;- the dii'ection of the skin fissures. Beneath the skin is the superficial fascia. Tiiis fa.scia is continu- ous with that of the head and chest, and contains the superlicial nerves and blood vessels, none of which, however, have any .ureat surgical importance. Between the sujterficial fascia and the deep fascia is jdaced the phitysma myoides muscle. ^'Iiis muscle is a thin sheet covei-inij the antei'ioi- part of the siile of tin' iii'ck, arisini;' from the deeji fascia of the i)ectoral region and from the clavicle. Its fibres extend upward and slightly forward. The greater part of the muscle is inserted into the lower border of the jaw but some of the libres are cuntinudus with the depressor labii inferioris, the depressor auguli oris, and the risorius. The anterior fibres meet across the middle line just below the chin. Just beneath the posterior part of the platysma is the external jugular vein. The line of this vein is from the angle of the jaw to the 86 ll'KI'.A TIVK .SLT,(;K1;Y of the nose, TIHIOAT, AXn EAR. iiiiildlc 111' the i-];i\irlc. It is t'oi-incd liy the .jiiiiclinii oT Iho jiostorior ;niri('ul;ir \-ciii with tlic iHislci-iov l)r;iiic]i of tlic tcin|i(ir(iin;i\ill;ii-y vein. It pHHSi's (low iiwaitl external to tlie deep fascia, crossing obliquely over the sternoniastoid muscle, and pierces the deep fascia in the anterior part of the subclavian triangle. It crosses in front of the third part of the subclavian artery and empties into the subclavian vein. Ahnost immediately posterior to the vein running parallel with its upper part will be found the great auricular nerve. This nerve is the Fig. fiS. Superficial dissection of tlie carotid triangle. 1, Masseter muscle ; 2, Facial artery ; 3, Su1)maxillarv gland ; 4, Hypoglos- sal nerve; .'5, Anterior group of the deep cervical lymph nodes; 6, Sujjerior t.h^Toid arteiy; 7, Facial nerve; 8, Posterior aui-ieular arterj'; 9, External jugular lym])h node; 10, Posterior belly of the digastric muscle; 11, Sternomastoid muscle; 12, Posterior group of the deep cervical l\^u|lh nodes; 13, Spinal acccssoiy nerve. largest of the superficial, or cutaneous branches of the cervical plexus. It pierces the deep cei'A'ical fascia just above the middle of the posterior border of the sternomastoid muscle and ascends in close relation wnth the external jugular vein. Immediately beneath the ear it divides into three branches; the anterior or facial branch which supplies the skin over the parotid gland and anastomoses in the substance of this gland with the facial nerve ; the auricular branch, which supplies both SURGICAL AXAIdM V HV TIIK rilAUVNX. I.Ar.VNX. ANH M".('K. S( sidos of the lower part nf tlic |iiiiiia: ami the iiiaslniil liraiirh. wliicii siii)p]ios tlio ^kill .if \\\r >calii lioliiinl ihc cai-. A1h,\c tlir aiii-icularis inau-inis. tltf small .K'ci|iilal iicrxc, a ln'aiicli d' iIk- rrr\ ical |ilc\ns |i;issos upward aloiiu- the pnsti'rini- luirdcr n\' tlir stci-|iniiia>luid. .Inst lu'lnw tile ui-cat auricular nfi-\i' tlir supci-lii'ial i-,.i-\ical \uT\r picrct'S tlii' diM'p fascia and passes fnrwai'd and I i-aii-\ cr-cl\ n\cr the stcnioiiins- tiiid aud liciicatii the external Jni^'ular vein. The deep t'ascia i<\' the neck invests all the muscles and fornis apoiu'iirotic covorings fur llu' t'sopluigns, piiarynx and tracliea, cap- snlos for the salivary iilamls. and sheaths for the larger hlood vessels. This fascia is attached hehiml to the liganh'Utnm nucha' aud the spinal ])rocoss of the seventh cervical vertidna. A supcrlicial layer passes forward, enveloping the trapezins ninscle and uniting in front of the nmscle, it crosses over the ])os1eri(n- trianiile of the neck to envelop the stenioniastoid muscle, .\lio\i' it is attached to the mastoid jirocess and the superior cni-x-eil lii I' tl cci|iital hone aud helow to the clav- icle. From the antm-ior edLiv of the sternnma^toid muscle it continues forward to the median lit I' the neck in a single layer. In the front ]iart of the neck the upper attachment is to the lower border of the jaw. the styloid process, and the hyoid hoiu'. Below, near the steninm. it dixides into two layer.s, an anterior and a ])osterior which aic attached i-espectively to the anterior and pos- terior edges of the upjx'r ])ortion of the sternum. The interval thus fonued (the space of Gruher) contains fat, the sternal head of the stenioniastoid and the anterior jugidar veins. Just below the mastoid process a su])erHcial layer of the deep fascia is continued over the parotid gland and the masseter muscle as the i^arotid and masseteric fascia, anil is attached to the lower border of the zygoma. From the deep fascia processes extend between the various struc- tures of the neck. At the angle of the jaw it becomes thickened and fomis the stylomandibulai' ligamiiit, which extends from the tip of the styloid process to the posterior hoidei- of the angle of the mandible. Other thickenings of this fascia form the i)teiygospinous ligament and the stylohyoid ligament. This latter ligament runs from the tip of the styloid process to the lesser coniu of the hyoid bone. Two main processes are given off from tiie deep fascia, a posterior and an anterior. The posterior jjrocess, or prevertebral fascia, arises at the anterior border of the trapezius mustde, and covers the numer- ous muscles of the back of the neck, the brachial plexus, the phrenic and cervical sjnnpathetic ner\'es and passes inward behind the large vessels, the phaiynx and the esophagus to meet its fellow of the other 88 autjle and is ])artially covered by it. It occu])ies a triauii-ular space w liicli i- luMindid externally and aliove by the inner surface of the mandible, exliinaily and below by the skin and fa-eia as tlicy pa-s rr(!iii llie cikjc nl' the Jaw \n tlic ucck, and internally liy tlu' mylnliydid niusele. The ptistcrior part of tlie Klaud also rests internally on the hyoglossus, the posterior belly of the diii'astric and the stylohyoid niii^cles. Tt is crossed extenially by the facial vein, \\hile the facial artei'y )iasses tliroiiuh a uroovc on its ex- ternal inferior surface. The posterior end of the L;laiiil which is really the most bulky portion very often reaches to the anterior edsje of tho sternomastoid muscle. Alonja: its upper border just beneath the lower edj>e of the jaw, the submaxillai-y lynijih nodes are sometimes very closely associated with its capsule, so that in niali,>;nant disease w'ith metastasis to tlie sulimaxillaiy lympii nodes il is piobablv best to re- move the salivary gland, as well as the lymph nodes in order to be sure that the dksease is erndica1e(|. The siihiiiaxillarv oi- Wliarlon's duct leaves the gland from the anterior end and i~ often accomiiaiiied by a toiiiiucdik'c ]ii'olonuatioii of the glandular tissue. The Digastric Muscle consists of two bellies, a posterior and an anterior. The posterior lielly arises from tiie digastric groove on the internal surface of the mastoid process. Tt runs forward and down- ward, ])assing through the stylohyoid innscle, where it becomes ten- ilinous. This tendon is attached to the upjier surface of the hyoid bone iiy a pulley-like band from the cen'ical fascia. The tendon passes on through this pulley and liecomin.ir fleshy, f(U"ms the anterior belly, which is inserted intarotiil lilaiul, >iiL:lilly in rrmil nj' tlic inriaiiiamlilnihir liraucli. sweeps rmwanl and ilnw nw aid to I lie iiircrinr ciii^fo ot" the nKintlil)le, follows this to the antci-ior lionlcr ol* the inasseter iiinsele, and turniiiu" slisrhtly uiiwai'd supplies tiic depressor ansi-uli oris, the suiiiew li;M \a I'i;! Iile, ;in(l oecasii mallv, just after it emerges from the jiaiolid .ulaml, its course is so far down as to make it very open to injury in reinovin.n- the lymph nodes at the angle iif the i;iw. Cnttini;- of this nerve is deiihualde ;i- il p;iralyzes one-half nf the hiwcr hii. 92 nrr.iiATivT, sriicKi-.v of the xose, 'rmtoAT, and ear. Internal Jugular Vein. — At alinid this depth it is iiii]iortant to re- moinhor tho ])ositi()n and rchitioii of the large veins in flic neck. The internal jugnhir vein whicli i.s a continuation of the lateral sinus, begins above by a dilation called tlie Indb which occupies the posterior com- partment of the jugular foramen. It runs obliquely downward and forAvard, tenninating behind the clavicle near the sternum Avhere it uiiilcs with the subclavian vein to fomi the innominate. At first it is behind the internal carotid arteiy, but gradually passes around as it descends until finally it is on the outer side of the carotid artery. In the lower part of the neck it sometimes overlaps it in front. The right vein is not very closely associated Avith the artery at the base of the neck, whilst the left vein is almost in front of the carotid arteiy on that side. An important tributary to this vein is the common facial vein. This latter vein is fonned by the union of the facial vein and the anterior division of the temporomaxillary vein. The common facial vein crosses over the external carotid arteiy generally a little below the posterior belly of the digastric muscle and frequently has to be ligated and cut to expose the external carotid near its base. Sometimes the common facial vein gives off at the anterior edge of the sternomastoid a branch which may be quite large and which runs along the antei'iov border of the sternomastoid to the suprasternal fossa where it joins the anterior jugular vein. The internal jugular vein occupies the connective tissue slicalli in coniiiion \\ith the carotid arteries and the jineumogastric nerve. The Hypoglossal Nerve heaves the skull through the anterior con- dyloid foramen. It arche.- downward and forward passing to the outer side of both the internal and external carotid arteries and internal to the posterior belly of the digastric and the stylohyoid muscles. As it crosses the internal carotid artery it passes below and around the oc- cipital artery. In its course this nerve communicates Avith the pharyn- geal branch of the A'agus, and sends a small branch to the thyrohyoid muscle. It passes foinvard beneath the stylohyoid muscle and external to the hyoglossus muscle just above the hyoid bone. In this position it is an important landmark for an approach to the lingual artery. The lingual branches of this nerve are distributed to the hyoglossus, the geniohyoid and the geniohyoglossus muscles and practically to all the intrinsic muscles of the tongue. The descendens hypoglossi, a rather large branch of the hypoglossal, descends along the external surface of the carotid sheath, though sometimes it occupies the interior of the sheath and fonns Avith a branch from the second and third cervical nerves the ansa hypoglossi. Branches from this plexus run to the omo- hyoid, the sternothyroid and the sternohyoid, but it is probable that the ;ri;iiiiAi. .waiomn ok tiik i'iiakvnx. i.akvnx. anh m;ck !):! iuiUTX alinll nf \\{r>r lllll>.'lcs ciillii'S tlllnuull lllc ciTvicnl llrlAi'S Illld lint Iliniuuli the liyiioiil(»s;il. 'I'lic Common Carotid Artei-y ariM- <>ii ihr riulil >\<\'' "f tlir iiim-I< iVoiii tlic iiiiioiiiiiiatc artery, aiid nri tlu' Idt .-i.l.- \'v>n\\ llir ardi of ll:.- aorta. Tn tlu' nock, liowovi-r, tlio two arterii's liavo prat-tifally tlio same ri'lations. It is iiiiiK)rtaiit to rciiU'iiilxT. liowi'vor, tliat tlio tlioraoic (liiot i)assos iiniiiodiatily luliiinl tlic Irft carotid artory just before arcliiiin- downward to ciih r tlic iiiiioiniii.itc \tiii. and tlie rocnrrent lar- yngeal iiciA'c has alirad> passed to tlic iiinci' side nl' llie artery liefore liie artery enters the neck proper. ( >ii the riulit side the recurrent hiryn- iioal ner\-e lies liehiiid the carotid artery in the h.wer |>art of the neck. At about the lov(d nf the lirst nwj; of the trachea the inferior tlm'oid artory, a branch of the thyroid axis, |)asses imniediatoly behind the conunon carotid. The stornoniastoid l)rancli of the su]»erior thyroid artory crosses over the conunon carotid alonji' the anterior ed<;-e of the omohyoid at about the lovol of the sixth cer\ ical \erlelira. A line for the conimon carotid is from the n])pei part of the -teniii<'la\ ii-iilar ar- ticnlatiiiii ti) a point midway Itetweeii the anule nt the jaw aiicl the tip of the iiKoloiil process. 'I'lie jioiiit of lii I'll icat i( m into the two termi- nal branches, the external and inteinai caioticcomes teiidiiiou.s henoath the stoniomastoid muscle. This part of the muscle is called the posterior belly. The auieii(U- belly begins from this inlermediaiy tendon and passes ohliipicly ii)iwar tii-st rib h\ a proces- of the deep cervical fascia. The anterior lielly of the tiiii>cle loinis the upper boundary of the infi'iior carot'hl trianule and cio^se- the cdinnioii carotid artery at about the Ie\-e| of the cricoid cartilai^v. The External Carotid Artery is uMiaily alioiit two and a half inches loiiL;' and supplier Mood to the upper part of tiie ne<-k and nearly the whole of the head and face, outside of the cranium. Its course is gen- erally at lirst slightly forward, then backwjird, upward and inward, be- hind till' posterior belly of the digastric and the stylohyoid muscles to the under surface of the parotid gland. It terminates near the upper 94 (IIM''.r,ATl\'I'". sriKM'.li'i' Ol- TilK \(ISK. 'I'llIKiAT, A \ 1 1 KAII. part (if llic iilaiid, ni'iicrally liciicatli it hut sonu'linics in its sulisfancc by ili\i(liii,<;- into the internal niaxillai'v and the suiicilicial tcni|Miral arteries. The Superior Thyroid Artery, tlic first Inancli ol' llic cxtcinal carotid, arises from the front of tlie carotid just below the tip of the ^Teat cornu of tlie liyoid lionc. The artery runs at first forward, but soon turns downward, sending- 1 tranches to tlie laiynx, sternomas- toid muscle and the thyroid ^land. Tn tlie be.yinning- of its course it lies on the inferioi- constrictor nmscle, an nkcic. :'•> i\tcin;il carnlid just liclow tlic pustcrini- liclly lA' the ilii;;is1iir iiiid riiii- iiiiit!: ii])war(l and l)a('k\var(l ihhUt tlic iidstcrini- ImHv iA' tlie digastrif, it crosses, lirst tlii^ iiitcnial carotid artt-ry. Ilicn I lie iiy|>(>i,d<)ssal nerve, llio piieuino.iiastric iiciac, tin' internal jni^nlar \'ein and la^1l> the -pinal ac-cessory nerve. Tin' liyjiniiho.-al nerv<' lioulo arniind tiic ailiTy Jusl as it iiranelies lidin the carDtid. I>y passin;;- lietweeii the transversa jnoeess of tiie atlas and the hase of the >knll. the ()cci])ital artery reaelies tlie diijastrie ijroove of the niastnid pidcess. In this ]iart of its course it is sepai'ated iVuni tin' xirtelual artery liy tiie I'ectns cajiitis lateralis niusole. The Posterior Auricular Artery, the sixth Inanch, leaves the back of the extei-nal cai'ntid Just almxc tin- dii^astric niuscli' and jiassincr uinh'r the ijustcrinr part i>\' tin' pamtid u'land I'uns hetweeii the niastnid process and extei-nal anditory meatus, wiiere it is in close relation with the postericu' auricular iii'anch of tiu> facial iu'r\e. The Internal Maxillary Artery, the seventh l)ranch, one of the ter- minal hranehes of the external carotid, hei-ins liehind the neck of the lower jaw and passes forward to supjily practically all of the inteiua! structni-es of the face, 'i'he lirst part of the artery is tdosely associ- ate(l with the auriculotemporal nersc and inteinal maxillary vein, and it lies between tin' sphenoina]nlii)ular ]i,i;ament and the neck of the jaw. Its second jiart, occupying' the zy.iidmatic fossa, may run either over or under the lower liead of the external i)tery,u-oid muscle. Wlien it passes between the heads of the external pleiy<>()id muscle it comes into close relationship with the third division of the tifth nen-e. The third ])art of the artery luus hetweeii the lower heads of the external )i1ery,i;<)id, thence through the pteryi;oniaxillarv fissure into the sphenomaxillary fossa. This ai'tery yives olf numerous branches, one of which, the posterior or descending- ])alatine, runs downward through the posterior palatine c;iii;il t1ylo.i;los.-ii> iiinsrlr-, the stylohyoid lii;anient, the glossophaiynucai nerve, tiic pharynncal hraneh of the vaiius, and some tine symiiathetic twij-'s. The dif^astric and stylohyoid museles run external Koth to it and to the external earotid. The upjier jiart of the inteinal earoiid in the neck is covered hy the i>arotid irlantl. As a rule no iuanches are i;i\cn olT from the internal earotid artery, while in the neek'. The Pneumogastric or Vagus Nerve oeenpies the carotid sheath lie- ing placed liehind and hetween lirst the internal, then the common car- otid arteiy and the internal jujiular vein. Two ganiilia are found on tlie pneumogastric nerve as it leaves the skull through the .I'ngular foramen. The upper and smaller one. the ganglion of the root, gives oil' a meningeal lu-anch and an auricular (Ariuilil's nerve) hraneh. The latter generally communicates with the tympanic branch of tlie glossopharyngeal, also Avith the facial nerve. The lower ganglion of tlie trunk gives off the phannigeal branch and the superior laryngeal nerve. The phaiyngeal branch which iiall\ derives its fibres from the spinal aceessoiy nem-e, nms between the internal and external carotid arteries and hel]is in the formation of the pharyngeal i)lexus. The Superior Laryngeal Nerve luus downward and inward behind the external and internal carotid arteries to the tiiyroid cartilage. In its course it divides into the intei-nal and exli'iiiai laiyngeal nerves. The internal laiyngeal lU'rve gains access to the laiynx by running be- tween the middle and inferior constrictor muscle of the |)harynx and tlirough the thyrohyoid membrane. The external laiyngeal nerve passev ddwnward u])on the inferior constrictor muscle ending in the i-rieot hyiiiid in the lower part of the neck. Tlie Recurrent or Inferior Laryngeal Nerve is a branch of the vagus. I >ii the i-iL;lit ~i(li' of the neck it leaves the vagus as it passes over the sid)clavian aitery. It then runs njjward behind the subclavian, the common carotid ami the inferioi- thyroid artei'ii's, and liehiml the thy- roid body. It entei> the laiviix liv passing beneath llie lowi'r border of the inreri(jr ciuislricloi' muscle. The left rei'urrent laryngeal nerve leaves the vagus as it crosses the aortic arch. Pa.ssing around and behind the arch it runs ujjward in the interval between the trachea and esophagus. In the neck its course is similar to that on the right side. yO OPKIIATIVK sri'.CKnV of the nose, TIIIIOAT. AXll F.AK. Till' Spinal Accessory Nerve dhidcs in Ihc ju.L^ular foiiinu'ii, tlie accessory iiorfnui of the nerve joining the vnniis. Tlie spinal portion ■of the ncrNc then lams downward into the neck, occupying at first the interval lictween the external carotid artery and the internal jugular vein. It iiuis downward, outward, and then crosses obliquely back- ward over the vein to rcaeli the internal surface of the steniomastoid muscle. It then pierces this muscle, sending fibres to it, and enters the posterior triangle of the neck near the exit of the cervical plexus. Crossing the posterior triangle it su])plies the trajx'zius muscle entei'- ing on its inner surface. The Glossopharyngeal Nerve leaves the skull through the jugular foramen and arching downward and forward passes between the in- ternal carotid artery and the internal jugular vein, and below the ex- ternal carotid. It passes around the outside of the stylopharyngeus muscle and the stylohyoid ligament and below the hyoglossus muscle, terminating in the tongue. It innen'ates the stylopharyngeus muscle and sends important branches to the pharyngeal plexus. It also sends a few direct fibres to the mucous membrane of the pharynx and another branch to form the tonsillar plexus which supplies the mucous mem- brane covering the tonsil and the immediate surrounding region. The Pharyngeal Plexus of nerves is made up of branches from the glossopharyngeal and the pneumogastric nerves and the superior cer- vical ganglion of the sympathetic. (•|i.\rTi:K III. Tin: SlRlilCAL ANATOMY OF THH HAR. Bv (iKoiiiiK I'l. Sii \Mi;\n;ii. M. I >. Introduction. Xdwlicrc is siii\:ivry iiinrc iU'iicimIi'IiI mi ;i kimw lc(li:r of .■inalniiiic ii|iiiii llir car. In tin' li'Mi|Hiral liuiu.' arc Icicati'il a iiuiiilicr nl' iiii]inrtaiil aiiatdiiiic >tnictiirrs a >lii:lit iii.jui'y of wliicli may 1h> fnllnwcl liy M'l'idiis rcsiili>. The fact thai tlic^^o .'t nictiii o. The perl'ei'iiiiL; uf aural -uriicry is the dirert result nl' the iiinih'rn tt'iK.k'ney to specialization wliieli has made it jiossihU' tor the olohii;ist to master the complicated anatomy of this region. The first i)roliieni for the snrii'eon ■who woiihl nn(h>i'tal imr is tiiis kimwled^c readil> gained hy attempt- to do tiiese operations on the eada\er. .\ tlior' drawings from aetnai preparations. "^Phe stud>' of such a chapter can in no sense ser\-e as an adeipiate suh stitute fiu' the actual liandlim:' of anatomic preparations, which after all is the only way of aeipiiriiii;' real anatomic kiiowled-e. it is ho|u'(l that thi- ciiapter nia\ -er\-c to call the attention of the lieginner to the more important surgical relation- of ihi' temporal hone >o that with this as a guide he may work , tlie pars jietrosa, the pars s(|uamosa and the pars txinpanica, which in the new-born are 100 ()PKi;.\Ti\ K sri;(;Ki;v of tiik xosk, tiii;<)AT, and kah. sliai'p]\' sc|i;ir;itcil li\ well iiiai'kc'il sutiiro. ( M' tlicsc llic pdrdus is tlio most iiiii'iii'taiit as it contains the laliyriiitli ami it is I'l-nin the ]i('ti-oiis bone that lln' mastoid process d('\('l()ps. Tlic 1>nipaiiic Ikhic in the hcw-Imiiii is liut a siiallow curved rim contaiiiiiii;- a liroovc. tlic sulcus tymi)aiiicus, for llic attachment of the mendirana tynipani. The rim is incomplete at tlie upper pole, the cleft fomiing' the incisura tymjianica in wliicli the mendjrane of Shraimell is attached. The squamous bone in the ne\\-l)orn forms the outer covering for the recessus epityinpan- icus (the attic and aditus) as well as the outer covering for the antrum tynnpanicum. The roof of these chanibei's, the tegmen tym])ani et antri, is formed in part from the squamous bone and in juirt from the petrous. The suture passing directly through the tegmen is quite patulent in the new-born. This explains the ready occurrence in the young of meningeal symptoms in cases of acute suppuration of the middle ear. The outer surface of the temporal bone in the new-born jiresents an ap]iearance quite unlike that seen in the adult. The most con- spicuous dilference is the complete absence of an osseous external meatus. The membranous meatus is connected to the shallow rim of bone, the pars tympaniea, in -wdiich the membrana tynq)ani is attached. This close relation between the membrana tympani and the mem- branous external meatus accounts for the occurrence of pain in a young child whenever in cases of acute otitis media the auricle is ma- nipulated. In older children this symptom disappears because the cartilage of the meatus is separated by a well developed bony meatus from the area of infilti-ation about the attachment of the membrana tympani. Another peculiarity in the new-born is the complete absence of a mastoid process. That part of the petrous bone from which the processus mastoideus develops presents a flat surface with scarcely a suggestion of a prominence from which the process develops. A con- s))icuous suture beginning opposite the middh' of the posterior wall of the tympanum and coursing upward and backward to a notch on the posterior margin of the temporal bone marks the union between the petrous and squamous bones. (Fig. 72.) This suture, the petrosqua- mosal, opens directly into the antrum tympanicum and often persists in the adult as a depression into which the i>erio8teum penetrates. The persistence of the petrosquamosal suture in children has an important practical bearing on the course of antrum infection at this age as it permits of the rapid development of a subperiosteal abscess. It ex- plains also why a simple Wild's incision in an infant is so much more effective than in the adult. A Wild's incision in an infant for the relief of a subperiosteal abscess formed by an extension from the THE srruiicAi. axatomv ok THK KAi;. 101 Miitnmi tliriiiii;li llic |ictriiMiii;imn>;il >iiturr ;iiiuiniils ol'lfii tn the s;iiiic as a Srliwartze oi»oration in the adult as it gives a free opening into till- antinin. the only pncnnialic space dexeloped at tliis au'e. I Ml till' oiiliT sui-racc u\' the lrni|iural licmc, ,iu>1 liack n\' ]\\r |i;ii-s tyniiiauiea, at aliniit the junriuni of the middle will: the lower tliinis of the i)ostonor wall of the t\ iiipaiiic cavity, is a round opening for the exit of the facial ncrxe. It is important that this position of the stylo UKistoid ojioning in l he iiii'ant he kept in mind w lien makiuL;- the ineisimi V Fig. 73. FifT. 72. Temporal l)Oiie from iiew-liorn, showiii}; distinctly the throe jiarts which go to make iip this bone: the pars sciuamosu, pars tnnpanica. pars petrosa. Note the aljsenec of bony external meatus and the absence of a mastoid process. The opening of the facial canal i.s on the e.\po.scd outer surface of the temporal bone. (Dr. G. W. Boot '.s preparation.) Fig. 7.3. Temporal bono from cliild one year old, showing the per- sistence of the petrosquajiiosal suture, also the beginning of a mjustoid l)rocess which is still too small to cover the oix>ning of the facial canal. The bony external auditory canal is beginning to form. The lower ante- rior part is still entirely wanting. (Dr. G. W. Boot's preparation.) for the relief ol' a suli]icriiisteal alisi'ess, fur this im-isidn nniiht se\'ei' tile i'aeial ller\-e. In the development of till' tciiiporni hone after hirlii tlu' two eon- spieuous ehanges l)rought ahout ;\vr tin' foimntion of a mastoid )iroe^ ess and of a hony external niratn-. 'i'lic processus mastoideus de\idops lai-u'ely from the jx-trons hone. It is first i-eeognizcd as a small tuhrrde at ahoiit tile aL;<' of one yeai'. (Fig. ~'-'>.) its develo])men1 taki's i)iaee in two dii'iM'tioiis, outward, that is external to the caxitx of the tyni- ])aiunn, and downward iielow tlie cavity of the tyini)anuin. It is the develoimient of the jiroeessus mastoideus that causes tlie stylomas- 102 ol'KKA riV|-, SfKCKKV (IF Tl 1 K XOSK. TlinoA-l'. A X 1 1 KAK. ti)i(l I'oriiim'ii to rcrt'dc t'l'din tlir Mirl'ai'c nl' tlic li'iiipural lioiir until in tlio adult it lies riilly '2') iniii. fi'dni the outei' sui-racc (if the mastoid. At tlio aye of tlu'cc Ncars tlu' mastoid has already assumed the shape found in the adult and the diiiastrie i^roove is easily i-eeouiii/.ed. (Fia'. 74.) The iieti-os(|uamosa! sutuic has usuallx' been oliliterated with only occasionally a depression markiuii' its site. The extei-nal l)ony eo\er- h\g of the antrum is still usually (juite ])orous. The develojniient externally of the processus mastoideus is shared hy both the sipiamous and the tympanic bones. All three enter int(t the formation of the bony external meatus. In its de\elopment the tym])anic bone forms a trough Avitli an oiieniiii;- above the ])osterior. This trough in the adult forms the anterior, the lower, ami ]iart of the posterior bony meatus auditorius exteruus. The u]ipei- wall of the bony meatus is formed jjy a horizontal plate from the squamous bone. The upper posterior margin of the external meatus is fonned by the ])ro- cessus mastoideus and is developed in part from tlie petrous ami in part from the squamous bones. It is this uptper piosterior ])art of the external bony meatus that is occupied friMpiently in the adtdt l)y pneu- matic sjiaces, mastind cells. Meatus Auditorius Extemus. In the new-born, as already iiointed out, the external auditory meatus consists only of the cartilaginous membranous i)ortion, there being no bony meatus. In the adult this cartilaginous portion forms scarcely the outer third of the canal. In the development of the bony canal the part formed by the squamous and ])etrous bones ]mshes out beyond that formed from the tympanic bone, so that the anterior lower Avail of the bony meatus is shorter than the njijier and |iosterior wall. This dehcieney is jiieeed out by an extension from the cartilage form- ing the auiicle. In this cartilage Avhicli forms the outer 3)art of the anterior lower wall of the external meatus are several clefts called the incisuras Santorini Avhich relieve the rigidity of this part of the canal and permit greater mobility of the auricle. Through these clefts in the cartilage a parotid abscess occasionally discharges into the ex- ternal meatus and tln-ough them a fnruiKde in the meatus may dis- cluirge info the region of the parotid. Tile anterior lower wall of the bony meatus is formed l)y a thin plate of bone which separates the meatus from the glenoid fosso. A severe blow on the chin may fracture this bone and drive the head of the mandible into the external meatus. The floor of the external meatus makes a decided curve downward at its inner third fonning TUK SlItClCM. ANATOMV <)l' TIIK K.VI! ^m Fit;. 71. Tpmpoiiil Iwno from cliiUl three years old, sliowiii}; the mastoiil proc- ess, the bony external auditory meatus, and ohiiteratioii of the petrosqua- mosal suture. (Pr. G. W. Boot's prepaiation.) Fig. 75. Temporal lionc from child ten years old. The adult eharaeters of the temporal lione are developed. Persistence of depression over the mastniil sliowinff the line of the petrosquamosal suture. (Dr. G. W. Boot's prepa- ration.) 104 Ol'KI'.ATlVK Srr>GEi:Y OF THE JC08E, Tlir.OAT, AXD EAR. tlio sulcus ol' llic c.xlci'iial meatus. (Fi.ii'. ~'i-) 'I'lu' uai-rnwcst jiart of tile I'xti'rnal lucalus is at tln' cntrauci' of tliis sulcus. 'I'lic sulcus itscll' Fit;-. 7(1. Frontal soction tlirnui;li tlie ;iilult tfniiionil lioiio; the iiiiterior part viewed from lieliiiid. Sccticui iiussos tlinniyli external nuatus, eavuni t\nn- ]iani. and lalivrintli. is at times so deoii that iusects and small foreiiiii bodies lodgiiin in it may be completely out of the lino of direct ins])ection. The upper postcrii)r wall of the external meatus is formed from the mastoid process and this is the only jiart of the meatus "wall en- Adult teniporal l">n<> sliowins the iiositicin of the antrum t\-mpanieum nd ma.stoid cells ahmo- the u|»per posterior wall of the external canal. eroached on by mastoid cells. These cells may be found external to the supramental spine (Fig. 77) which is located often somewhat within TirK SritCICAI, ANATOMY 111' 11 1 K K.Al!. 105 the outiT niariiiii of tlic im-atus. Tlic Jiiitniiii t> in|iiiiiic!iiii lir- iilK)ve tlie upper ))Ost('rior wall of the iiu'atiis just cxlcrual to tlic un'iiilii-aua tyiniKiui (Fiys. 77. 78. 19). lu t-asos of acute mastoid disease Avlieu the Fig. 78. Iloiizontal section tlirough tlu' tomporal l)one vipweil from alxivo. Spc- tion through the external winal, (•aviun tvnipaiii, laliyrinth and interna] meatus. temporal l)oue is l)einn- iuvolvcil, a periostitis over this poition of tlie canal freiiueiitly results in a liuliiiuu' or sinkinn' of tliis part of tlie i)os- Fig. 79. Section Uirough nijustoiil proc^'.ss and exteninl canal, showing pneumatic type of mastoid with the larger cells on the peripliera, also the position of the antrum above and posterior to the external canal. terior wall. A mastoid aliscc-v iViMiiicntly discliariics into the extri'iial canal at this point, hi case of clirouic suppuration with cholesteatoma formation in the antrum the cholesteatoma fiecnieiitlv hreaks tlirouj-h lOG IPKIIATIXK snUlERY OF THE XOSE. TIIIIOAT, AXD EAR. into tlu' cxtcnial niriiliis at this jiniiit. < )u the (itlicr liaml it slimild \)v i-ciiU'ii'.li('i-('(l that a I'liniiicic hjcatcd ah)ii_ii' the jiostcrioi- wall (if thf luratus may be coiirused with a inasloid aliscess, since in addition to producing a bulging of this waU of the canal it is often associated with an infiltration and edema over tlu' mastoid process with dis])lacenient forward of the auriele, smdi as a mastoid ahscess pi'oduees. '^I'he rela- tion of the facial canal to the upper and posterior walls of tlie external meatus is of great surgical importance especially in doing the radical mastoid operation. The inner rim of the upper wall of the external meatus lies directly over the facial canal from the point where the nerve eiitei-s tlie tympanum in front of the oval window until it begins to curve downward toward the stylomastoid opening. (Figs. 76 and Section through temi)Oi'iil lione, showing the lelation of the facial canal to tlic fenestra vestilmli and of the horizontal canal to the antrum. 80.) In this part of its course the facial nerve is covered by an ex- tremely thin shell of bone in which dehiscence frequently occurs. From the point wdiere the facial canal turns downward until it emerges from the stylomastoid foramen it lies in the hone \vlii(di forms the posterior wall of the bony meatus. ^Vt the jioint where this canal enters the posterior wall of the liony meatus just ]iosterior to the oval win- dow it lies on a level with tlie inner wall of the tympanum. As it passes downward it lies out fnrtlier and further along the external meatus so that at the level of the floor of the tympanum the canal lies several millimeters external to the inner wall of the tympanum. (Fig. 80.) Again the relation of the facial canal to the external meatus is such that where it enters the posterior wall of the meatus near the up- per part of the tympanum it lies close to the meatus wall but as the TIIK SllKIICAl, AXAIiiM V ol' IIIK KAII. 107 canal jiasscs (k)\vii\\aril il recedes rmlhei- ;iii'l nii-tlier rroiii the Jiieatiis until at tlic lovol of tlie tlimr nl' the t\nipaiiuiii il lies several niillinu'tors liosterior ti) the ex1etu;il nuatus. (Figs. SU and SI.) These relations neceftsua B^iTvMPANiCua Fijf. 81. Section thioiigli tenii>oiMl liono, exposing tlio facial canal. of the facial canal to tlie jio.stcrioi' wall itoi(| exenteration. staiiilini;- a jiart «\' the posterioi- \v;dl nf ihe c.-iiial. iVla. Si'.) On tli,. "til. 'I- li;i||d it iv |,n»il,l,. In IVlimM- IJlr |,m|m,. nf |„,1|,. j V i ] | m' in front of the facial ciiiial which >e|iai-ates the canal frnni ihe iiicatn<. 108 OPEHATIVE SriICEKY OF TIIK XOSE, TIIIIOAT, AND KAU. The Processus Mastoideus. The mastoid process is surgically the most important i)art c)f the- temporal lioue. Most of the serious complications arising in the course of snpiijurative middle ear disease develop from disease of this proc- ess and the operations undertaken for the relief of these com]ilications begin with an exenteration of the mastoid. The outlines of the mastoid process present a cone-shaped appear- ance, the apex of the cone pointing downward, the base of the cone uppermost. The size in the adult is not constant. The outer surface is more or less rounded or flattened deiiending hu-gely on the size. In Fig. S3. Ailult tpmpoial hone, sliowing- tlic typii-al relatinu of tlic liuea tem- poralis extending in a lioiizontal direction liack from the external canal. the well developed process the outer surface is more rounded while in the small process the surface is more flattened. The markings on the outer surface of the mastoid process are of importance. They serve as a guide in making an opening into the antrum. The base of the mastoid is marked off by a horizontal ridge, a continuation of the root of the zygoma. This is known as the linea temporalis and is constant although not developed as prominently in some cases as in others. The linea temporalis risually extends directly back from and on the same plane with the root of the zygoma. (Fig. 83.) It lies, therefore, a little above the external meatus. In some cases, however, it curves down around the upper posterior margin of TllK SntC.lCAr. ANATOMY (IT TIIK KAl! 10!) tlic external iiiejitus juiil takes its liorizuntnl (■(iiii>e iVdiii almul tlic middle (if tlio oi)eniiij;- o\' the cxIiTiial niralus. ( Fi;;-. 84.) In otlior eases the linea teiii])ornlis takes a >liai|. eni\f upward immodiatoly liaek (ifllic in>|ii'r |j<).-trriiir niai'uiii i<\' Ilir external niealu-. I l-'i;;'. S."). ) It is iiuiiorlaiit tn nink'rstand these \ariali1oid. ( I'ig. S4. 1 It frequently repre- sents a point of increased tenderness in cases of tliroiiiliosis of the lateral sinus. The location of tiu' oj)ening should he kept ia mind Avlien operating on mastoid cells located along the posterior mai'gin of the process. The tympanomastoid suture is seen along the posterior mar- gin of the external meatus, ll marks the separation between the part of tlu' ]iosterior wall of the meatus fonned fi'om tlie tympanic lione and Fig. 8(5. .Section tluoiigli mastoid process, jiiitiiini nl. (Pneiiniatie tj-pe.) tvinp: that formed from the mastoid iirocess. Tlie petrosqunmosal suture is well marked in the young child hut is usually (piile ohiiteraleil in the adult. The mastoid jirocess in the adult usually contains ])neumatic spaces which communicate with the antrum and are known as mastoid cells. In the new-born there is an absence of a mastoid process and of mastoid cells. The antrum, wliieli is in reality part of the tympanum and is known as the autriuu tympauicum, exists in the new-born. As the mastoid process develops pneumatic spaces develop and as a rule eom]iletoly fill the ju'oce.ss. (Figs. 79, 8(i, 87.) These cells often extend lieyon occupying the tip of 112 orKiiATivK si'i;i;i;i;v of tuk xose. tiitoat, and kai;. tlu' mastoid and thost' lyiiii;' aloiii;- llic posterior iiiar,i;in arc usually niucli laru'cr. (Figs. 7!>, 8(), 87.) In Figs. 88 and 81) is shown an iinusu- Fig. S7. Pncnmuitic type of niastoiil. Larger eells arranged along the periiiliery. ally large mastoid cell outside the mastoid process lying internal to the digastric groove. Such a mastoid cell is especially dangerous be- cause in the first place a suppuration here could produce no symptoms Fig. SS. Fig. S9. Figs. 88 and 89. Soeticiii tlirough temporal liene. Section passes through antrum, vestibule and inteiunl meatus. Large pneumatic cell de- veloped internal to the digastiic groove. (Anatomic variaticui.) over the outer surface of the mastoid and in the second place such a cell might readily escape detection when operating on the mastoid THE srncicAi- axato.mv ok tiik kai:. 11:; ])i-ocoss. The iiiasloid ccIIn ;i11 i-dimiiuiiicalr witli the aiitiiiiii and al- Ilioiiiili till' walls sc'iini-aliiiL;- adjoiiiinn' cells usiialiy sliow deliisccncc's itIIs may retain tlieir own openinus leadini;' to the anti'iun. In this way it is possible for a largo cell at llic tiji of the mastoid to commnni- cate with the antrum tlirong'h its own cliannri and without commuui- catinti' with ad.joiniui;' cells. This condition may oxplain the occnrreni'i' of an isolated abscess in the tip of the mastoid process. The process of pnenniatization of the mastoid is often incomplete so that mastoid cells are fornu'd in but a ])art of the mastoid. In such cases the cells are located close to the antrum while the tip of the proc- ess and the posterior margin are free fiom air cflls. (Figs. 80, 90, 91.) Fig. 90. Soctioii tlir<>ii<;li ti'ni])(ii al bone, sliowiiiir relation of tlic horizontal canal and facial canal to the middle oar cliambers; also relation of tlio carotid and bulbar jugularis to the c^avum tympani. In other cases no mastoid C(■ll^■ whatever exist. (Figs. 92 and 9;].) Here tlie process is tlatter and smaller tiian normal and the size of the an- trum also is quite small. In other words the whole impression one gets tVom an examination of this type of mastoid is that of an undevelo])ed infantile condition. It is this type of mastoid process that is found in cases of chronic suppurative otitis media dating from eai'ly childhood. Air. Cheatle interprets these facts as indicating that cases of acute purulent otitis media are more inclined to become chronic when occur- ling in the non-jnieumatic (yjje of mastoid. Others are inclined to be- licvr that the lack of j)n('uniatizati(m in such cases is itself the direct result and not the cause of the chronic suppuration. The suppuration lieginning in early childhood before the development of the mastoid lU OPKKATIVK sriICKKV (IK Tl 1 K XliSK, •nil'.DAT. AXI) EAH has progressed very far liiiulers its I'nrtluT (IcvcloiJUR'nt; tlie result being these cases of (•oini)lete absence of mastoid cells. This condition -J-^r 'V"^ •■'E""^ .JDITOSPUS EXTEBNUS Fig. 91. Soctiou tliiousli the mastoid process, showing Imt ]!artial ])noiimati- zatiou. A few small mastoid tclLs near the antrum are all that have formed. Dipltttic type of niustoid. C' Antnmi tnnpanicum contracted. t |iiii'iiniatic> spac slionld not be confused with tlie process of osteosclerosis or hanh'uing of the bone surrounding as a rule a cholesteatoma fomiation in the an- Tin: SlTiGICAL ANATOMY OI" TIIK KAU. U.'l (nini. The iiiof of tlio mastoid is a tliin shell of lionc which separates ihi' aiitniiii and tiic mastoid cell- riniii the middli' lii-;iiii I'cissa. Over the antrum it is t-alU'd the te^riien antri. Dehiscence in the hone t're- ([ueiitly exists so that only the lininij of the mastoid cells and the dura separates the cells from the hrain cavity. (P''i,i;s. 77, 90, 94, 95.) A luimher of im])ortant structures come into close relation \\itii tlie mastoid pideess. The siunmiil eur\e u\' ihe lalerai sinus lies in- ternal to this process and encrnaches iiiuie nr less on spaces of the mastoid. (Fig. 82.) The distance separalinn' this sinus from the pos- terior wall of the external meatus varies in ditTerent individuals. Usu- ally tliere-is ample space between the sinus and the posterior wall of tiie meatus to permit of a Avide opening into the antrum. In other <'ases the sinus lies so close to the meatus wall that the opening into Fig. 9.3. Section tlii()iiji;li ailult temporal lione, sliowius' i>('vsistpiu' t^-pe witli abscncp of pneumatic spaces in tlie inastoiil. Tlie i^ horizontal and facial eanals to the middle ear spaces. i> of infantile ■lations of the tlie anlium has to l)e made by working along tlie n])per posterior wall of the meatus instead of posterior to the suprametal spine. The location of the sigmoid curve is usually the same on both sides. The important relation of the facial canal to the mastoid has already been discussed. It is important In remeiiilier tiiat mastoid cells may develop in close proximity to tiie facial canal and that these cells may lie deejier than the facial, that is inteinal to it. The facial nerve is most readily injured in its course through the tyni|ianiini nr at the ])oint where it makes the bend downward tdwanl the stylmnastoid n]iening. (Figs. 77, 80, 81, 90, 92, 94.) The horizontal semicircular canal forms a ]ii(iininenri' in the floor "f the antrum where its liarrating on Ihe mastoid, for its hard ca]isnle foi'ms a partial iMiveriiig Inr llie facial eanal just back of the oval window. (Figs. SO, !»!), !I4, '.'.").) The superior semi- circular canal encroaches at times on the anteridi' inner wall of the antrum. (Fig. 96.) In antrum disease it is jjossible for an erosion into the superior canal to occur. This canal is not exposeil to injury in operating on the mastoid as is the horizontal. Section tliroHgii aduU teiniii)i;il bo: carotid to the eavum t\niii)aiii sus epitympaiiicus. )iie, sliiiwins' tlic lelatinus nf tlic tructiHcs ill the ticior of tlie leces- Cavum Tympani. Anatomically the tympanic cavity forms but a |)art of a larger cavity Avhicli includes the antrum tympanicum and the passage between these two, the recessus epitympanicus. (Figs. 80-95.) Pathologically also these chambers should be considered together as they are usually involved in the same process. The division of the passage way from the tympanum to the antrum into two parts, an attic and aditus, is not feasible anatomically. (Fig. 95.) The inner wall of the tympanic cavity is formed largely by the capsule of the labyrinth. The first turn of the cochlea produces a TIIK sniCICAI. ANATOMY Ol' Till'. KAI:. Ill proiiiineiico just pd-sti'iior to tlio rciiti-r to wliicli tlio trim ))n)iiioiituiy is given. Just above the ]irouuintory is an oval opening into the vesti- bule of tlio Inliyi-iulli calicd the fenestra vestibuli. Tliis is the oval wiiuliiw in wliicii llic I'ooi |il;ite of the stajies is jiltaclicd. The "win- dow itself is at tlu' liottoiii of a dr|irrs>iini out ol' wliicii oidy the head of the stapes ami a suiali part nf the ciuia' projrct. dust posterior to the promontory, lying l)\it a I'oiiplc of luilliuu'tt'rs from the oval win- dow, is the oiH'uing into tlif lirst turn of the eochlca called the fenestra cochlea'. This is the round window coxcrcd o\i'r liy a iniMnhrane which separates the tympaniuu from the scala tympaui. Directly posterior to that part of the promontory which separates the oval fi-om the louud windoAv is a de])rcssiou often extending under the canal for the facial Fig. 95. Section tliroufili mastoid, ca\^lm t_viii])ani. tulia auilitiva, sliowiii<; lavfie tiilial coll. nerve. Tliis depression i.- known as tlie sinus tympanicus. It is diffi- cult to smooth out this pocket when perfonning the radical mastoid operation. A eons^iicuous marking ou llie inuer wall of tlie tympanum is the canal I'oi- the tensor tyinpani muscle. 'I'liis lies just aliove the tymi)anic orifice of the Eustaeliian tuiie. The pi'ocessus cochleari- formis which forms the posterior end of this canal projects out a short distance over the anterior inariiin of the oval w iinhiw. (Fig. 94.) The relation of the facial canal to the innei' wall of the tympanum is of great surgical imjioitanee as the laeial nerve in its course through the t\niii)anuin is eo\-ereil !iy .-m i'\l ieniel\- thin delieate covering of bone wliich can readil\- he fractured hy the use df a nirette. The nerve en- ters the tymiiannm in front of and just above the oval window. Its course is more or less horizontal until just posterior to the oval win- 118 OPERATIVK sriUiERY OF Tl 1 K .VnSK, Tl 1 IK lAT, AMI V..\\\. (low it curves (Idwnward toward tlic styltmiasloid opciiiiiii-. (Fi.n's. 80, 81, 90, 93, 94, 96.) The ]jroiuinence formed by the liorizoiital seniicir- eidar canal in the floor of the passage from tlie antrum into the tjnn- liaiimii projects out beyond the facial canal and in this way serves often U) protect the nerve from injuiy wlicii operating in this region. The roof of the tympanum is foniicd by a i)late of bone separating this cavity from the middle fossa. This is called the tegmen and is often extremely delicate. (Figs. 77, SO, 90, 94, 95, 98.) In the new-born it is crossed by the suture between the sciuamos and petrous bones through which blood vessel communications extend between the dura and the membrane lining the tympanum. Through this tegmen sup- Fig. 96. Section througli the mastoid and tympanic cavity, showing the relation of tlie horizontal and superior canals to the antrum. pui-ativc disease in the tympanum frecpu^utly penetrates into the brain cavity. The floor of the tympanum contains a numl)er of depressions called tympanic cells. These cells are occasionally quite extensive in which ease it becomes difficult if not quite impossible to clean them out entirely in operating on the tjTupanum. (Fig. 97.) The floor of the tympanum extends somewhat deeper than the floor of the external meatus. This depression is called the recessus hypotympanicus. The relation of the bulb of the jugailar to the floor of the tympanum is such that infection occasionally extends from the tympanum directly to the TIIK snidlCAI. AXATd.MV (iK ■|lll'. KAl!. ll!l bull). 'J'iio luilli is l'rci|iiciilly ('Xi)osc(l to injiiiy wlicu ciircltiiiir tlii' floor of the tynipamiiii. \u most cases \\u- Imlh is separated from the tyiniiamiin by a lliick wall .if bone. (Fi\' Ikuu' in iVniil hI' tlir I'acial (•aiiiil ill till' lower liair of the iiustcridr wall nf the iiicatiis. ( l''ii;-s. SO and HI.) Ill the tiddi- III' thi' l';ii>tacliiaii tiiKf iirar its tyiiipanic. orifice arc the lulial cells, which iiiusi he (ipciHMl with urcat caution on account of the location of llic iiiti'rnal carotid just antciior and internal to the tym- liannin and internal to tiie Eustachian tnln'. The roof of the tyra- jianum, the tognicu tjnupani, scjiarales this cavity troiu the middle I'ossa. It is a fra,s>ilc shelf of hone easily ])crforated by a curette. In curcttiusi- the inner wall of the tyinpaunin the i-ejiion just below and in front of the ]n-oniincuco for the horizontal canal slionhl be avoided be- cause the facial canal crosses the lyMi|iannni liere and in this region is the oval window with the stajics. A dislocation of the latter may lead to an infection of the lahyrinth. The relations of the lateral sinus are important to keep in mind not only when operating on the sinus itself but whenever an opening into the mastoid is made. The variations in the location of the sigmoid curve of this sinus are such (hat unless the\- are understood there is often gi'eat danger of opening the sinus when performing the simple mastoid operation. The si,es the cortex of the mastoid should be reiiio\-ed with caution until the location of the sinus has l)eeu itioii of tlie Inilh of the Jugular and it> relation to the sur- roniidiiig >trnctures must he iiiidei>tood hy the surgeon who under- takes to operate on the mastoid. In cases of infection il becomes neces- sary to exiwse the Inilh and lo lay it frecl> open. Tlir relation of the hiilb to the cavuni 1\ inpani has already liccii div-rrilicd. When the bulb occupies that relation to the lloor of the tyiiiiiannni which is .shown in 122 orKI'vATIVE sriiCKKV OF TITE XOSE, TIIRDAT, AM) EAK. Fiii". !)8 or ill Fig'. 90 an oxposure of tlic Imlli Uy (i|HT;itiH,n' llirousi'li the tyinpamnn is feasible. Tlie locatioTi of the l)ulli varies, however, even more than does that ol' the lateral sinus. In most cases the Inilb makes but a shallow inden- tation in tile lower surface of the temporal bone, so that a curette passed forward along the lateral sinus will remove clots located in it. In these cases it is separated from th(> floor of tlie tymjiannm by a tliiek layer of bone. In other eases the dome of the jugular bulb is pushed upward higher and higher along the posterior wall of the petrous bone. In these cases the appearance is not nnlike an erosion produced by an eddy in a stream. The extent to which the bulb is pnshed upward in these cases is often surprising. Occasionally the bulb extends to the highest margin of the petrous bone. In Fig. 100 is shown a case in which the bulb extends through the superior margin of Hiiiiziiiitiil section tliviuii.Ii the teiii|i(iial bone seen t'l velntiiins of tlie biillius jiisularis to tlie Interal sinus. above, sliowinf; the petrous bone and in its course obliterates part of the postei'ior wall of the internal meatus as well as the bony covering of the aqufeductus vestibuli. The surest route for the exposure of the jugular bulb is to fol- low along the course of the lateral sinus until the bulb is reached. By chiseling along in front of the sinus a layer of bone can be removed Ijosterior to the facial canal which will usually permit of a more or less free exposure of the bulb, depiending, of course, on whether the bulb is shallow or deep. The thickness of the bone that can be removed in this way along the anterior wall of the sinus without an injury to the facial nerve is often as much as 0.5 cm. (Fig. 99.) Care must be taken in making this opening into the bulb not to extend the chiseling too far up along the posterior surface of the petrous bone for here there is danger of opening into the posterior semicircular canal. Tlir. SriKllCAI. ANATdMV HI' TIIK KAK. 1 2:5 Til oniiiKM'tii'ii with the sinuicnl iclnlimi of tlic lateral .sinus it shoiiM lie m.-ulioiicl tiinl this >linr|iirc s.Tvrs as llic best guide for the oin'iiiiiii' i>r a rt'rclicllar alis<'css. 'riicsc ahscossrs lie usually snuio- whero alouii' the iioslcrior surface of llic ])efr()us lioiic in fnml dl' the lateral sinus. 'I'd atteni|il to ili-ain >ucli an alisccss liy an ii|iiMiinu- liadc of the sinus is niore (liflieull liecaux' n\' the ^icat distance from the sur- face. The hest I. Mile liy wliirh lo reach tliese ahscosses is by uiakin.a,- an oiieiiini;- in lidut df the h-iteial >inus. If the anterior wall of the lateral sinus is fiiHoweil and llie chiseiini; is not carried too far for- ward it is |)dssilih' td e\|id>e tile ceicliel I uin witliout au iiijuvy of the ])()rior a.siicct of tlio tonipoval Iioiic, showing Inillms jug- ularis extending to tlie upjier ni;ugiu of tlic petrous liono. (Anatomical variiition.) ^riie snri;ica] anatdiny df the lahyiintli i-. lic-t exiiiained in Cdu- neetidii with the d|iei-ali(in du the iahvrinth. in tliis cdinieetidU aflen- tion may lie cuMed id tlie ivlntidn- df the laliyrinth td the middle ear chamhers. In the c-ixniii t\nipani the ea|i>nle dl' the |;ili>rinth is I'reely exijosed. The iirdmnntdiy dii the imuT \\all i> formed hy the large turn madi' hy tlie iie,<;inninf'- of the hasal coil. By chiseling from the lower edL;e df the fenestra vestibuli a free opening into the vesti- bule is made and in remox ini: \\\f pi'diiidntdix \']-i-t' drainai^c df thi' <'dcli lea is acc(niiiili>hed. in i-emd\in,i; the pidiiidntdry the i-elatimi of the bnlli df the .jugular >lid\vn in fig. !•"< -honld he kept in mind. In Jn.-t >nch a ca>e the author ha- dpened the hnlli while iemd\in,i;' the 124 (IPKRATIVK sri'.CKI'.V Ol' Tl 1 K XOSK. T 1 1 IIOAT, AM) KAI;. proinoiitdiy. Tlic apex of tlic coclili'.-i can lie ('X|ii)S('(| hy cliiscrniL:- I'or- ^\;u•^l IVinn the aiiti'rior iiiai',i;in ol' lln' oxal window. TIh' apex of llic ('(icliica lii's inti'i'nal \n IIm- t\iii|)ani(' oi'ilicc ol' llic I']iis1acliian tulic Its relation to the internal earoti.l lyin,i;' just ])os1eri()r or extei'nal to this stnictuve makes it iieeessavy to exercise ,ureaf cai'e when workiiii;- ill this region. Two of" the seiuicivciilav canals come into more or less close i-ela- tion to the middle ear cavities, the hoii/oiital and the superior. The capsule of the horizontal canal forms a white glistening prominence readily seen in opening the antrum. It lies in the floor of the rocessus epitympanicus at the point whei'e this o))ens into the antrum. The re- lation of the superior canal to the middle ear is not nearly so intimate. It lies just above the anterior end of the exposed ])art of the horizontal canal. In this way its anterior cms is readily exposed by chiseling above the ])rominence of the horizontal canal and directly over the oval window. In opening this canal the position of the facial nerve along the upper margin of the oval window must not be forgotten. The pos- terior semicircular canal does not come into close relation to the mid- dle ear. It can be reached by removing the triangular piece of bone between the superior and the horizontal canals. (•|i.\rTi;i; i\\ KXTERNAL OPHRATIONS ON THI< LARYNX. I'llARVNX. HTI;R KSOPIIAIil'S, AND TRACIII'A.^ Jiv CKdiKJK AV. Cnii.i;. M. J). Special Difficulties and Dangers. The toclinio of oxloni;il opt'ralioii.s upon Iho i\\>\Kn- air passages and llio osoiiliaiius Avoukl hv sinii)lo t'ii()iii;li wore it not for certain special dillicnlties and dan.c'ors jieculiar to these oi)erations. It is avcII tlierc- fore to first consider these, that the full signilicance of the various steps of the operations to be described later may be more fully appreciated. Pneumonia. — PneiiTiinnin t'ollcnving nporntion on the upper air passages is due in iiinst iii>i;iiirrs In mn' nf Iwn causes: (a) tlic inhalation of blood or niucus, and (It) the inhalation of infected wound discharges. These injurious inhalations occur usually in the course of the operation, although occasionally the postojierative oozing is in- Jialod. These dangers nmy be pn-evented in i)art by scruiiulously main- taining a dry field during the entire (-(mrse ii\' the dissection. This is ac- complished by picking up e\-eiv xcssel large enough to be considered at all, either before dividing it or inn liately after it had been divided. In this manner tlie field will lie kept sn clear of lilood tlnit all an- atomic structures may lie easily seen and ideutilied. During the later stages of the dissection the vessels which have been ])icked up may be ligated with either light catgut or light silk. AVhile this man- ner of dissection may at first seem to lie tedious, it will in the end prove the quickest method, and is the method of choice in dissections foi' the exposure ni' ilie laryux, pliaiyiix, trachea, or esophagus. When the field of oiicration has lieen reaeiied, however, the prevention of blood inhalation becomes (piite a dilTeiint jiroblem, because the blood supply of the mucous nu'inhi-ane is maintained principally by terminal arterioles Avhich cauunl he elTectively controlled by ligaliiui. At this I)oint in the ojieiatiou one nl' two enui'ses may be adopted. The patient in;iy lie |ilaeed in a lie.-id dnw n, inclined jiosture at such an angle that the lilood will i;i-a\itate ;i\\ay fidui tin- lung: (ir liy the hypodermic use of novocain ami adrenalin the trachea, the larynx, *Operations within the larynx through I'Ktcrnal it^cisions will he considered in the chapter on cndolaryngeal operations. 12(> (ii'KiJA'i'ivi'; sri;(;Ki;v nv tiik nmisk. tiu'.oat, and f.ai;. and llic iiliavyiiN may l)c iMitcrcd witliniit i-csiiltaiit ediiuhiiii;' or nia- tci-ial oDzinu'. ir I 111' inucdiis niciiiliram' has Ix'cii locally anesthetized the bleeding may usually lie controlled by the local applieation of pledgets of cotton saturated with adrenalin pressed firmly against the bleeding ])oints by hemostatic forceps. The further control of hemor- rhage dejtends nj)on the circumstances of the individmil operation. If conditions peniiif, a rul)l)er tube which snugly fills the trachea or even distends it will entirely control the dangerous factor of blood inha- lation. There are both advantages and disadvantages to the control of hemorrhage by ])osture, for the amount of hemorrhage, especially of venous hemorrhage, is increased by gravity. Then too, the head-down position is less favorable for the operator. The direct control method has the advantage of light, accessible position and the minimum bleed- ing. The author has rarely found it necessary to resort to the head- down posture, although it has sometimes been temporarily used during some phase of an operation. Occasionally, of course, a great emer- gency may exist in whicli the head-down posture is urgently demanded. Local Infection. — Tlie next great daiigcM- associated Mith opera- tions on tlie \i|i}ier i-es])iratoi-y tract is lliat ot local infection, t'oi- it may happen that after the air ])assages have been opened a serious local infection Avill spread over tlie contiguous territory and along the deep planes of the neck. The occurrence of some infection must be taken for granted, but it is for us to consider by what means the amount and the virulence of the infection may be diminished and how it can l)e localized. In the first place, the danger may be minimized in advance by canvassing all of the contiguous territories and mak- ing sure that there are not present any active foci of infection, such as decayed teeth, pyorrhea, alveolar abscesses, discharging sinuses, peritonsillar abscess, pharyngitis, oi' imrulent rhinitis. At the time of the operation itself we may control tiie local severity of the infec- tion by using only sharp dissections and by minimizing to the utmost the trauma of surrounding tissues; by leaving no oozing of blood; by making careful decisions as to the immediate closure of the soft parts overlying the wound; and by using iodoform packing if there must be any wound in the soft parts of the throat and neck. When infection has been inaugurated there are no better theraiseutic measures than the hot pack and the inhalation of medicated or plain steam. Mediastinal Abscess. — After pneumonia, mediastinitis and meriton('al ahsccsscs which also conic lali'. aif alimisl painless. proi^M'css slowly. >hn\\ a >ti'r|)lcclia-i'. Imt lnw Iciiipcral iiri' cui'xc. anil md nsnally in death. The explanation of the cliaractciivt ic, painless, tt'dimis and fatal course of mediastinal abscess is prulinlilx rnund in the fact that this v(\t;ion of the body has always liccn innicctrd rrtmi wounds by the lioii\- elii'>t w;dl. iM'ini;' cldx^d In wdiiiids tlirons^li the \a>t pcfiods of man's cv-olntion. it lias hccn rloscd likewise to infection. The tissue ot' this proteete of th(> body, ill \-iew of this fact, we ninst unai'd this helpless teri-iliir_\- witii speeial care. As we ha\'e shown that incoperatix-e nieasiii-es may in lari;-e dei;ree pre\ent tlie extensive cdiirse of local infection, so tlie danii'er of iiiedi;i-l iiiitis may he unarded a,i;aiiisl li\ pieoperati\e pnitecticni. II' in the conrst' of a larsii-ei'toiiiy, for instance, tlie di\-ided trachea is stitche(l to the skin, there is i^ri^at danger that snbsecinent con.ii'hing will cause il to liecolne detached. its llloolilll^s I la \ i 111;' been lost, it will l)e thrust hack and forth, in and out of the thoracic box, like the piston of an eniiine. Mediastinal infection will he the almost imn-itable result. If, on the other hand, the free end of thi> trachea is not tixi'd hy sutures, hut is held hy L;nnzc packini; ahinit it, then the trachea will retract within the thoracic cai;e like the head of a turtle, and auiain infection inn~t result. It is oh\-ious, then, that the trachea should he so fixed hy preliminary operation that there may he ]iroduced all iii\incihlc harrier of manulations extending across the hase of the 1 k all I the eiitiance to the tliorncic eai;-e. Thei-e are two methods hy which tins may he ihnie: The ordinary sini|ilc 1 racheotoniy will lix the trachea and will stimulate lli<' formation of elhcieiit .yrannlatioii li-siie; or ex|iosin,u- the trachea and the lower laiNiix and packiiii; the lateral planes of the neck with iodoform y-auze will result in the |irodiiction of ^rannlat imis and in lixiiii;' the tracliea so firmly that con^liiim cnmiot lueak its mooiin.us. \\nr\i of these methods of itself alone Ims certain advantai^es and disadvantages. The simide tracheotomy is not so certain a safe.unard asninst infection of the niedia-tinum as is the latter method, and it docs not result in so linn a fixation of the tiachea in the deeper jiarl of the neck: hut il has the advantage of estahlishinu' a strong defense mechanism in the mucous membrane of the trachea itself. < »n the other hand, the jiackiiig of 12S i>pki;ativk si-kckiiv or tiik xusk, tiiuhat. anh k.ai;. Uie ck'C'|( |iliiii('s with iodoronii, wliilf otherwise nil ideal protectiou, does not sup]il\- the ])rotective defenses in tlie imicous membrane of the trachea. An ideal defense, then, is fonnd in a comhination of the two operations, that is, in opening and packin, Tiiiiior pIu'iimiiiMion ])rculiar Id Hie >iir.t;ci-> ol' tliis I'l'iiion. Kut il is li'pnili'il In li;i\i> IC.-ullcl ill ,-('\rl;il (lr;itll> ;ill(l lin- (■.•IUm'iI niUc-|| aiixit'ty aiiil iMnilili' lo ihovr wlm liavc iic\('|- knnwn ol' its (■xislnicc and wild lia\c not known how |o iiitiT|ii rl ami oli\ iatc il. In a laryiigccldiiiy the tciininals of I lie superior larynj^cai iici'vi's in llic larynx and on the surracc ol' tiic liiiia uloltidis arc of iicct'ssily dis- liiiitcd. and till' trunks ol' liicsc nerves are divided in the cdurse oT o])eration. The I'unclion of the larNii'^cal ihmxcs is the |iroteetinn ol" the pulmonary tract rroni tiic entrance of I'liriMun liodies. Tlie sliviil- ost toucli df tlieii' cndiiiL;>. therefore, causes a cou^li I'cllex, and a stroufi' contact will cause an iiihihition of resj)iralioii and of tlio licart. Tlie nerve su])])ly ol' the tiacliea has no such I'unclion. Init the area of distribution of the inliibitory nerve ending-s extends over a jiart of tlie pharynx and a part of the posterior nares even. Fortunately, wc have an absolute protection against this dramatic and sometimes dangerous phenomenon, in the hypodermic adininisf ration of lldd gi-ain ati'opin (adult do.se) Ixd'ore the djieratidii. In additidii a >pia\-. a Ideal appli- cation, or the local hypodciinic in.jectidii of novocain a\ ill confi-nl abso- lutely the inhibitory reflexes. Selection and Care of Tracheal Cannula. — The last special dilli- culty wliich we shall consider relates to the after-care of tlie patient, and refers to the selection and care of the tracheal cannula. After trying many kinds of cannula', the aiithdi- has fduiid that the counium male or female curved cannula, or plain rublxu' lulling even, will answer all puiposes. The greatest care should l)e exorcised in adjust- ing the metal tubes so as to i)reveiit pressure necrosis. Rubber tubing is preferred by some patients, 'ml the metal tubes usually are best. A rubber tube drawn over a metal tube is perhaps the easiest to wear, but the author has found that patients become careless by their familiai'ity with danger and will weai- loose-fitting tubes. This ]ioint was strongly impressed on the author by the difficulty once encoun- tered in extracting a rnbiier liiKe that had slipped off the metal tube and had been carried deep into the trachea. After a stormy session in which the patient almost suffocated, the tube was caught by groping deep within the trachea with a curx'ed henioslal forceps and it was extracted while the jiatient was unconscious from aspli\\ia. In time all laryngectomy cases get along without lulies. In fact, in recent cases the author has been able to disp<'nse altogether with tracheal tubes, both at the time of the operation and ever afterward, and the author'- )iatients lia\e all pi-eferred to get along without phonating apparatus. 130 OPKIIATIVK SIKi.KIM' Ol' TIIK XdSK. TIIIIUAT. AXU KAI;. Operations on the Trachea. Tracheotomy. — A tiaclieotoiny may lie lii^h or low, an emergency or a planned ojjeration. There is bul little difference between the technic of the high and the low traciieotomy, bnt there is a vast differ- ence between ])lanne(l and emergency operations. The latter will therct'dn' be described se))ai'ately. Emergency Tracheotomy. — Foreign bodies in the larynx or trachea, the pressure of tnmors, the closure of the trachea, by the swell- ing of previous strictures, the pressure of an abscess, the encroachment of malignant tumors of the thyroid or other tissues, the closure of the larynx by intralarjaigeal tumors, at first gradual but finally sudden, and many other causes of obstruction may demand an emergency tracheotomy. Then, too, the trachea may collapse during the removal of a large obstmcting goitre — especially if the operation is being per- formed under ether anesthesia. Whatever the cause, this emergency presents one of the most dramatic of surgical crises. Under the iirgent necessity, it is Tisuall}' a laryngotomy and not a tracheotomy that is performed. But in the presence of an emergency when a life is flicker- ing fine distinctions are lost. In emergencies which occur in the course of operations upon l)atients Avho are laboring against respiratoiy obstruction there are several very important points to be considered in the effort to prevent respiratory collapse. First, the patient must be kept free from ex- citement, — by morjihin and ati'opin if jiersdnal influence be insuffi- cient. Under excitement respiration is accelerated. The resultant in- crease in the exchange of air at once accentuates the diminished space at the constriction and makes the ]iatient feel acute symptoms of suf- focation, whereas (piiet l)reatlung can be accomplished easily through a smaller aperture. Second, a little mucus may precipitate respira- tory ol)structioii. ilajipily, the secretion of mucus may l)e wliolly controlled by the use of atropin. Third, a general anesthetic is abso- hately contraindicated Avhen a patient is exerting more than the normal muscular action in effecting an exchange of air, especially w hen lie is using the extraordinaiy muscles of respiration. The author has seen instances of the fatal error of giving a general anesthetic to such a patient. Inhalation anesthesia paralyzes the extraordinary muscles of resiDiration. Tliese muscles are used only when enough oxygen to sustain life cannot be secured by the action of the ordinary muscles of respii'ation. Under these circumstances therefore the extraordinary muscles become vital. Therefore, in cases of respiratory obstruction in which the extraor- i.AKVNN, rilAinXX, riM'Ki: KSOIMIACrs. AMI TKACIIKA. lol iliiiniy iiiiiM-Irs (if respiration nrc uscil, tlir ii|ii'i-;itiiiii inu^l lie jicr- rnriiicil uiuliT lcic;il aiu'stlii'siii — iiiul it' W\ chaiici' iIh'it is no Incal aiu'stliotic availalili' it must lie ddin' witlumt aiu'stiu'sia eri>: posture so that the hleediuL;. whicli nndei- the Inllnence of asphyxia is sure to he increased, may not hi' iidiahMJ and cause a septic lironcliitis m' pneumonia. lu enier^encii's tlie pnihahility of blood inhalation is so i^reat that the patient >li(udd at once he placi'r,';- |)o-ition. The trachea should not he opened by a plunging incision, a procedure which has hi-(Uinlit many a promising attempt to grief. An orderly hut aci'cleraled dissection wheri'by the operator may ilistinctly see the tracheal riui;s yields the (piickest red i cf e\en in t he hands of master surgeons indeed it is by pei-forniing controlli'd operations that one heconies a master surgeon. As soon as the trachea has heen perforateil nothim;' hut had lechnic can cause the jiatient to sulfocate. if the soft paits are sufliciently retracted hy instruments or fingers (U- hoth so thai the hlood is kept out, the patient M-ill do all the bettei-. A> for the tracheotomy tuhc any ph-er of rubber tubing will answer, in the absence of rubber tubing or tubing of any soit tin' tracheal i-ings may be stitched to the skin on each side. After an emerL;-eiic>' opening of the ti-ach(\a ^vhicll has been pci'foi-nied imder the partial ain'stliesia of asphyxia, the patii.'Ut will rapidly revi\"e uiuler a noimal supply of oxygen though his suffei'ing will be gi-eat. Morphia should therefore be gi\-en as ipiickly as possi- ble, lu the nmnagement of the excited patient upon whom an einer- .i;'ency tracheotomy is pierfornied it i> important to take extraordinary care to ]ii-e\ciit fmiliei- I'xciiemeiit or further |iain. Such a ]>atient needs rt'st and ipiiet to regain normal composure. Planned Tracheotomy. — The selection of the )iosilion for a trache- otomy depend- eutiridy upon the condition foi- the ndicf of which the ojieratiou is to he performed. Technicallv, indeed, iwo ciuisiilera- tious mii;lit seeiu to intlui'Uce the ehiiice iif ihe position of tlio Opening. The upper porti(Ui of the trachea i> the most accessilde, but at this point the thyroid renders the dissection dillicult; in the lower portion of liie trachea tin- thyroid does not interfere with the dissection but here the tiacllea is much more i'osed line of iuei-imi and dixidrd. ( Kii;. 102.) After com- ])lete division of the tliyroiW the cut margins may i)e secured ayainst Fig. loi;. Tiacliootoiiiv. Tncisidii tliioujrh thvroid "iliUKl ami tiacliea. hleeiliuL;- 1iy the inseilion of l)utton hole stitches with a curved needle. When the trachea is freely exposed it is carefully infiltrated with novocain — first, the suiierficial layers, theu .uradually and slowly the dee]iei- parts of the tiaelical wall, — care being taken not to allow the needle (which should lie a line one) to penetrate bryoud the advanc- ing zoiu- of iniilti'atimi. The needle point siiould always be in anesthetized tissue so that the tracheal wall, including the keenly sen- sitive mucous menibraiu', may be anesthetized without causing a single conuh. Tlu' adilition of adrenalin to tln' no\oc;iin solution makes possible the Opening of the trachea without pain and with little or no oozing. The prevention of oozing is an impoi'tant i)oint, first, because blood should be scrujiulonsly excludecl from tin- traelii»a as a pro- 134 oPEr.ATiVK sit,(;kt;v (H- ri:K xosk, •niKnAr. and kak. Icctidii ;i<;;uiisl sul»sci|iR'iit iiiri'dion : niid -ccoikI, liceausc tlif t rickliu.t;- tiiaciika. i:!:> liigli trarlieotoniy. It may he wdl lo iin'iitioii Iwn lalhcr siii-prisiiiii: facts, liowever, the extraordinary doiilli of ilic trarlica low in a lliick neck, a dcptli wliich ajipariMitly increases in a resllcss iiaticnt. and llic asloiii^liin;4ly i'\lri]>i\c cMMii^ion of the li-achiM in \\\r art of congliinii'. In this connection one sees a rt'niaikalily licantil'nl dynamic adapta- tion in tile contraction of tiic varions mnsck's of the neck to jjrovent rnptnre of tlu' jilenra. AVerc it not for the stronij ])rotection offered liy the neck museies tlic lilcnra at the apices wouhl snrely lie i-nptnred. Tracheal Tube. — Amon.<;- Ilie many types of tracheal tnhes tlie standanl curved metal cannnla consisting- of an inner and an outer tube — gives the best service. (Fig. 1"4.) An albolene or other oil sjjray applied to the traclieal mucosa is an added protection against secri'tions and against too nincli drying Fi-. nn. TiiicliO(i(i)in_v. .Vl'tcr the iijicration. of the air which is now (|epii\-ed nf tlie iiiiii>liii-e and perliap> warmth that it gains in passing tlirongh the npper ;iir passages in ]U)rniaI lireatiiing. At all e\cnts the liberal nsi' of an oil s))ray not only adds to the ciiiiifoi-t of the patient lint also lediico till' leiideiicy to dessication of small masses of Mincii> in the iieiLihliorhiiod nf the tracheal tube. After-care of the Patient. The hiiihly eflieient after-care of tracheotomy p;itieiit> is indeed ;i dillicnlt .-ichievement. There is an enormous dilleleliee lietweell the ellicielicv of ;| nnise .•ifler expelienci' in the r[\v<- of t l-;|clieiitoliiy c;i-e> :ilid in hel lil'-t ca-e. It is well to specialize such work. l-"oi- the pro]iei- eaic of hel- patient the nurse lo(i OPKIIATIVK. SriHJKP.V OK TlIK XOSK, TIIIUIAT. AXU EAK. rcqnin-s a supjily of roatlicrs tiiiiimod doAvn in sucli a manner tliat tlie inner tnbe may be prtnniitly cleared of mnens as .soon as the j)ecnliar nmens noise is heard. At first the patient tends to become panicky whenever any nuunis olistruction exists, and the inex])erienced nurse may share the ])ati('iit 's apiii-chension, — sun-lx an uiibap|iy aliiiosplicrr. The ex])erienced nurse k'aiiis to manaue llic imiciis so that there is only an occasional necessity to remove ami ch'ansi' the tiil)e. 'I'he first removals of the tube sliould be (hmi' liy the surgeon since tlie excitement and the coughing may <-aust' a ccitaiu amount of obsti'uction which may tlirow the patient into a iianic. I'nder these conditions the effort to replace the tube may increase the obstruction, cause bleeding, distni'b the local field and so do much harm. Until the granulations produce a living mould of the tube and thus guide it to its place it is Ix'st in r('i)lacing the tnbe to use a pair of slender retractors — by means of which the opening in the trachea may be brought into view. The tracluMitomy tube will then readily dro)) into place. The air of the patient's room should l)e kejjt eveidy warm and moist and may be medicated by vaporizing pine needle oil. The moist air and a piece of gauze moistened with salt solution placed over the tracheal tube will decrease the desiccation of the secretions about the tube — and will maintain a higher temperature in the trachea. The inhalation of cold air per sc is not liarmful as the ordinary cold air breathing shows; cold air ma,y produce a different effect, however, Avhen one part of the respiratory tract is cool and the remainder re- mains Avarm just as one usually catches no cold when entirely naked but readily takes cold if there is only a partial exposure of protected parts. The tracheal tulie and the entire wounds should l)e jirotected by gauze which should ))e changed frequently. Tlie patient may sit or lie in any desired ])0stnre, though sitting is usually preferable. The entii-e che.^t and neck slioiihl at all times l)e well covered with oil over which a pneumonia .jacket is ])lace(l. Cold drnl'ts in the room ai'e especially to be a\'oide(l. Xonrishment sliould be well maintained. It is most inqiortant to keep the wound free I'lom pus accnmulation because the iidialation of wound discharges is a distinct danger. Tf there is no contraindication, such as an exi.sting obstruction, it is well occasionally to remove the tuiie for a time, especially if the ])atient is fretting about the irritation, if th<' general precautions ai'e sci-u])ul()usly ob- sei-ved the great danger of ti-acjieotomy, ti'acheobronchopuimonary iii- Tection may be avoided. it has been an agreeable sni-i)i-ise to obsei've the facililv with i.AnvNX". riiAinxx. i tpki; ksoimiaci's, anh tiiaciika. 137 wliicli itiilioiits cari' for tlicii- I lacliciil IiiIk-s .iritT llicv lijivc hccoiiu' ;ul.jii>(>'tl. It is doiu' as a iiialliT of iDuliiic ami with tlic |ir<'cisi<»ii acr()in|iaii\ iiiu aii> olliri' ili'Inil nl' lln' ilaily toilet. TIh' aiitiioi' has had palii'iils rrtaiii Irai'liciiloiny liilics for a.- Inii.n ii> twcKc years liel\ire tile ()|iellillL;- was closed. Closure of a Tracheotomy. The ultimati' closun' of a tradu'otDiiiy i> ea>ily aecoitiplished. The entire ^rai- i> hloodlcssly .se])arat('d ri-i»iii tlio iioniial tissues sun()Uiidin.n- it .just as tlu' scar is dissected out in a case of lu'vuia t'ollowiuu' alidouiiual di'ainauc. AVlicii tlic dissoctiou lias reacliecar the ])arts will show a surprisiuii" tendeney to fall toii'ether e\-eu after many years of separation. The anllmi- has found that the wnund heals l)y first intention and that afterward there does not remain a dimple or a de]ire»ion e\en. If the oriuiual skin incision was tranverse there will soon he no noticealde scar to mark the place. The cases in which the ti'acheal tuhes were worn louLicst were those in which there were larynx lilliui:- papillomata in little children. In thri'e >nch ca>es a >ncce;-sful i-sne wa> linall\- reached in one after twelve years, in another after nine years and in the third after fonrteen. The ]iatients Avere inspected at \aiions intervals. Particularly note- • worthy was a case of Dr. W. If. Lincoln in which after fourteen years the larynx was found to lie free. The tracheal trad was then closed. Duriuii' this time the larynx i;-i-ew normally tlionL;h it had heen hut slii^'htly u-ed. Cicatricial Stenosis of the Trachea.- Cicatricial stenosis of tiie trachea usually follows syphilitic ulcerations, dec\iliitns from weariuir intubation tubes, and ulceration from other causes. This condition presents a very difficult piohliMu. If the trachea lie opened merely, the scar dissected out a- neally as iiossible, and the trachea then closed, recurrence is ipiite sure to occur. Dissection followed liy the iiiseition of a tulie i;i\-es no better results. Tlie presence of the tulu' appai'eiitly increasi's the i-eaclion wliicli is marked hy the formation of even more scar tissue, in tlie antiior's opinion there i- hut little hope in any metho<| except in resection of the trachea. This ojieration offers at least one formidai)le dinicuKy — the surprisinsfly AT, AM) KAU. cougliiii.t>'. Tliis rctiiU'lioii of coui'st' throws a licavy sti'ain on tlio stitches and on the lini' of lioahnij'. This diniculty can 1)0 met hy the nso of lualtvoss stitches of silver wire which incUule in their grasp a ring ol' the trachea above the stenosis and one beloAV it. A good (•h)snre is seen red by inserting three such silver wire mattress stitches, one on eacli lateral side of the esophagns and one in front, leaving the free end long so that it emerges freely from the wound. By twisting these wire sutures the apposition of the trachea is readily secui'ed. This, of cour.se, can succeed only when the trachea is ({uite normal. If the rings are soft or the tracheal wall edematous, the method can- not succeed. In one of the author's cases the tracheal wall was in such poor con- dition that the sutures could not hold and it was necessary in the end to resort to a permanent tracheal tube. Fortunately there are not many of these cases. Surg-ery of the Larynx. Laryngectomy for Intrinsic Cancer. — The legitinuicy of operation upon any part of the body, especially those parts the damage of which may cause immediate danger to life, depends upon the answers which can be given to three vital questions: Will the operation result in the cure of the disease? Can the risks be overcome? What will be the extent of permanent disability? So uncertain until yo\y recent years have been the ansAvers to these questions as applied to laryn- gectomy for cancer, that it is not strange that the operation is one of the most recent developments in surgical history, having been first performed by Billroth in 1874. Even after surgeons had become convinced of the possibility of the cure of intrinsic laryngeal cancer by this means it was, and is still, most difficult to persuade patients to submit to it — the instinctive objec- tion to deep throat operations being the natural outcome of the expe- riences of the far distant past when the throat was the point of attack in our carnivorous evolutionaiy ancestors, and it being still the part most liable to danger in hand-to-hand conflict. Does laryngectomy for cancer result in a cure of the disease? Ul)on our answer to this depends the need for considering" the other two questions. We still accept Krishaber's classification of lar\aageal cancer as intrinsic and extrinsic. As the tenn implies, intrinsic laryn- geal cancer starts within the larynx itself in the vocal cords, the ven- tricular bands or the parts below; while the extrinsic form starts in the epiglottis, the arytenoids or other parts outside the larynx proper. Intrinsic cancer, then, is contained within a hyaline cartilage box, and l.AI'.VNX. l'll.\i;VX\, llM'I'.l! ESorilAllCS, ANM) TKAC'I I I'.A. l->.' is ill largo iiioasun' cut nil' I'ldin the |>iissiliilit y of lyiuiilmlic iiivolvo- iiionts; \vliil(^ the oxli'iiisic I'diiii i:i(i\\> i-;i|iiilly ;iiiil c.-iii (■.■i-ily and early t'Xti'iid tliruimli till' lyiii|ih cliaiiiii'ls. Marly (iiai;iin>i> and rrninxal i> llir kcyimti' n\' NalVty in cani-ci-- oiis urowtlis aiiyw lii'i-i', and laryngeal cancer makes itself knnw n alinrist at (iiice. since IVoni its xcrx lieuinninL; tiie |ii(ilialiility nf its |ii'eseni'i' beciiines evident in the persistent Imar-e Noiee of the patient. We may say then, that intiinsie laryngeal cancer exists, as it were, in a safe deposit hnx. It early aniioiincos its preseiiee and has Imt I'eehle power of exti'nsixc inxasion <>r i>\' metastasis. We cdnclnde. t liei-e|ni'e. that this form nf cancer ' excisicm. Kxtiinsic cancer, nw \\]r cithei- hanIM I ACTS, AND TIIAl'l I K.A. 14! pressed, so tlial ;i liiiiil liulit lit results, l^y this menus, llie eiiti-aiu'e of any blood into the res|iii;itni\ tr.ift is |ii-<'\ciiled. iVlv:. Kxi.) The long piece of nililier tiiliiiiu' iiiiiy then lie attached In the nitrons oxid- oxygen apparatus, or it may be Joined to a special apparatns consist- ing of a funnel covered witii gauze upiui w liieh ether may lie di-o|)ped. By this arrangement the anesthetist is at a ilistanee iVnni the licld of oiM'i-atinn and is nnliani| lered hy the (iperatdi-. while Ihi' n|ii'r;itiir on his si(h> is nnhani|ieii'i| hy the anesthetist. There re-nlts an e\en anes- thesia and tile 1mv-i (ip|Hii-tnnit\- \\. nnxin-ain is used as a local anesthetic. The maimer of its administratinn will he given in the description of the opel-ati\e fechnic. Technic of Laryngectomy, l-'irst the skin is tliornugldv iufiltratod 142 (ipI':i;ati\I': sikoi'.kn (tv ttte xosh, "rniKiAT, Axn kai;. with novocain alon^- the median lino from a point al)ove the liyoid bone to the tracheotomy ojjoning-. Tlie tissues are divided down to the box of the laiynx, the divisions of the platysma and of the other soft parts being- preceded also bj- novocain infiltration. The dissection is then Fig. 100. Laryngectomy. Five days after proliniiiiarv traelieotciiny. Arrange- ment of tulie for anesthesia. carried down along the lateral aspects of the larynx until the larynx is completely freed. If there is lack of free working space at the upper end a lateral incision is made parallel with the hyoid. The thyrohyoid muscles above and the sternothyroid muscles below are severed. So far as its muscular attachments are concerned, the larynx is now com- pletely mobilized. If the laryngoscopic examination has iixed accu- LAiaxx, i'iiAi;vNX. I ri'Ki; KsoiMiAcrs. axp thaciika. 14.'! vntoly tlio limits of tlu' ii('(i|ilasiii, the li'\-cl of the division of the hiryiix IlKiy he |irc(lcti'l-lllillc(l, ;ill(i lllc lli'Xl slr|i will lie lilc ilivisioil of tllG trachea oi- the ri-i,-oii| at a li'\cl five !iiiiii .li>ca>c. I'-i'Toiv lliis last (lix'isioii i> iiiaiii'. Ikiwcmt, iioxdcaiii i> inlilt ratrd into llir iiiiicosa tlirou.u'iiout till' entire leimtli of the pidjiosed division. I*>,v this means the tei'niinals of the sniierior larvn^eal nerxcs are completel) hlocj^cd and the mu<-o>a ma> he diviih'tl and the larynx opened withoni ean^inu' a chan.nf in the resjiii-ation or the circulation. IT the patient is old and till' cartiia.^c is ossified it is necessarv to exei'1 the ,iii'eat<'s1 pre Fi-. nj7. I.:nynKoctoiii_v. S(>jiai;Ltiiiii of tlic lumix fnnii the csopliajitus. caution in dividino' the larynx in order that the csoplni.n'us may iH)t l)e iii.iui'ed. The (li\"ided end of the larynx is next raised up and the attaclnncnt Ix'twoen the larynx and the esoijhajLifus is divided with knit'o or scissoi-s. ( l-'iu. Iii7.) In a shoit, thick neck tlie wings of the larynx wjiich extend down laterall>- to pi-otect eacii side ol' the ('S()pliafi'»>. ai'e di\ided with >ci.-sor.-. 'i'lie dissection is then cari'ied upward until the uppei- end of the larynx is leached, whei-e its pos- tei-ior wall liecome> I'u.-eil with Ihe anteiior wall of the phar\ nx. The upper end of the lai'Nnx i> then cut \'\-i'r. the lari^ei- artei'ies heing- severed at the Ncrv last. llemo>ta.'~i> mii.-t Ik- nmst tiior()nu:hlv ob- 144 oim;i;a'i-ivk snicKuv or ttte xo.se, tiikoat, and ear. served t lirouuhoul Hie opei-.-it ion. If the caiicei- is iiiti-iiisic llie lyiii- ])Iiatic .liiainl,- w liicli ilraiii 1 he diseased /.(iiie slioiild he careriilly lemoxed with the hiryux itself. Two iiiipoi-tant questions now ai-ise repaid in,:; the nianiiei' of ileal- in.i;- \\ilh the wound: (1) What sliall he done with the end of tlie tnu'hea .' and {'2) Shall flie entire wound of the neck he cIoxmI .' As to the trachea, there are two alternatives: It may l)e freed suffieienlly to hrinp,- it forward and stiteli it to tlie skin, oi- it inav l)e left where it lies, exceptin.t;- at its very nj)]'ei- end, which may he heiit forward Fig. 108. Liuyngeetoiiiy. Clo.sure of ]iliaryngeal opening and sewed to flaps of skin hrought down from each side. The advan- tage of the first method is that by this means the trachea is protected from the inhalation of wound secretion. The disadvantage is the very- definite possibility that the loss of )>lood snpply may resnlt in gangrene of the trachea. This did occur in one of the author's cases. The objection to leavini;- the trachea in its natural bed and transplant- i.AinxN, ruAin \\. rrri:i; v.soniAins, and iiiaciika. 14:, ing to it llic -kill l!;i|w is tiif I'm-t tluit wouiid si'ci-cf inn will almost cortaiiil}' ciitcr il. \'>y i:i\iiii; tin- wnuiid ;ii|i'(|iiatc can', lidWcN-cr. this clanger may lie axoidcil. As to tlic care of tlic M'sI n[' tlic whuikI, lln' aiillinr's Ix'sl pro- codnro has boon to sutui'c tlu' o|H'iiiiii; in I ho |ihar\n\ and (Fig. 108), if possible, to roonfoi'co tiiis siitiin' by diawiii:^ dthci- suit jtarts togotlier over it. Tlie rest of the tidd is Icl'i ii|mmi. liciim' paidvcd lightly with iodofonn ganzo. ( I'ig. UH'.) \\'ith sm-li a wide open wound the secretions may bo easily (•iiiilrnlli'il and pri'vcntrd tiDni entering the trachea. The )ia1ieiil shouhl he sustained hy the fullest diet he can Fig. l(li>. Lai'viifiectomy. Closiup of wouiul with iudofm-in giui/i' pac-kiiig. 1)0 made to take, and by inost carerul iiiirsiiiu-. The sutures in the ))liaiynx may not laild, hut the fnniiidahle biokiui;- wound will close \-ery readily by mainilatidii and emit ractioii. liai-yugeetdiny is fnlhiwed usually by a brisk hieai reaction; l)ut since the mediastinuni has been prnteeted by the ]ii-eviiius gauze pack- inii', and the bi-oiichopuhnonary tract has bot'u given a special defense l)y the prcdiminary ti'acheotoniy, the ])ationt is well ei|uippod to meet the new cdnditinii. In the autlmr's 1 w ciity sexcii laryimectdiiiies there wore two di'atli-, and these twci were appaii'iitly the most promising cases of all. The pid-iiosi- in t he.-e cases seeinecl sn I'avMH'able tliat 1h(> author 14() OI'KIt.VnVK SURGERY OF TTIE XOSK, THROAT, AXD EAR. veiitnivd to discavd the full preliminary preparations. In one case no preliminaiy ])rotective operation of any kind was made and the patient died at the end of five weeks with mediastinal abscess. In the other case a preliminary gauze packing' was placed in the neck around tlie ti-nchea. but no preliminary tracheotomy was performed. In this case the isolated ui)i)er end of the trachea was brought forward to the skin and anchored. The entire isolated ])ortion necrosed, as did also a portion of the trachea beyond the isolated ])art. As a result pus was inhaled into tlie respiratory tract below the level of the sternum. An autopsy showed no pneumonia and no mediastinitis, but a septic tracheitis and bronchitis. Death was the result of local absorption, and of absorption from the trachea and from the bronchial mucosa. This case demonstrated most conclusively the efficiency of the granu- lation barrier which is created by a pi-eliminary iodoform packing. Had a preliminary tracheotomy been made, or had the trachea been allowed to remain in its bed, the patient would surely have recovered. In sixteen of these twenty-seven laryngectomies for cancer the laryngeal box was so choked Avith the growth that tracheotomy was required to prevent suffocation. Most of the author's patients gave a long history of hoarseness followed by gradual, though intermittent obstruction to respiration. In two cases, there was associated lues. One of tliese last two cases illustrated well the clinical difficulty of diagnosis. The lesion was first diagnosed correctly as luetic, and under a course of treatment the greater part of the growth disappeared. The residual growth, however, showed a progressive tendency, and Avas later diagnosed as cancer. Laryngectomy was performed and the patient is now alive and well, more than three years since his opera- tion. The si^ecial lesson from this case is that cancer of the laiynx, like cancer of the tongue, may follow local luetic lesions. There is dangei-, therefore, that the hope of a luetic cure may defer too long the laryngectomy which is the only chance for the cure of the cancer. Extrinsic Cancer of the Larynx. — As ali'eady stated extrinsic ean- (•(']■ of llie larynx ])resents a diiferent and a more desperate problem than does intrinsic cancer. Extrinsic cancer is more difficult to attack on account of its ])osition; it is disseminated earlier and more widely on account of the greater muscular activity of the parts involved. Ex- trinsic cancer of the larynx is however more accessible than cancer of the tonsil or cancer of the pharynx. The same considerations apply to cancer of the base of the tongue. In attacking cancer here a prelinunary tracheotomy is essential, wide neck incisions are made, the cancer is exposed most cautiously and is thoroui^hlv thermocauterized. In the further dissection great i.ai;yxx, PiiAnvxx, itpki: ksopiiaccs. and rKAciir.A. 147 ctivo must 1)0 oxorcisod not (n ili-^tiirli the cscli.'ir. At'lcr cninijlrli' mid wide excision of tlic cniiciT tlir wcniiid sliouhl lie li'ft wide npcn for llic free use of the X ray. In one instnnce tlu- autlidi- cxi-iscd the liasc n\' the ton.i^ne, the pillars of the jtharynx, tiie i)liarynx itself, Uic entire laiynx, tlie hyoid, — in short all of the tissues lyin.c," between the jmictnrc of the jiosterior and the middle third of the tong-ue, the uppi-i' riiii;' of tlif trachea and the upper end of the esophas'us. leaviii.i; Uul a .-li^lit covi-riiif;- of tiie vertebrfp. This enormous wound looked hopeless for a long time — durinu- which the X-ray was used freely — but finally closed completely. About four years later metastasis developed in one of the sub- maxillary lymphatic .ulands. "When the author saw it, this gland was (piite large, was inflamed, huggeil tlie jaw elosely and involved the swollen reddened skin coveiing it. Again a wide excision was uuidc, so extensive that the wound couhl iH)t have been closed ha jaw was sawed off longittidinally — the sawed fragment of bone coming olV with the rest of the caiu'cr. Tn due time the wound was skin grafted and closed. It has Keen oxci- li\-e years since this last operation and nine years since tlie first. The ])atient is now at work. He speaks with a sort of a buccal whisper, — is able to sAvallow, to drink and to smoke with ease and comfort. This case taught the author that no one can tell when a case is hopeless — for surely this patient seemed to be in a hopeless condition. The repair of the mutilations ])roduced by this operation in which so many iniijortant structures were removed and the consequent recovery have been a source of encouragement and inspiration ever since. Tn another case of extrinsic cancer the operation in a local lield was not so extensive but the lyni))hatic involvement was much greater. Tn this case the growth had so filled the larynx that the obstruction lia will cause the death of the oatient in less time than 'would the orijjinal iirowth had it been left unmolested. This is ])erhai)s the most imiiortaiit point to lie considered in the treatment of eancer of tlie pharynx, tlie tonsil, the pillars or the riina iilottidis The oi)enitioii is teeluiieally beset with diilicnlties liut no instrument, no linsi'er, no sponge, that has toueheil the cancer surface, should be used aiiain. nor shdiild the\- touch anvthiui;- else that may be used ill the operation. The o|ieratioii -^lnuild iint be undertaken if its result is to be no more than the iinplaiilation of a new ciineer that may extend e\cii farther than the orii-inal growth. The only means by wliich the reiniplaiitation of cancer cells may be ])revented is by the immediate and complete destruction of the oriuinal fi:rowtli liy thermo-cauterization. Care must then be taken to jirevent the dislodgment of the eschar- and even after these precautions have been taken it is best to follow the operation li\- the use of the X-rav if the field is acces^ilile. It is wise also to iiiaki' a xciy wide excision of the ijrowth, and to renioxc .-ill the lymphatic nodes which drain the involved area. Jn serious risks it is liest to perform the operation in two staires, first excisin,i>- the local field, and then after ten days or more removiuo- the lymjihatic beariii,<>- tissue of the iiecdv by a block excision. If the growth is located in the tonsil or tlie ])illars it is possibl(> to give the anesthetic and to )irevent tlie inhalation of lilndd either by passing- tubes through the pharxnx and packini: them with gair/.e, or by the intratracheal insuffiation method df M'ltzer and Auer. If the cancer is still lower down, it is lle^t td iiiaki' .1 preliminar\ trachcdtdmy ami introduce as large a rublier tube as the ti'achea will lidld. thus pM'\-eiit- ing the inlialati' will minimize the hemdrrhauc. Excision of the Tonsil for Cancer. —I'earing in mind the gi'iieral precautions stated almxc. the excision of the tonsils for cancer is ]ier- formed in the followiim manner: 1. A tube fdi- the administratidii of t he anesthetic is passed through the iiharynx and held by gauze packing. 12. All of the visible growth is com|iletel\ ;isr <<( ih,. -irictiiiv. 'I'Ih' Imsc of the ptricturo was tlu'ii jiii'i-cccl, llu' nccdli' imssini;- iiitu tlu' nmiitli. 'I'lu' silvor wii-t" was tlim dclaclu'il tVdiii the i'\r and llif in'cdlr was with- drawn until the pnini was uncc nun-c external tn tiie liase n\' tlic stric- turo, and was tlion i)assod tlifoiiiili the small openini;- in the center of the pharynx. The free end of the sihcr was attain tlireaded into the eye of the needle anil the needle was withdrawn. In this manner one side of the scar was ura.-iied liy Ihi' huip of heavy silver wire. Another wire was >iinilai-ly inseited intn the ii|iiiosite side and l)o1h wires were tJLiiitly twisted, 'i'lie ]mi-|Hi-e of this ]iroeedure was to foi-ni a iHueous inenilirane-eo\-ered iistnla analou'ous to the skin listula one makes when upei-atinL:' for wch linL;'er. This was i'aithrully ti'ied hnt nnfortunatel\- the wake of the wire> lilled as fast as they cui their way out. The ant hoi- tiien ahandoned further efforts and made an (>sopha,ii:o?toniy, which appeared to he the only possible means of relief. Esophagostomy. Like tiacheutomy and enterostomy, esopliasos- touiy iHa> he |iennanent, or it may he used for temporary purposes only. The author has many times niaile use of esopha^'ostomy for a temporary ])urpose, elosini;- it after it has served its purpose. The most striking;- case of this nature was the eas(> of extrinsic laryngeal cancer already described in whi<'li the larynx, the liyoid, a large por- tion of the pharynx, the tonsil>, the base of the tongue and all of the intervening tissue were excised. .\( the end of the operation no pharyngeal mucosa was left. The esophagus was stitched up into the skin at the side of the neek and was seeiindy fastened with silk sutui'es. The traehea was stitehed to ti jiposite side. After a lime new mucous membrane spread o\cr the |iiiarynx. The author then in several stages freed the esojjhagus from its attaehiiieiit to the skin at the side of the neck and brought it to the median line. In two more seances he sutured the larize hiatus in the anterior pharynx. After a good union was secured the e-ophagostomy opening was linally closed. The jiatient made an excellent recovery. In performing an esophagostomy the important ]ioinl is to make the incision so ample that all the fiehl may he >een clearl>\ (fig. 110.) The dissection shoidd he so controlled that tiie recui-reiit laryngeal nerve, the big hloiul vessels, the \a,i;iis and the other important struc tures may all be so clearly seen that they cannot be mistaken mu- in- jured. (Fiu-. 111.) If each steji in the operation- howcxci- minute- is controlled not the slightest mishap need occur, .\fter the esoi)hagus has been reachetl, however, it is important tn a\iiid extending the dissection in the ne(d\ tiie least l)it more than is reijuired; for, in the 152 (ii'ki;a-|'i\k sri;iiKi;v ok tiif, xosk. tiiikiat. axd kak. lirst iil;ifc, :i wide disscctidii is iidl needed: and, in the second place, llu' di'e|i iilanes of tissue ill the neck JLave linf little jiower of resisting infection. If no oineriicncy exists, it is even safer to liriiig tlic esoitliagns well np into the wonnd; to jiass a small strip of iodofoi-ni gaiizo around Fig. 110. Es()iilia)j;ostomy. Ample incision of sliiii aldiiK the anterior l)or(irii.\i;(s. anh TiiAciiKA. IT)!) Cancer of the Esophagus. CaiKiT of tlir esophagus is rarely ciu'cd Tor iiMially the ciuidit icui i> iint ri'co.ii'iiizcd until symptoms of olistruftiun a|ipcai-. li\ wliii'li lime tlie disease has ahnost certainly spread into inafcessihle teriitorx. The toclmie of i-eseclimi nf liie e^iipliaiius for cancer is essen- tially the same as that alicadx dex-iilied W^y esnpliaiiostomy. The incision should he ample eiiniiL:li tn expose the eaiieer l'oi- a considcr- alilo distance alui\e and helow llie liiint> of the caiit'eroiis tissue. It is rarely pos>ilile to llinte the ends of the divided eS())iliaiillS. Diverticula of the Esophagus.- opeiat ions for diverticida of the esophagus jjresiMit a sharp coiiti-ast to tiio>e for pharyiiu'eal stricture, for the forniei- ai-e usually successful. Tin' autlioi- has opei'aled on five oases and found them readily cin-aMe. I'.efore operation X ra\ hisuiuth pictures should lie made to de- termine the exact location, the extent ami the nature of the sac which is most comuionlx situated at the upper lateral aspect ol' the esojjha.ii'us. often exteiidiuL;- downward helow the claxicie e\-eu. The o|iei-ation i- p<'rl'oi-med in the folhiwini;' mauiU'r: 1. .V lon.u' \-ertical incision is made ovt'i- the middle of the sac. '2. By sharp knife dissection the sac is exposed, the field being kept liloodless and trair-luceut li\- pickim;- up and clMmpiuL; each \-ess(d either hefore oi- at tlie moment of its division. '■'. The entire poncdi or sac is i>olated up to its esojihaifcal or lihar.vimeal point of origin. i:.4 (IPKIIATIVK SriUlKltV OK TIIK XO.SE, TllKiiAT. AMi KAII. 4. 'I'lie siU" is cut off exactly as one cuts oil' a lu'inial sac. Tlio oi)eniii,ij: of the diverticulum is closed by a silk siiture preferably willi a (•(^lililci- stildi. Tlif first row of stitclios is roonfnrccd 1iy a second row, and a small drain is inserted al (he lower end ol' the wnund after rlos- itii;' the o\ crlNin,';' tissues. If tile diverticulum he hi^h uji on the eso]iha,iiUs, especially if it involve the jiharynx, the )>atieut should not he allowed to swallow until the line of union is well estahlishe(l. As the victims of esophaueal diverticula have usuallv had mucli experience with throat ami Es(il)liafr')stniir Fig. 112. Esophagus stitcliod to skin. esophageal instrumentation, the insertion of a small flexible tube through which nourishment may be given will be no liardship. One of the author's iiatieuts had had another diverticulum re- moved twelve years previously. In this case the phar^aigeal wall was strikingly thin, and in addition to two diverticula the pharynx was greatly dilated on the same side. The site of the first ojieration was clearly visil)le, the scar being sound. Both diverticula were re- moved and in addi1i parts of tin- larynx reversed. The indirect method of examining and operating \ipon the larynx must lie ci'edited with vei'v great accom]ilis]iinents, and it will always be em])loye(l, but tin- -p<'eial workers of tin- cuniing uvniTat ion will turn instinctively to dii'ect manipulations npim the larynx latlur than to the older procedure. Contraindications. Absolute contiaindieations to the employment of (liiect inspertiiin (if tile larynx are seldom found. Chief among these is a high grade of criencc furnishes a certain small part. ICpitomes of new work, and sucii in great measure is this article, must go to the original sources for the facts. This the author has udt sn iinicli a routraindicatioii, altlmnuh the result is tlio same, as it is an insurmountable obstacle. Where the direct ex- amination iiroves to l)e impossible, it is generally due tn uncontrollable i-eflexes. Howex'er, unless there is some disease of tlie crrvical verte- bi'a' or some unusual mali)osition or deformity of the larynx the direct examinatidu is almost always possilile under general anestliesia. Where the ]iatient is suffering from marked dys]inea the performance (if tracheotduiy usually makes the direct examinatidii possible. Uncontrollable gagging, the chief difficulty in carrying out direct examination, interferes fully as much in the indirect method as it does in the direct. In either case it uuist be successfully (■(lud)atted before the examiiuiti(Ui can proceed. The Choice of the Aesthetic. — In I'xamining the larynx directly the operator has the choice of local or general anesthesia. Some form of anesthesia is necessary on account of the gagging and coughing far more than on account of the ])ain, since the manipulations employed in the direct examination of the larynx and trachea give rise to but little pain. It is essenti^d, therefore, to do away with the sensitiveness only of the mucous membrane. This can be brought about either by the use of coca in locally or by the production of general anesthesia in addition to local anesthesia, because even with the general anesthesia, the use of cocain is necessary. The operator ought not be a partisan in this matter. He should employ either form of anesthesia at will. In- fants and children are best examined under general anesthesia. In many adults a satisfactory examination is possible only under ether. Certain systemic diseases like multiple sclerosis, bulbar paralysis, tabes, and hysteria, increase the sensitiveness of the mucous membranes. In old subjects the mucous membrane of the larynx and trachea is often very tolerant. In robuist males with chronic catan-h. twice or three times the amoiuit of cocain as is re(|uirtNl foi- women is often needed to produce anesthesia. Cocainization. — Briinings with his customary thoroughness has studied the iiietliods of cocainization exhaustively. He has demon- strated that cocain applied by a brush or swab is three times as effec- tive as it is when introduced by a spray. If adrenaline is added to the cocain solution the anesthesia is noticeably prolonged. Briinings uses a syringe which he converts into a swab syringe by winding cotton on the tip of the canula. The barrel of the syringe is graduated so that the operator can control the dosage of cocain. This author finds that on the average five drops of a twenty per cent solution is sufficient to produce anestliesia in an adult. In children the strength of the solu- T.Ai;Y\(ins(^orv, r.i;oxci!()scor>'. F.sopiiAcoscorY, ktc. 1;)7 tion is reduced Id ten piT i-ml. Iirc-ni-c IIm'V dn im) lolrr.-ili' llic dnii; as well as adults. AVilli a >\vali or llic >\\ ali >> i-in-v, a drop of ;i 1 unilx \iit cent -ohi lion of cocain is aii|>lied to the lia>e of the toiiuuc. .-md another to the poslei'ior jiharynaeal wall. Aftei- ;iii inteixal ol' tlu'ee or I'our minutes the cocain i> aiijiiicil to the ti]i of the epiulottis. (•'inaliy a dro|i oi- two i.- placed ill the larvnx. Thi^ call> for accurate doyrin,ae. hut lia.s used the simple >wah and with it a ten per cent soluti.ui of (.'ocaiu for the lirst of the aiiest lie>i;i. and a twenty per cent -olutiou ill tic laiyiiN. The weaker solulion allow- the cocain to he employed more freely. I'ntil the liei^inner perfects hi- technic he will do well to use the weaker soluliou for the mo-t |)art. If cocain is mixeil with adrenalin chloride much stron,j;-er solulions can he u-ed iii the larynx. Some operators eini)loy as hii>li as fifty ])er cent. The Difficulties of the Examination. — 'I'he i>reatest diOienlty in the way of a siiceessfnl exainiiiation is iiic(uiiiilete aiu'sthesia. ^Pinie is lost and the examination is rendered inconiplete or made inipos-ilile unless the anesthesia is profound. Fr(Hii its nature the i)roeedure of direct examination is disconcert inji- if not alarinin;;- to an inexiierieiiced pa- tient. Therefore, the patient should he calmed l>y the assurance, repeated if necessary, that he will not straniile. lie is encouraged to hold tlie head as loosely as he can and to hreatlie i|uietl> and re,i;-u- larly. From time to time the exainiiiation is interniiited in order that the patient may sjiii out the accannnlated saliva, lie is cautituied to do this quietly and not to hawk. Durinii- the examination the patient is lialile not only to heiid the head loo far hack hut to allow the whole hody fr(uii the knees up to swin.i;- hackward. The assistant should see to it that the jiatieiit keeps strai,<>iit ami erect. These are the principal ami natural faults into which the patient falls. The faults of technic to which the examiner is liahle are also natural ones. The first, incomplete cocainization, is due to haste. For the patient's sake he wishes to y'et the examination over (piickly. The second mis- take on the iiart of tlie ])hysician is to insert the siiecnlnm too deeiily at first and in conse(|uencc to miss and to jiass the epiglottis and to strike the point of the instrument anain-t the posti'rior pharynu'eal wall. This produces nncoiit rollahle naiiiiimz' ami oflen, for the da\ at least, makes further uianipulation impossihle. In pressiiu;- tin' epi glottis and the hase of the tonmie forward the specnlum slnuild he held firmly and the procedure executed in a deliheiale ami nnhesitatin.a,- fashion. Otherwise the tonp^ie is tickled and rehels. I'nder lirni pres- sure it yields and suhmits. AVlien the tip of the s)ieculinii has en- \'^^ (irKMATIVE SnUiEKY OK THE XOSE, THIIOAT, AX1> EAR. torcd the lar\mx there is daiiiior of the sliaft striking' a.^-ainst the teetli or the unprotected gums, thus causing pain. The examiner's finger should be so placed as to prevent tliis. Tin- success of the examina- tion depends most of all upon the eliaracter of the patient's neck. If he has a thin neck, and if he is fortunate enougli to have no teeth the prospects of a successful examination are good. If, on the contrary, the patient has a short, thick neck, and a protruding ui)i»or jaw and retains all his teeth, the outlook for the examination is not so liopeful. The amount of force required to bring the lar^nix into view varies with the individual neck. Briinings has made the observation that a force of 10 kg. is bearable, 15 kg. painful, and 20 kg. unbearable. He has found also that the ease of seeing the anterior commissure varies greatly; in fact it may be thirty times as difficult in one pa- tient as in another. The harder it is to obtain a view of the anterior commissure the smaller must be the diameter of the speculum. With a speculum of 9 mm. diameter a pressure of 9 kg. will expose the anterior commissure. With a speculum of 14 mm. diameter the same amount of force will expose only the posterior part of "the lar\Tix. The Method of Making- the Direct Examination. The patient should be examined if possible when the stomach is empty. If the physician feels that his patient will be unruly a dose of bromid or morpbin some little time before is of benefit. The patient is seated upon a low stool (30 cm. in height), and the assistant stands behind and supports the head. The patient's head is bent slightly backward. The patient protrudes his tongue and holds it witli liis left liand. The examiner guards the upper teeth of the patient with tlie forefinger of his left hand at the same time pushing the upper lip out of the way. The thumb of the left hand is held against the left forefinger and the angle between the two fingers is made to serve as a guide for the shaft of the speculum. Two forms of specula are used for direct exam ination, the tubular speculum of Jackson (Figs. 113 and 114) and the speculum of Briinings. Su])pose that the instrument of .Jackson is the one wliich the examiner is usiiic'. It is maiiipuUited as follows: Tlie blade of the speculum is carried into the mouth along the central line of the tongue until the tip of the epiglottis appears. As soon as this is recognized the end of the speculum is carried over it This is the first stage of the examination, if for purposes of clcainess the exam- ination is described in stages. It is vital for the success of tlie ex- amination not to have this first manipulation miscarry. Wlieii tlie epiglottis has l)een passed by the tip of the S]i('cuhnii, the luuidlc of i.Ain X(;()sn(r\, iiiioMiKisroPV, icsni'iiAcuscopv, ktc. ]:>'.) (lie iii^truiuciit is iiciilly laiscd and at tlio same liiiii' llic |)alii'iit's licati is allowed to swiim- l)aci<\vaid slightly and Ity dcf^Tocs. As tlic licad of the patient uucs hack the (MkI of the siieciiinni is puslied (htwnwaid aloii,2: the posterior surface of the epif^lottis into the vestibule of the larynx. From the moment that the tij) of the ejti^lottis has l)een ])assed until a satisfactory view of the larynx is ohtained, firm pressure is ke])t upon tlie Itase of tlie toii.nue liy lifting- u]) the handle of the s])eculuni and lliiis forcinu- its sliaft and tip forward. The discovery and tlie passing;' of the tip of the epiglottis constitute the first sta,2;e of the examination, the sinkini; of the speculum into the vestibule of the larynx the second, and the ]nishinu- of the e]ii glottis and the base of tlie tongue forward. Fig. 113. .Jacksim's tubular speculum. Tlic instrument is made in two sizes, for eliUdren and adults. Johnson has moditiod this speculum In- making the horizontal part of the handle detachable. till' thiid >tage. If at aii\' lime the exaiiiinei- loses his way, that is, misses the e])i1criimi>, the >pcculuiii should he withdrawn and the examination starteil again from the heginning. It is a help, after the tip of the e])iglottis has been ])assed and the speculum is about to enter the \c.-1ibnle <>\' the hir>ii\. to ask llie palieiit to speak, in ordei" that the iiHAciiiciit of the arytenoid eartiUiges may give the ])ropi'r direction for the (lee|ier introtluction. .\ successful examination should be a matter of only a few minutes. Passing the Speculum from the Comer of the Mouth. — If there hapjM'Us to be a sufficient gaj) between the teeth on either side of the u]i])er jaw advantage may be taken of tliis .space to pass the .speculum 160 OPEKATIX'!'". srndKlIY OK THE XOSK, THIiOAT, AXD EAR. at this placi'. If no ,t;a|i exists and tlic incisor Icctli afc prominent, tlie s|)ernhnn ina\ Ite jiassi'd lietween the liicn^pitl teetli or from tiie coi-ner of the mouth. 'I'he distanees are shorter and the miiseh's more rehixed. l''or this jairpose tl:e head of tlie ])atient is I'otateil a litth' and heiit sliiihtly to the opposite si(U'. Carried out with a sniad Jackson spec- ulum this metliod of making- the direct examination is very successful in children and infants. This ])rocedure has heen especially dexclopetl l)y .lohuston. The Direct Examination With Counter Pressure. — In the direct examination it is the forward pressure of the si)eculuui -which enahles the operator to see the larynx, hut this at the same time limits his view hecause the laryux as a whole is dislocated consideral>ly foi-\vard. Tn Fig. lu. Didgraiumatie vopieseiitatiou of diicct laryngoscopy and schema, show- ing direction of force applied in using the tulailar speculum. (After Jack- son.) oi'der to counteract tJiis the operator almost iustiiu'tively ])uts his fins'er on the larynx from the outside and pushes it hackward. Briin- iiifi's has o'iven this common manipulation a special name, direct exam- ination with coiniter-pi'essure, and has devised an insti-umeut to do the work of the physician's hand, and so free it for other uses. With this instrument the inventor states that the antei-ior commissui'e can he seen in all cases. The Direct Examination Under Ether. — The ]iatient is ])re])aied for general anesthesia in tlie usual way. Before he comes to the exam- ining tahle h(> is giA'en, if an adult, a sixth of a grain of mori)hin and one one-hundred and fiftieth of a grain of atropiu. The patient is placed on his hack on a tahle high enough to ))ring the head to the same level as the face of the examiner if he i)refers to work sitting. If he in-efers to work standing the tahle is ]iut ni)on a i)latform. The l..\l;^■^"(;os^■^l■^ . r.iidXciKiscdiM . I'.soniAiinscdiM'. K'i'c Kil ■■nitluir lias Inuinl il Ir^s lii-iii- and Ic-s a\\l<\\anl \i> iiiallit)ul(lors of the pa- tient are linmulit over tlir mil nf the laMf wliili' an assistant supports the head with his left hand n|"in his left knrc. The knee of the assist- ant is sujjportod at the proper Inniiht hy an ad, instable foot rest. WIumi the ether has been well stalled the phvsii'ian eneaini/.es the deeji pluw- ynx of the jiatii'nt and the region of the pyril'onn sinnscs with a swab Fij,'. llo. Position of second assistf.nt and I'utient for endoscopy per os. Gowns, paps and covers are omitted to show (lie |iositi(iii liotlrr. (After Jackson.) saturatetl with a ten jier cent eocain solnlimi. Often it is a help to have a suture throu.yh the ton.uiie. The introdnction of the spec- uhim is the same as under local anesthesia exeeiit, of course, that in the majority of cases it is easier. The ether examination is resorted to when the patient is inti'aetahle nndev local anesthesia. It is used in the case of children, or when. lM>>ides makini; an examination, oper- ations of consideral)le extent are to he canied ont. The assistant should so hold the head of the iiatieiit that he can at anv moment k; OI'KIIA'I'IVK sniCF.r.V ok the XdSK, lllllllA'l'. AXII KAi:. traiisl'cr it to the lininl oi" the pliysieiau. Ol'toii tlio physician can obtain a Itcttcr vifw l>y iiiaiiii)ulating the position of the head for hinisclf. In a hard examination tlie liead passes many times from the hand of the assistant to tlie iiand of the examiner. The assistant's free hand is ready at an> ninnu'iil to push the biryux Itack and to nianii)nhite the Fig. 116. Bronc1uisco|iy khuii ;it. Massachusetts Greneral Hospital. The elevated platform is shown, with the operating table and the assistant who holds the patient's head. The iheostat and dry cell battery are seen on the wall at the left. Behind the assistant is a Coakley lamp. On the left also, but not slioBTi in the photograph, are the electric suction pump and the ground glass box for holding X-ray plates. anterior commissure into view, or to close the cords in order to show the presence of a new growtli. In examining children under ethei- it is not always necessary to bring the head over the end of the talile. If the occiput is allowed to rest on the tal)](' and the cliin is brought up, in very many instances a Iterfect view can be obtained. It is well to try this ])osition first. Often I..\RVXliO.St'i'l'> . l!l;n\(l|n<(n|>\ , KSOl'l I AtJUSCUPV, liTC. lliis ))()siti»ni is suctH'ssrul also willi ailulls. If it (Iocs not succoL'd the lioad may ln' tuinril to tlic sidi' and the spoculimi carried down lictwccii llic l)iciisi>id tooth or Troiii tlu' coiiit-r of tlic iiioiilli. This maiii|iiilatioii is csprciaily iisci'ul I'or introduciii.i;' the hroiiclioscopo hotwocu the cords liccauso it is easier to jict in line with the trachea in this way tlian it is TroMi tlie niidide line. For operatini;' pnrjioses Briininys enijdoys an Often s]iecnlnni. Some years i\v:o the author de- vised practically the same kind of a speculum, and used it for some time but soon replaced it hy an open adjustable speculum of the pattern shown in Fi tlic end d' the sliall ami whidi rli.sr u|inii cacli (ttlicr froiii almxi' dow iiw ai\\\ hrlnw. If \\\<' liLnlcs ar(> tlu'ii sluit tlic l)it(' is usually succi'ssrul. In lianl oxauiinalions wlioro noitlici- tin- iiosilimi of llic licad uor (•iiunttT-prossurr will caiisc the s]i('ruliiiii tu IniiiL; almiit a sullicii-nt view of tlio larynx, and tlic writer nni>t cdidV-s that lir lias had such cases, a small, short iironelKiscoin' iiitnidurrd Ironi tiic anf?le of the mouth will at times hring' into view the desired ]>art of the larynx. The writer well remembers a youuii' sailor of sphMidid jiliysique who had a small fibroma situated well forward mi tlir lil't vocal cord. Under ether a most tryinif and humiliatin.n' oxaniination followed. Success, however, followed when a small hroncluiscope was introduced from the an,yle of the mouth on the riiiht and caniid into and across the larynx until the urowtli was pinned inside the tiilic and a.i^ainst the lateral wall of the larynx. An a>sistant nicaiiw liilc pressed the larynx backward and made counter-iu-essure dh tlie left. A wdrkinii: set of instruments for linnielinscoiiy is as follows: 1. .Tackson's tubular speculum (adult and child size). -. -larksou's lirouelioscopes (7, S.o, 10, and 12 mm. in diamotpi). u. Biuning.'i' universal electroscope. 4. Briinings' extension double tubes (7, S..5, 10, ti;. auil II niiii. in diameter). il. Briinings' autoscope or sjdit spatula speculum (11 and li! nun. in diameter). (i. Briinings' extension forceps witli five dilTcrent tips; or .Tackson forceps with tips; or Coolidge forceps witli .sliaft of tliree lengths and tips. 7. Suction apparatus (hand bulb, hand or electric aspirator, with three tubes 2.5, 35, and 50 cm. in length). N. Foreign body hook, il. Casselberry 's pin cutter; or Mosher's jiin bender. 10. Briinings' or llosher's safety pin closer. 11. .Jackson's dilator for the bronchi. 12. Mosher's adjustable speculum. l.'i. Two angular locking forceps, for use with the open speculum (MosherV H. Twelve Coolidge's cotton carriers. I.'i. Kirstein "s head light. Hi. Angular laryngeal knife. 17. King punch, for work about the mouth of the esophagus (Mosher). Tiiis list includes instruments for obtainiufi: li,s. The head minnr juid a stamlini;' electric lamp I'uniish a r\ ideil I'nr hel'oro the examination is bc- .unn. The operatcu- must lie willing t and smoothly. The suc- cess of the ojjeration often di'iK'uds nimn tlic t horouiihiiess of the prej)- aration. On an aceessoi-v taliK' the instruments for tracheotomy should be sterilized and ready I'nr use. There should he enouiih assistants for eai-ryiuii' out this procedure and llu'y should lie surgically trained. The Inhalation of Oxygen.— A cylinder of o.\y,i;-en ,u:as should lie in every operating;' room for use in cases calliut;- for lirouchoscojiy. The administration of the uas nia> make i1 po^^il)lc to avoid a trache- otomy il >c\-('|-c dyspnea is present, whih' the usi' of the ;jas to comliat shock and respiratory arrest is important. If a i)ronchoseoi)e is in place when the emergency arises the gas nia\ lie administered through this directly, or through the suction tube if the .Jackson type of bron- cho.scope is employed. Daeger has devised an ajijiaratus by which the amount of oxygen aihninistei-ed c,-in be accurately nu'asured and con- trolled. Suspension LarjTigoscopy. About three years ago Killian introduced sus])euslon laryngos- copy. Within the last twelve innntli- his perfected instruments have begun to be used extensixcly. The underlying princi]ile of the pro- cedure is the transference nf the weight of the patient's head from the band of the cx.-unincr tn tiie handle i\\' the specninni. This gives the physician a new linriil, his left, with wliicli to work. The sns))ension is accom]>lished Ky ehmgating tln' handle (if the s|iecnlnni, and ending it in a hook. To tlii> handle is nttaclied a skeleton inonthgag. A nut and a screw in the handle of the speculum control the width of this. A second nut and screw elevate the tij) of the specninni. Spatula? of different sizes are fitted njjon the handle. I'lacli of these has incor])o- rated in it a narrow secondaiy sjiatuhi. The position of the tip of this is again regulated by a nut and screw, 'i'he .-iiiiiaint us is ellieient and beautiful, but coniplic.-ited. The elnini 1> niadi' for it that besides hold- jng the ]iatient's head it will al\\a>> hiing the anterior connnissui'e of the larynx into view. 'I'he writer's experience with the apparatus as yet is too limited to pass on such a slateini'iit. Init from what hi' saw at Killian's demonsti-ation in London in IIM.".. and from what he has learned fi-om the nu'u in this country who have employed the method and Killian's instruments extensiveix . lu' considers this state- 168 OPERATIVE SI'IUiEKY OF THE XdSE, THROAT, AND EAl! nioiit mueli too liroad. Tliis is relatively a small matter, of course, be- cause tluTc will always l)e a percentage of cases in whieli neither a speculum nor the human hand can force the anterior commissure back into the field of vision. The gist of the matter is that an advance has been made, how great time alone can settle, by the introduction of suspension. The tired laryngologist eagerly grasps the relief which it affords. (Fig. 120.) The wav having been shown bv Killian, tlie rest of the world of Fig. 120. Killian 's suspension niiiiaratus. laryngologists will rush in witii possible improvements of the ap- paratus, aiming especially to simplify it. The writer admits that he is one of those Avho have made such an attempt. A hook in the end of the liandle of his af Killian is enk'ient, of conrso. but it is luilky and doi's not lit every table. For convonicnco in carryinii' the writei- lias had a foMinu' frame constrncted. Tlu' board which supports tiiis slijis nmliT llir liack nf llic patient. Sn I'ar it has mot oxiieotations. (Figs. li!l and lilJ.) Fig. 121. Moslier's fdldiiig fiamo for stispi'iisinn :i|.|.:ii;itus closod. Fif?. 122. Moslier's folding frame for s^iispensiiiii ;i|)i>uiuUis opoii. Ill) (U'KHATIVK SriKiKIIV OF TIIK XOSK, THKdAT. AN'D KAII. TRACHEOBRONCHOSCOPY. The r the perfonnance of the tracheotomy the second method is tiie simplci- and so will be described first. Lower Tracheobronchoscopy. Unless the lower route is used for the extraction of a foreign body it is well to wait a few days until the surgical wound lias healed a little Fig. 12.3. Uretlirascope used as .1 tracheoscope. before attempting thorough examination of the trachea and the bron- chial tree. The earliest examinations of the trachea by the lower route ■were made through short tubular specula like the female uretlirascope, and the illumination was obtained from a head mirror (Coolidge.) At the present time self-lighted specula of this pattern are made. (Figs. 123 and 124.) For the examination of the trachea as far as the bifurca- tion these are the simplest and best iustrunu'uts. l.AUVN'cldSCnIM . I!|;i IM I K ix t il'N . I>i in I \i .1 ISCOTV, I'.TC. 171 Contraindications to Lower Tracheobronchoscopy. Inlos ir.i c-licot(iin\ is (■nnli-;iiii(lii-;ih'.l llii' |n'i-f(>riii;iiicc nf liiwcr 1 r.-irhiMilinni ell(iscn|iy is |icnnissiiilr f\ri>|il in llu' | ncsi'llcr (if | ilh'UllKHlin. Anesthesia.- .M'lcr ;i iTcmt ti-aflirnldinv in ;i rase in wliirli tiic iiincoiis nn'inliraiif is ihnnial. a iir^iiin lirlnw the ulnlti- i- tliiTi' rxci'ssive sensitiveness, 'i'ln' Irarhca hijciatcs liic tulic wi'll. .M'tcr tlie insertion of tlio tnhi' llic Fig. V2i. I'ri'tliraseopc used a? n tiacliens('ii|ii .showing' iiKiiviiliiiil parts. swal) syriiiyo may he used i., aii|il\ aiii In tlic walls of the tradu^a. the iiio.st sensitive i>ai-t licinu the anterior wall. In ]iatients who have lieen wearini;- a traelical cannla Un- sipiiic time tlic imicous nienihrane alinut the 1ul>c is Very in-italilc and il may he imjiossiljle to coeainize it. in ciiildrcii the strcii.uth of the cdcain solution shonld be retlnced to live per ct-nt and in adults in the iircsmcc n\' !ii-nnrlii1 i^ a twenty per • •ent solution slioidd not lie used oi- should hr iinpl,,\-,.d spaiini;ly. Jf thiM-c is a forci-n \uu\\ in llir liarJM.a. tl M'aini/.al ion sliould be ac- eomplisla'd with a sxriiiyr, nipt with a swali. 'i'li,' pari- of the trachea 17ll OPKI'.ATIVK SrilCKIl'l' 111' TNI'; XOSK, T 1 1 IM lAT. AXII KAR. wliicli ;iri' the nicisl in-it;il)K' ;ir<' the iiciulilHirlindd of the iistula, tlic liit'urc.-itiiiii, ;iii' the tulie fnnii side to side, misses the bifurcation and carries the tube into tlir rii^iit main Inonchus. In this connection it slimdd lie Ihh-iic in mind that the median si'ptnni is often pushed far to \h>- left. The sr|iinni slnmld always be located be- fore the tidte is ))assed into a liiiim-lins. The Endoscopic Picture. In a tulmlar orsau like the tra('ln\a liaviniT a i-onstant liiini'ii. when tlif (ilix'rxcr hniks tlinm-li liic In-nn- choscojio ho sees at .some distaiiec ahead (if the end df tlic tnWe tlie lumen of the trachea and its walls. ( l-'i-s. l_'."i and IJii.) The he-inner is liable to introduce the tube too far at lii-t and not to i-ot the jiictnrc in persi)ective. If this is done iiatlmhiuic naiidw inn- of tho Inmen wonld not be roco.uiiized. The .same wonid Ik- tine oi' an\ derorniity of tho walls caused by pressui-e of tho nei-hhorin- or-an<. In order to ob- 174 (IPHRATIVK srr.CEliV OK THE XOSE, THKOAT, AND EAIt. Iain a ]iro])cr porspoctive the tiibo sliiniM lie liold lu.uli, but for a g'ood view (if the walls the tube shoubl be canicil well down and as near to the wall to lie rxaiuiiii'il ;i^ pdssililc. Tile liiiiiicr llic lulic tlie larsi'er the field wliicli appears in jierspeet'n'e heyinid it, the s('(ii'N . uiioncikiscoI'n, iosoI'iiacoscoi'V, v.tv. h-i lu'oiirliial iri'f i> iilili/.cil to llic uTi'Mlot cxti-iit in lniiiuiim the lirst lii;iiirli lit' llic Icl'l iiiiiin liroiiclms iiitn \ic\\. In ii(l(litiluni ln'onclms to tlio lower lobe into view is about 1..") cm. In lower l)roiicboseo|)y even less latei'al excnrsiou is necessary. (Fi-. ll'S.) The Interpretation of the Endoscopic Pictures. — The greatest dif- Right recurrent laryngeal. Transverse artery Right common carotia artery. Suprascapular artery. Thyroid body. Left recurrent laryngeal Right coronary artery Thoracic vertebra Intercostal vein Intercostal artery ~L Vena azygos major. . — Intercostal Intercostal artery Intercostal vein. Intercostal artery Fig. 129. The arch of the aorta, with tlie i.uhiioiiaiy artery ami chief branches of the aorta. (Morris' Anatoiiiv — From a (ni'\ . i:>i)i'iiA<;ns('(H»v, ktc. I t i till' trat'hra llu* oltsrrxrr ran lirl). Iiiiii>rlt' iiy o. mil in-" tin- riiii;s. In the main Itruiiclii iiirasiii'i'nu'iils arc n\' iMon- a'nl. Tin' liTcatrst li<*l|) of all is ohtaiiu'il iiy layinii" tlir niamlriii ut' tin- <^\aiiiinin,u- tiilx' nn thr surface of tli.- du'.-t ainl Jinluiim' \\\r iiiimial .li^laiicfv tVniii tliis. 'riir h'imlli i)\' a >1iMiuli(' ai-t-a i> liaid li. .Irlmnitii' l.y >i^lit. ami is l)csl iiiiult' niil Iiy ihc u>(' nl' a iin'lal nli\r lipiM-.j huimic Ohjrcts at the oiul ol" \\\r lulu' ajipcar snialliT lliaii 1Im'> rcallN aiT. Tlicir 1 riu^ Right commoD carotid artery Innominate artery -A. ,ir,. r;\ Right Bubclanan artery Right innominato vein V anonyma dt- xtra Superior vena cava V. cava superior Right broDchos Bronchus dexter --. Trachea Left common carotid artery Left ianominato \ Cervical pleura' Cupula pUnir.r Arch of the aorta Esophagus (thoracic portion) \|V Mediastinal pleura '.' ■■■^JAf I'lcur.i nu-Ji.ibimal.s J \A Pulmonary pleura • > \\K" l'l>;iir.-n>ulmonalis Omental tubero^ty of the liver Tnhcr omcntalc licpMii 'Hepatoduodenal ligament or omentum' •Lig. hcpatoduoJcnate Candata lobe of the liver caudatub hcpatis Showin;; tlie iclat (From Toldt.) sizi' (•••111 lie rcckdiicil nialliiMMJit ii-ally, lnit il is easier In ohtain il l)y ineaslirilli;- a iln|iiieate nf liie (plijeet. ( l''i,i;-. i;'.(l.) The Choice of the Upper or the Lower Route. l'\ir the IxvuiiimT l'i\\''|- liMiiieli(i>cn|iy i> I'asier aiiil -al'ei'. Ill iiil'aiils ainl ynuiiL; ehiMreii il is >al'el- ami dftell the llletliiiil of clidiei'. The e\|ierieiicei| ii|ierat(ir will succeed with ll|/|ier hrunchiisc(i|iy w ilere the llii\iee will fail, hill it is well til tr\- llpliel- hlH||el|(i-i'(i|,y a> a Inlltilii. in all ease>. IT it does ll"t .~l|cei-ed the ( i| mT;i t ( iT ^hnllld 1|(,| llesilate \n aliaildiHI il fnl' the loWel' |-i)Ule. There i> 11(1 divuiace ill ~,i ddiiii:-. It ha> heen |iid\-ed ihat ill casi'S ill which a rnrei-n IhmI)-. like a lii'aii, has heeii playiim' ii|> ami down in the tracln'a fni- sdiiie liiiie the traiiiiia -n caii-.eil (il'leii |)i-(uluft,'S siJJisiii III- ecleina (>r the larynx, so that after u]i|ier hroiieliosci)))y, cvon ITS OPKItATlVE Sl-i:CiE7tV OK THK XOSE, TIIKOAT. AXll KAi;. if it has been sueeesst'ul, an I'liiergoiicy traclieotdinx- may lie necessary. Tile question of ui)])er oi- lower l)roiiclioscopy slioulil iicxci- depend on the priih' of the opefator hut on the i>-()od of the patient. The Dangers of Bronchoscopy. — Operative bronchoscoiiy is jiatu- rally more dangerous than examinations merely for diagnostic ))ur- poscs. Jackson's statistics of ninety-four cases of upjper and lower lu()nchosco]>y give a mortality of two jjer cent. The chief danger of the examination is its length. lender ether tliree-quarters of an liour is a safe limit. Bather than prolong the operation it is better to try again at a second sitting. In one of Killian's cases of a foreign bodv Rami broncluales ventrali lobi superiort5 Bronchial branch of the middle lobe ifirst ventral hypartenal branch of the right bronchus i i lobi Ventral bronchial branches of the lower lobe Rami bronchi.ilcsvcritralcs Ventral bronchial branches of the upper lobe ! n I broncbiales ventralcs lobi supcrioris Ventral bronchial branches of the lower lobe Rami brnnchi.ilcs \cnira!c5 Showiuij tiic ilivisions ;it* the traclu':i and Inonchi. (From Toldt.) ill the ])i'oncluis ten sittings wore retinired l)efore the extraction was successful, and many of these lasted two hours. Briinings gives the time of the ordinary operation as five to fifteen minutes. Jackson has re]iorted the removal of three tacks in tliree minutes. (Fig. 131.) i,Ai;\ ^•l;^s^■ll|•^ . iu;(inciiii>('ii1'\ . lmH'iiacoscoim-. ktc. i7;» Asepsis. Ill InuiicluiM'tiiiy tlic numtli i>\' the imlicnl sIkhiIiI I.c iiKulo as flcau as possililc. .lacksdii ail\-isi'S a ihiily \>r]- cciil Miliilimi of alciiliiil as a iiKUiIli wash. It <;iics witlidiit sa\inu that tlu' iii^lni Fig. 132. Sliowiiiy: tlic lolalidii of tlio nuiiu bioiiehi to the rilis jiiul the lOiest ttall (Anterior view). (From Ansitoniicnl Dciiartiiient. llarvanl Meilii-iil School.) incuts jilso slioulil he cli-aii. (iciicrally iiniiiiT>i.iii in -cxciity )icr c-ciit alcoliol is -(IcjHMKled u])oii Tor the stciili/.atioii. |-"(innaliii vapdi- can lie ^-niploycd if |iifri'rrc(l. 180 OPKRATIVE Sl-RCiKKY OF THE XOSK, TIIUOAT, AND EAK. The Size of the Tubes. — Biiiiiings uses tulx's of four sizes. Ul'PER BuONCnOSCOl'Y. XuiiibiT Size Age 1 7 mm 1 to 3 years. 1% 7V> mm 4 " 5 " " 2 S14 mm 4 " " :', 10 mm 9 " 14 " 4 ^2 mm \ihilts (men and women). Lower BiiONCiroscoPY. Xiniilii'r Size Age 1 7 mm 1 to 3 years. L' . S 1/0 mm 3 " S ' " ?. 10 mm S " 14 " 4 12 mm Adults (men ami women). BRONCHOSCOPY. In order to see the secondary bronchi the main bronchus is dis- located laterally and the tnbe brought into line witli the bronchus to be examined. The patient's head must be lient in the lu'ojjcr manner to allow this change in the position of tlie tube. In changing the position of the head the neck should not be held far backward and cramped be- cause tliis interferes with the mobility of the trachea and the bronchi. As soon as the lumen of the right main V)ronchus is entered and lighted by the tube, the observer sees in the distance the opening of the bronchus to the lower lobe and within this smaller dark, oval patches Avliich are the openings of the tertiary bronchi. Between these dark patches appear the median septa. The picture constantly changes. With every movement of the tulie new openings of noAV branches come into view, in the dejhlis of which other divisions are seen. (Fig. 133.) In the deeper lironchi there is a rliytlunical cliangc of t]\v picture with I'espiration. When the tube is jjlaced high in the main bronchus the opening of the branch to the uj^per lobe as well as of that to tlie middle lobe gen- erally are not seen. It is cnily after inserting the tube to the ]3roper depth and dislocating the bronchus between one and one and five- tenths cm. to the side and upward, that the lower circumference of the opening of the branch to the upper lohe is discovered. If the manipu- lation is not successful the tube is inserted below tlie origin of the first branch and lateral pressure is made as before and the tube withdrawn. As the tube comes up the opening of the bronchus springs into view. (Fig. 134.) LAnvNcnsiiii'N , r.i:i iNC! insc(ii'\ , i;sni'iiAi;iisriii'\ , i:rt'. ISl. II ■f. --Jl 182 OPKUATIVE Sri'.CKKV OK TIIK XOSE, TIII'.OAT. AND KAK. Diaj,'r:im to sliow the bioiielKJSt-ciiiic iiii-turc. (After Jackson.) A. The bifurcation of the trachea is sliown to the left of the middle line. 1. Left main bronchus. 2. Right main bronchus. E'. Picture of the left main bronchus (see Fij;. 128). 1. Bronchus to upper lolie. 2.-.'i. Bronclii to lower lobe. C. Picture of right main bronchus. 1. I^rduclius to upper lobe. 2. Bronchus to middle lubo. 1.-4. Bronchi to lower lobe. No. 4 is the practical con- tinuation of the right main bronchus. Ill luWiT lir(ilicll(iscn|iy lllO ii|M'iiiim' 111' the liraiicli to till' u])])*'!- ]()))(• i.'< easier to liiitl. So readily can the opeiiiii.u' l)c ap- proached tlial the cireuinfer- ciice oT Ihc lirsl two I'iiiii's can he made out. The Held often increases rhythniii-all\ with the res])iration. The cavity of the lii'aneli to the upper lobe can be explored by placing a small mirror through the examining tube into the bronchus or by insert- ing a small cystoscope. AVith the latter Briinings has dem- onstrated even the tertiary hronclii. The cystoscope should have a diameter of 8 mm. and if designed for both upper and lower bronchoscopy it should be about 30 cm. long. Although cases have been reported of foreign bodies lodged in the branch to the up- per lol)e (Wild and Gottstein), as a rule such cases are rare. Killian calls attention to the fact that the examination of this branch might give a clew to tuberculosis of the right apex, that is. pus might be seen coming from the opening of the bronchus in such cases. (Fig. 134.) The direct examination of the branch to the middle lobe is easily accomplished when the tul)e is carefully introduced and pressure is made in a for- ward direction. This opening, hoAvever, can be readily con- fused with that of the branch l.Ain X(i(lS((i|'V. Ili;ti.\<-||(IS((I1M . i:>n|'|l.\i;nS(illM , ICTC. 18:; t(i iIh' Iciwvi- lol.c. In all cmscs in wliidi llic olisciv .t is in iImhIiI iIk tiiho slnmld lie w it lidraw n In lin' liifiircat ion ami Ilim caiiicil duwii \varil anain stcii li\ step. Fig. 135. DiiiKr.-mmiafic ilrawiiig tci .show the bioiichospopic picliiro at various Ipvols. The in-aiicli t>\' the rii^lit main bi'dnrlins In the lower IuIm' i- irally a cnntinnatinn n|' tlic main Ihhim'Iiii-. I'm- this reason llic dinMiin'^ «\' tlie tliinl Mcmdai-x ln-miclni.- i> nn| nnly easy tn sec and ciilcr witli '!!'■ 'iiIm' Km thi> i- III,. l.innrlni> w liicli most (iftrn catcln- fnivii^'ii lH>di,.>. ( l-'io'. i;;.-,.) TIh' Ii'I'I main linmclms k-avcs tiic trarln.a nincli nnnv sharply tlian llir riyiii liidiiclnis docs. For this reason it is iiai'dci- in naiii access 184 OPEKATIVE SUIUiKllV OF TIIK XOSE, TIIIiOAT, AND EAR. of s S - - i ^ M ef- y. a ... ce c -^ t- £ s Tt !° 3 rt — 1 rH > c ^ ::^ c < c ^^ 3 % o '"' p K \ p > 1 o "S ^ K p < tj tri O S j: +-» f4 9 ^ % «H - gH C' ? C i. . §:".S .< ''• H =« ,5 £ .y ■gig « ^ .-? = ^ --£ S ■§)(£• £ g a cs ^" • - a 2 S-i3 >>;; g. ^ L, a 3 -p « .i:; :: = " 3 "^ "" r-; .-ai ■•:< a oi ^+^ " hJ . rt p- ^ ■*? ° ^4 ^' >4 '^ r S >, . S . . S LAIIYXliOSCOrV, r.i;ONC'IIOSC(»I>V. KSOIMIAUOSCOPY. KTC", 185 to it ;in 4 to .") cm. from the hilnrcaticin. It i- to he fnun.l on the lateral wall and >omewhat anteri.)r!y. It is often missed hoth on the inser- Fig. 137. Hiirizontal section of thorax of man, aged 57, imnioiliatoly alio\e tlie liifuifation of tlie trachea, seen from ahovc. (From Quain.) U. L.. upper lolie of right lung; U. P., L. L., upper and lower lolios of loft lung: K. B., L. B., origin of right and left bronchi, in this specimen the ter- mination of the trachea was lower than usual; A., arch of aorta; D. A., descending aortti; D., obliterated ductus arteriosus; N., left recurrent lar^^l- geal nerve; L. G., lymphatic glands: other letters as in Fig. 1.36. tion and on the withdrawal of the tnhe, and a sight oi' it is to he gained, if at all. Iiy stmn- l;iter;d and npward dislocation of tln' main lironclms and with the enes a i-dnt innal ion nf the main hronclin-. 'i'he tnlie, i hereluii', iind> it rc;idily and the |iictnre seen throngh tiir tidie simws tin- iunieii nf the thii-d hraneli :iiid then the division into tlie dorsal ami vrntial hi;ineiies. isd ()i'i';i!ATi\'i': sritdKin' ov tiik xose, TuitoAT, and ear. Lower hronclioscopy carried out as lias liccii imlicatcil is imt difli- <'ult. The broiielii should be examined lioth (ni the iiili-ddiirtidn i,\' the tui)e and on its withdrawal. The cxaMiiiiatiuii cannot In- considcicil (•otni)lete nidess both main lironchi, the secondary lironchus nu llic riL;lit to the middle lobe and the branch 1o the lower Inlie on hoth sides have lieen examined. The exploration of the two main hrunchi and the branch to the lower lobe on the lin-ht is especially demanded because foreis'u bodies often lod.no in them, in the authoi's experience furei.ii'u Fig-. 1.38. Hoiizdiital >:fcticju of t)ic thorax of a luaii, ag'-d .17, at tlie level of the loots of tlie liiiijjs, seen from a!)Ove. (From Quaiii.) I. S., superior and inferior lobes of lungs; £., eparterial lironehus; A. y\., anterior mediastinum; E. P. C, right pleural cavity; P. C, pericardial cavity; A. A., ascending aorta; P. A., i)ulinonary artery; R. P. A., its right Ijranch: K. I'. V., L. I'. V., right and left pulmonary veins; A. V., azygos iii;i.jnr \eiH; other letlers as in Fig. VMi. bodies lodge oftenest at the hifurcation of the trachea, in the dilatation where the first branch of tiie ri^'ht main bronchus comes off, or in the internal branch of the bronchus to the lower lobe. The tertiary bronchi are so small that neither the bronchoscope nor light can In' made to enter them. In such cases the use of a sound will enable the operator to palpate these small tulies even to the ]iei-iph- ery of the lungs. (Fig. ^oH.) Lower bronchoscojiy is easier witli the patient in tlu' sitting posi- tion. It can and often is carrieil out with the p;itieiit lying on his back. i..\mN"i;nsc(ii-\'. iiKdNciiosciii'N . i;s(Pi"ii.\i;nsi i)r\ . i:ri \<, It is li.-uilci- 111 iiiniiaiic tlu' imsitioii ol' llic pntirnl '- lir.-id i!' lie i< iipmi llis li.-ick. lirr;msc llir ll.-llhllr iiiiicli innir (lilliciilt tli;iii Ihwit liniiirlio scopy nil ;li-C(UlIlt nf tlli' lllnrc ci im| ilirji.t I'l 1 li'clinic Iriinircd to insert ^ \ \\ J FiK. i.in. Horizontiil section of tlic thorax of a man, agecl 57. mi iIh- li\rl of tin' iiiliplos, scon from nliove. Xntc liow tlip lnonclii Jsepp near the nieiliaii line. Tliis is fortunate in tlie removal of foieign Imdie.s. (From Quaiii.) n.. nipple; M., middle lolie of riyht lunn; B. A., rijjlit anriele; R. V., ri^'lit ventricle ; L. A., left auricle; L. V., left ventricle; K. V. P., riglit posterior valve of aortic oiitice; r. />. <•.. riylit pleural cavity; other letters as in Fiji, l.'ili. tile Iir(iiir|i(,sc(,|i... ,|ni. t,, ih,. iniin (if the l;ii->n\. ;iiii| hccnnsc i^\' tlu' sli.uiiter niDliilily of ihc tnl..' ;iihI it> -ivjit.T Icii.ulli. Anesthesia, 'rin- (icrni.-m schnnl arr slrnim ar on liis liack. The n>c nf dlicr (loi'.s jiway with the sense of hurry which attends liKmi'liux'dpy niKh-r local anesthesia. The Method of Performing Upper Bronchoscopy. If hical anes- thesia is to 1)1' cnipioNcd the iaiviix of thi' paiirni i- i-i i.'ai iii ;'i'd as for 188 ni'KiiATivE snuiEnv of the kose, throat, axd eak. direct iiis|i('cti(iii. 'I'lie refiexos of tlic larynx arc llic niosl active. After the aiiestlicsia has l»een accoin])lislic(l the vocal cords nvv exposi'd. If Briiniiiiis' instruments are selected, this is done with the tul)uhir spa- tula used after the fashion of his speenhini, em])loyed for direct ins]iec- tiou of the L-u-yiix. It is not necessary to expose the anterior connnis- sure, so that the operator is content witli disclosing' the ])osterit)r third, or tlie posterior half of the cords. If this much is not read- ily Vironght into view, the assistant pushes the larynx backward. The pjassage of the larynx is the difficult part of the mani])ulation. This is best accomidislied by cautioning the patient to breathe quietly and regnlarly. When he does this the cords part in ins])iration and the tul>e is slipped between them and into the trachea. The cords need not l)e widely separated. Sometimes it is necessary to turn the spatula- like edge of the speculum anteroposteriorly and to insert it in this manner between the cords and then to turn the speculum and force the cords apart, 'i'he introduction of the warmed and oiled tube is brought about not so miich by force as by manipulation and a lever-like move- ment of the tube under the guidance of the physician's left foreiinger. The Introduction of the Bronchoscope with the Patient Lying: on His Back. — Where the jiatient is placed on his hack it is necessary for the introduction of the tube to have the head held over the end of the table. After the tubular speculum has passed the ujjjier i)art of the epiglottis the head must be lowered for the exposure of the cords and the passing of the tube between them. In the prone position of the patient the handle of the electroscope is somewhat in the Avay. This difficulty is not encountered if the Jack- son tubular speculum is used because the speculum is discarded as soon as the bronchoscope has entered the glottis. If the introduction of the tube is difficult the patient may be turned on his left side. The tubular speculum is then carrie(l in from the left corner of the month. The head is unsupported. The si»eculum easily passes into the tra- chea. After the si)eculum has entered the trachea the ])atient is turned upon his back again and the examination completed. The cords hav- ing been passed the rest of the examination is carried out as in lower bronchoscopy. When the tubular speculum lias ex])lored the trachea to the bifurcation the inner tube is inserted and advanced step by step to the main bronchi. Naturally it is not possible to move a tube when passed from tlie mouth as much as a tube introduced through trache- otomy wound. Therefore there is less lateral dislocation of the trachea and the bronchi. To make up for this loss the alteration or moulding of the patient's body, chiefly the ])ositiou of liis sjiine, is called into plav. The bronchoscojie is sliiften\ in infants and childi'eii is often com|iarati\fly eas\ . The vtrnctiires are diminntive so that the field obtainetl is small. 'i"he epii^lottis is nnde\elo]ie<| ami often very iniruly when the specnhnn attempts to control it. The difficulties in the examination of children arise fi-oni the smallness of the structures wjiich necessitates tubes as small as ()-7 nnn. Through tiiese it is hard to get a good view and to manipulate instru- ments. In addition the examiner's ditlicnlties aic increased by the unndiness ol' the patient, by tlie tcndeni'y to sjiasni, by sabnation, by tlie strong respiratory mcixemenls of the trachea and the brinichi, and lastly by the greater tendency to collap-e either with hieal o|- gelliTal anesthesia. Tn most cases bi-micliosedpy i^ undertaken in ehijdi'i'n for tlie de- tection and the rcniii\al nf foniLMi bcdies. foreiizn boilies are most connnon in eliildrcn. U\ >nniniai-i/e a table fiMni (iottstein. between the seeoiul and the sixth year. Sixty nine pei- cent of cases occur l)efore the twelfth \car. and oiil> thirty-eight per cent fi-om the twelfth year onward. Instruments.— Ixelatively wider specula may be u.sed in cliildren than in adnlts. Forceps iunl all other instruments which are to be used tlirough the diminutive tubes which are employed in children must be especially snudl in calibre. Hrunings has a sjjccial form of electroscope wliiili lie advises for this work'. Other instrnnients are the open si>ec- nlnni nf I'riinings, or that of the wi'iter. A self liiihted urethrascope 1!"> lil'KKATIVK sntCKIIV OF T M K XOSK. Tlli;()AT, AND KAI;. is of serxirc Inr use tliidiiuli ;i tr.-icl Inmy woinnl. The siz.' (if such tnbos \';irics liclwccii 7 niid S imn. 'I'hc sizes nl' the uicl lii-ascopcs should lie ."), i; ami S uiiii. Scxciilcni cm. is a suriicinit Icimtli I'oi' Ihc foivrps. Direct Laryn^osccpy. 'I'iic simplest way to cxamiiu^ a l)al)y is to wrap it ill a Maiikct and to place it on its liaclc on a tahlc and expose tile larviix with the open specnlum or the childreirs size of the Jack- son speculinii. 'Idle examination of tlu' child held 'ii a sitting posture in the ai-ms of a nurse is also satisfactory, i^'or this purpose tlie spec- nlum is ])assed along the center of the tongut' or introduced from the cornel- of the month. In infants and children the author lias had no exju'rience with local anesthesia. He prefers to use general anesthe- sia. Briining's gi\'es the imju'essiou that examinations conducted in this Avay are less satisfactory than when local anesthesia is iMiijiloyed. It is douhtfnl if the exjierience of ojierators in this coTiuti'v accords with that of Briinings. The Method of Examination. — The method of making the direct inspection of the larynx in infants and children is the same as in adiilts. The distances are very short and the epiglottis is ])laced high so that only a slight depression of the tongue is reqnii-ed to exjiose it. The pharynx and even the glottis often close in a s])hincter-like fashion, and from time to time the whole Avorking held is Hooded with mncns. A speculum with a liroad end is especially serviceable in raising the stidthy and elusive epiglottis. Often the anterior commissure of the larynx can l)e moulded into view by external ))ressure. In holding th<3 head it should not be l)ent too far liackward. Lower Bronchoscopy. — Lower bronchoscojiy is can-ied out wit'i children in the s;iiiie manner as in adults, for the examination of tlu; ti'achea in the neighboihood of the Hstula tlie urethrasco])e or a small bronchoscope constructed on this jjattern is of service. In examining the trachea and the bronchi the respiiatoi'v movements of the air pas- sages ai'e a great annoyance. In strong res]iiration the Held may be lost altogether. This is embarrassing in the bronchi because if the mucous membrane is swollen it is only during inspiration that a view can be obtained. Upper Bronchoscopy. - I'liper lironchosco|)y in children is the most difficult feat which is attempted with this procedure. 'I'he examiner should 1)1' ready and willing at any momeiil to sn]))ilaiit it hy lower bronchosco])y. The jiuthor lias had most experience with upper broncdioscopy performed under general anesthesia. Small doses ot ati'opin control the secretions. The intioduction of the tube is easily accom))lished in I.AUVNiinsCnI'V. llllnNCIIOSCOl'V. KS( (I'll ACI ISCOI'V. IVW. 11)1 llii" iisiuil i-;is.' witli tile >iii;iil .larksmi siirciiliini ur willi tlir .•kIJu.-I.iMc open spociiliiiii. I'lipi'i- l)i-.inciii)-cciiiy in rhilihcii >li(niM iirvcr !»■ ;it tciiiiilcd \vitliii\U iiistniiiii'iil^ aiiil ;is>i>t;ml> ciinnuli I'm- ihc r\ccii1iuii of .-i v:\\>\i\ tr;iclif(ilciiii\-. 'I'lir il;iiiL;fr "\' suli-l«i1 1 ir >\\clliii'-; .-il'li'i- ludii- (•linscMipy in vliiiilnMi sIumiM alw.-iys lie in llic minil nl' iji.' diFiTntur. The liatiiMit ni;iy ivtiuii-f an cnnTui'nc) l lai-lu'dli.nis imi .mly durin- tin- operation hut <\\ any time dnrini; tlu' nv\\ day n|- two. Tlio .ui'iicral conduct nf the examination liy ihr npper mnlr i> aloni"- tile sanu' lines as iIh' exannnalinn in the ailuit. Instruments for Bronchoscopy. Tlie essential instiunient for liie perrornianee of direct insjiection i<\' the larynx, tlie liachea. and the liron- chi, is a inelal tnhe of a|iprn|iria1e >i/.e aud leu,e:th. Km- dii-e<-1 examinaliini of the larynx the tulmlai- sprcnhiin i.- constniete(l so 1liat it is open foi- a ])art of its leiif^tii. i-"or lin' e\aniina tion of the hrouchi tlir spciMdnni he conies a h)n,ii-tuhe. The speciilnin and the lon.ir tuhe can he lii;lited from within or from without. The simplest method of liiihtiuii- the hroncimscoite is that ])opulaii/.ed hy .larkson. A small secondary tniie is (■anie opposite the window and when the lam|i is Inii-iiim;' its liuiit iliinniiiates not only tlie end of the lai-ii'er tuhe hut shines ahead of it. The illumination of tln^ tnlie iiy the second method is accomplished hy- attaching!: to a lumdle w hieli can hold various sizes of tuhes, a small i)ut jiowerful electric lamp. ( Fi;.;. 1411.) Ahove this a mirror is so |)laced that the lifilit from the lamp is thrown down and throuiih the tuhe. Briiniufjs has (Ievel(>|)ed this form of illumination to a hinh dcii'iee of efticieucy in his various forms of electroscopes, iiotli metlnuls of liirlitinir the examininu' tuhes are hiiihlv successful. Kach has certain ria. ]-in. Hiiiniiij;s' cli-ctroscdpc. 192 OPEKATIVK SriiGKI'iV OF Tl IK XOSK. TIIIIOAT, AND EAR. advanta.i^'os. Tlic exaiuiiuT sliduld ^ifdvidc liiiuscll' with lioth sots of instriinieiits. Ili' certainly slanild not allnw liiniscll' td liccduic so prej- udiced as to be willing to use but one i)attei-n. 'Pile disadvantage of the self-illuminated tul)e is that the light is liable to become clouded Avith secretions and blood. It is surprising, however, especially if the examination is contUieted under general anesthesia and the secretions conti'olled by atropin, how long the light will burn before it becomes dimmed. As a rule suction will keep it clean. Theoretically a strong case can be made out against the self- lighted tube in the presence of abundant secretion, especially blood, but the results of practical work refute most of the objections. The lights call for a little more care than the larger lamp of the Briinings electroscoi)e. The thread of the small lam]) and the thread in the light carrier should be carefully standardized so that new lamps will fit and burn. If this detail is attended to, the small lam]»s give almost no trouble. The great a(h'antage of the self-liglited tul)e is that its handle is not complicated and so at times in the way, and tliat the eye of the observer has the fi;ll diameter of the tube to look and work through from the beginning of the tube to its end. This reduces the eye sti*ain — the physician's eyes are his capital. The advaiitnt;-!' of illiiniiiiating the tuhe l)y reflecting light throngh it is that the illumination is uevei- lost in the ])i'esence of secretions. A candid observei' nnist admit, however, that it is more tiring to look through tlie nai'row slit in the mirroi' of the electrosco))e than it is to look through tlie full lumen of the self-lighted tube. The author has read the discussions which deal with the question of lighting from the standpoint of optics, but has settled the question for himself at the examining table. The beginner in ])ronchoscopy is advised to do the same. The Jackson Tubular Speculum. — The Jackson tubular spt'culum is shown in Fig. ll."!. This si)eculum is made in two sizes, tlie larger for adults and the smaller one for inraiits and children. The cut makes detailed descrijttion of the instrument unnecessary. Johnston has modified the Jackson speculum by making the handle detachable. The Briinings electroscope is shown in Fig. 140. It is inade in at least three patterns. The author has found it necessary to provide himself so far with l)nt one pattern. The Briinings Elong-ating Bronchoscope. — The main tube is a long tubular speculum. This is used to examine the trachea as far as the bifurcation and the esophagus as far as the arch of the aorta. For ex- T,.\nVX(;ilSC()l>V. HKONl'IKlSCnl'V. KSorilAcidSCOPV. KTC. l!i: aiiiinatioii lieydiul tlioso dopllis a siiialltT tiilic is littcd into tlir larjicr one and carried down and l)eyond it liy means iif a stont spring. By this device tlie lulu- can lie len,i?tliened at will. 'I'liis form of tnlie is especially ii.-eliil in examinalions jjerformed iimlei- lural aiie^l hcsia. The Briinings Elongating- Forceps. — Briinin,ii;s has ajiiilied the jninciple of the elomiatiiiu- tiilie t( of forceps is very usefnl espe- cially as the shaft is fitted with tijis adapted for all necessaiy ma- nipulations. The operator should sni)i>ly himself with a lilieral as- sortment. It is vital to have a fjood tip for iiraspinu'. a tip niaile in the form of a puueli, and a tip of the ))roper form for sei/.iiiu' heans and other see short- circuited ill the instrument bag and its power exh.austed. An iimperemeter is used to test the battery before it i.s used. The physician always knows whether or not there is suiricient current. 194 (ii'KUATivK sri;i;Kiiv ok thk xosk. TiiiidAr, .vxn km\. oiidary lulic wliicli carric-^ the linlit a si'i-niid auxiliary tiiln' for tlit' ri'iniixal of sccrctidiis. A iiaml hull) may he used attaclicil in tin' siu/- tinu ;iiln' (ir ail ai)i)aratus such as is t'iii})lo\('(l Inr rcui(i\iiii;- lluid frdni the clii'st, or best of all an aspirator run by clccl ricity. Small amounts of secretion are rcmoxcd by folded nair/.c swabs. The ('oolid,ii,'o cotton carrier is excellent foi- this iiurjiose. ( Fi^- l-fl'.) In direct examina- tions of the larynx, lon.i;' angular forceps, the blades of which lock Fig. 142. Coolidae 's cotton paiiier. Fig. 14.-!. Aiii;ul;n- forceps for use xvitli tlio afljustalile specu- I'lni. The forceps are employed chiefly for sponging with cotton or gauze, Init are extremely useful for e.xtracting foreign bodies from tlie nioutli of tlie esophagus. They ca7i also be used for removing intubation tnbes. The ■author uses this instrument for cocainizing the pharynx and larynx preliminary to direct examination of the larynx, or esopiiagoseopy or bronchoscopy. C5= Fig. 144. Mosher's alligator forceps. These forcejis have locking han- dles so that tlie blades hold firmly whatever they grasp. They are made in two lengths. The shorter length is useful for direct work upon the larynx, and the longer (14 inches) is very con- venient for carrying cotton for swabbing out the shorter esoph- agoscope. It is mucli easier to load this forceps with cotton tli.'ni the usual cotton carrier. (P"'i^-. 143), are useful for removing the thick secretions in the pharpix. Long alligator forceps (Fig. 144), also Avith handles which lock, are a luxury when short tubes are used because it is very easy to replace the sM-al)s. (Figs. 145 and 146.) Acquiring Skill. — Briinings in his course to students drills the men in the extraction of foreign bodies ]ilaced in a rnliber mannikiu of the respiratory tract. Practice of this kind is very valuable. By it the ))eginner learns to see, and learns the Itest wav of nsini;' the different T..\i;vNi;os((ii'v, itr.oxciioscdpv. KsoriiAcosrfU'v. ktc 1!).". kinds i.f forceps. IT Killi.iirs iii:ninikiii ( Ki.i;-. 147) is ii<»t at Imiid iimcli llic saiiif kiii.l iif pracliri' can lie ..litaiiied if a furcifjii luidy is placed in a ndilier tube, l-'urei^ii hodii-s may l)e placed in liie air passaiics of narcotized dous. 'I'lie cadaver >ised for lironclidscopy <,dv('s liotli jirac- tice in reir.oviim' foreign liodies ami what is even more important, a cs»c 'i^—^^^^x Fig. 14o. Jackson's tulio fdicops. B, actual size of liilie and jaws of forceps: P and K. dilators for l)ronclioscopio strictures, wliich can lie used in con- nection with Jackson '.t tulie forceps liandle. Fig. 1-16. Coolidge's forceps. knowledge of the applied ;niat(ini\ of the Iniuu-hia! tree. The hest practice of all is afforded hy an adidt patient wearinii' a traclh'otomy tnl)c if tlie pliysician is fortunate enouijli to find such a patient who is willinii- to nviko cajiital of liis inlii'mity. If the jihysician who undertakes Inimchoscopy oi- esophanDscojiy is meclianical. and, in addition, has or will ac(piire an elementary knowledge of applied electricity, many dillicnlties in his new work will he easily oveicome. Jackson is fond of sayinJ,^ and sayinu' it in liis forcible way, that the extraction of forei.mi bodies is ])-,irely a matter of mechanical skill, inlmni skill, however, can be offset and sometimes surpassnl liy tlh' ~Kill whirli I'cmies from wiHinune-^ to le;irn and at- 196 OPERATIVE S;tkgERY OF THE XOSE. THROAT, AXD EAR. tciitioii to detail. And the details of iiistnuuents and instrumentation in bronchosco]jy are many. Tlie physician who is not willing to deal with these petty details is happier out of this kind of work. The moral of this little preachment is — learn your instruments, how they are made, how they should work, and how they aie to be kept in order. "Gridley, you may tire when ready." You must be Gridley. Fig. 147. Killian's manikin for practir.ing bronchoscopy and esophagoseopy. Direct Laryng-oscopy for Diseased Conditions. Malignant Disease. — ^^lalignant disease often calls for the direct examination of tlie Iar\mx in order to obtain a clear view of the growth, and especially to secure the removal of a satisfactory specimen. By the use of a good punch forceps (Fig. 145) this can be taken from the most favorable place, that is, from the margin of the growth so that the diseased and healthy tissue appear side by side. In small growths direct laryngoscopy and direct instrumentation should not be depended uiHin for a cure — the larynx should be opened from the outside; but in T.Ain XCllSCdlM , lU'.dNCIIOSl'Ol'V, KS(H'llA(i(ISC'()l'V, KTC ll'l advaiu't'il and iiioiKTalilc niali^iiant dist-aso palliative iHin'cdiins like tlie roiiioval of obstniftiiiii; masses aro JustiliaMi' and arc easily e\ eeiited. (Fi-s. US inn. ) Non-Malignant Disease of the Larynx. Beni,nn iie(i|i!asnis of the larynx ulTer a wiilo lield Inr ilic eiii|il(iynK'iil y Clai-k is the (me followed by tlie author. The child i> e\aiiiined nuder ctlii'r by the |icr's spiral win- fniccps (Fig. ].")! i will i|nickly i'cnio\-e a large amount and allnw tlic rcmaiiiini;' uuissi.s: i,, I,,' di.alt wiih leisui'elv 198 OPKUATIVK SritdlCKV OI' 'I'l i K XOSK. THIIOA'J', AXU EAR. and with tlic sanio iiistniniciit. The sjiiiai wire rnrccps cniiii's up with l)a]>ili()inata l)otwoeii the \arii>ns wiix's like a lish iirt lilicil with tish. It is iinpoitaut in rcni()\ing' i)apiik)iiiata tn wniiiid the normal mucous mcmhranc as Htlic as jiossihle Ijccansc cat'ii ahiasion is ahuost sure to lun'c the growtli transjilantod uijon it. When the jiapillnma is ])laeod well forward on the cord or in the anterior eommissurc it Fig. loK Mosher 's spiral wire forceps for removing jiapilloma of llic laryn.v. is often very hard to expose even nnder general anesthesia. In such cases the triangular guillotine tuhe is useful for securing it. (Fig. 152.) It has been the experience of Clark that after a child has Avorn the traclieotomy tube a year or more the papillomata shrink markedly and in time disappear. At appropriate intervals the child is etherized Fig. 1.52. Moslier's triangular fenestrated tuVje. Used for the removal of pedun- culated growths from the vocal cords. It is especially useful when the grow'th springs from the anterior commissure. In use the growth falls through the window of the tuhe and is cut off by forcing hcimc tlie iilunger which has a cutting edge and acts as a guillotine. again aiul tlie remaining growths thinned out ov eradicated. Some operators like Jackson do not i)ractice tracheotomy in cases of papil- lomata but follow the growths through the cords into the trachea even without the safeguard of this jjrocedui-e. An emergency tracheotomy, hoAvever, may be called for at any moment. Tliis operation can l)e taken out of the emergency class and performed at tlie leisure of the opei-ator if the patient is given air b}^ intubing the larynx and trachea with a small bronchoscope. The author has made for this purpose the small iiistrum(Mit shown in Fig. l.")!^ which lie carries with his trache- i,.\i;vx(;iis((>rv. r.iKiNriiuscni'v. ksoi'iiacoscoi'v. ktc. '!'!' (ttoiiiy si't. It is >iii;ill ciKiti.uli 1i> pMss into ■■my l;ir\iis jiikI loii^ i'ii()ii;;li to uii well down tlic traclii-ii. It i> lilt.'. I willi :i pliiii.^vr .-o (liat viTV littlo oxposun' of tlu' larynx is lu'ct-ssaiv lor it.- c|ui(k Inl rocjuctioii. Tliorc arc bivathiiij;' lioh's on tlic sides wc-m tlu' lowii ciid. To li,i\<' this sinipit' iiisti'iiiiicut .•il\\;i\> :i1 liaiid i> a i^ifal roiiiforl. Il cin !"■ ust'd willi adidt.- a> well a> willi rliildii'ii. Harris has lately iv|ioiti'ii thf di-a|i|"'aiaii<'>' of a papiihuiia iiiidi'i radium. Other lM'ni,iiii neoplasms occui-. and tlicsc. Just as iia|)illomata. arc Ix'st d(>alt with liy diifi-t laryngoscopy, .\mouj; tiicsc aic liliromata. li|)oniata. (•y>1> and cdi-matous polyjii. Sinjicrs' nodes mi^lit he treated liv this method sho\dil removal he- advisahie. Fig. lo?.. Small l)roiiihosi'0]>(> for eiiiergoncy iiitiiluitioii wlii'li llio author ahviiy~ carries in his kit. By means of it iMtul)atioii eaa be quiel (if the larynx are easv to make out and to treat hy tlic direct nietiiod. An appropriate -peculiini and a joni;- lar\ni;i'al knife are tiu" Old) inslrunient> usnaliy needed. Al'tei- diphthci-ia. especiall\ when it has heen necessary to iutube often, the cords nia\ Liine toLiether for a certain ]iart of their lenutii. (Jpiionilly the anterior third or two thirds of the inner surfaces of thi> cords adhere. Sucii teases can lie manaiicd by prolonged intubation with lar narrowed also, is strctelied with the dilatin.a: meclianism of tiie nnthrotoi r belter with a dilator • •nnstnieted on tlie pattern ot' Kollman. .\s the liodiicis tube is con- ical and tends to slip ont of tln' lar>n\ il i> retained liy a (das)> inserted 200 OPKKATIVK SriKlEllV OK T 1 1 K XdSK, Tlll'.OAT, AND EAR. aiiil \v(irii tliroiiLili ;i pcriiiaiiciit tnu'licutoiiiN' woiiinl. For (lihitiiii;- the cavit) of llic larynx iiialc urotliral sounds may l)c passed tlirouiiii flic trat'lieoloiuy wound ujiward into tliu larynx. Naturally the opei-ative procedures are earried out hy direct hnyn.i>oseopy. The insertion of Ihc tnlie is most conveniently perform(M| h\ dii-cct intuhatiou. In this country AVilson was the first to bring direct intubation before the pro- fession. Tile autlioi' has devised a set of instruments for handling the tubes. Tile authoi- also has used direct inspection a few times for the detection of laryngeal di]:)htlieria, the removal of loose membrane and inuney was given its first great impetus when it was ])r()Ved that it is i)ossible to remove by its aid foreign bodies lodged in the trachea and bronchi. This field has been well exploited. In tliis country at least, Imt little work has been done with it in the \'arious diseases which can be disclosed and treated by it. In the near future there should be a great advance in this line. For the fullest knowledge that we have on this subject the reader is referred to the book of Von Schroetter. Ulcerations near the l)ifurcation of the trachea Avhich were causing chronic cough have been found repeatedly and cured by applications. Chronic catarrhal inflammation of the trachea which does not yield to the usual forms of treatment justifies direct examin.ation and treatment. As a surgical feat which as yet has not been dn]>licated many times, but which may at any moment become a common procedure, the finding of pus near the perijjhery of the lung may be mentioned. ^Vbscess of the lung due to a foreign liody can be localized by the lu-onchoscope I..\l;Y^'^i()s((ll'^ . i;i;(i.\( lMl.--((ll'^ . i.xii'iiAiioxni'N . i-.n L'dl ;iiul if ihc I'oroijrii Ixxly cjiiiiKtl lie sciMiivil tliroiii^li tin- tiiln', the (iilif, til- .1 luolio i)asst'il tlironn'li it can lu' iiscd as a nuidc to liu' surnt'im cutliim- iVolu tile (illtsiilr. Stenosis of the Trachea. Xi'iL^lilHiriim- (ir^ans not iiiri-ciiuciitly pivss njiitn the traciicn and cause il> |i,iili;il oci-lnsion. Tho tliyroid iiiaiid is a TroiinLMit olVcudiT. As a nilr it I'lr-si's liackward and sinct- ono loho is .nonorally nioir ciilaiiicd than the other tlie rt'sultin,i>' nar- rowinn' of tho trachi'a oeenrs in tiie anlen)|iostiTior ilireetion and soniewinit hiterally. AVhen the rctrotraclu'al portion of tlic uland as well as the anterior part eidariics tlie traehi'a heeomes a narrow o\al slit, the "s<'alil)ard" traelu-a. It lias boon dcnii'd that eiilarncinent of tiie tliynms could |iro(hice resent. Wlu-n the case was sci'ii it demanded an immediate tracheotomy. This did not relieve tlic dysjmca. The jiassaiic of the traclieoseoi)e showed that the trachea helow tlie incision was Hatteiii'd almost to complete closure frnm before liackward, Imt the insertion of a huiv; tracheotomy tulie linally ndiexcd this dys|)iiea and then the u'land was i-emoved, llie case result in.i;- in a cure. Tuliercular ^laiid-. csjiecially those at the liifiircation of the trachea, maliii'iiaiit disea.se of the cso|)haf;ns or of tlie mediastinum, and aneurism often narrow the lumen of the tracliea or ot" the jirimary hronclii. Tli" diauiiosis of these eoiidilions may be conlirmed or estab- lished by broncho.scopy. Jacksou n-ives the followiii.n- table of diseases of the walls of the tracliea and the liroiichi whicii canse stenosis: 1. ^laliiiiiant iieojilasms. 2. Benign neoplasms. 3. Specilic inflammations. (a) Syphilis. (b) Tuberculosis. (c) Glanders. (d) Typlioid fever. (e) Diphtheria. 4. Tiiflamniations. (a) "Catarrhal." (b) Trritative. (c) Traumatic, id) ()perali\e. (c) I'ost-oj)erative. '). Post-iiillammator)' conditions as cicatrices .-iiiil atlln'sioiis. (i. \'asomo1or dis1urliaiice>. anuionenrot ic edeiiia. 202 OPERATIVE SURGERY OF THE NOSE, THROAT, AND EAR. IJonign neoplasms are not frequent but when they are ]3resent tliey arc well adapted for removal through the bronchoscope. In asthma sensitive areas have been found in the ti'achea and bronchi ;ind appli- cations made to them gave relief. Syphilis is the most frequent cause of stenosis. Next come the narrowings caused by the healed ulcers of diphtheria or of typhoid fever. Stricture of the lironchi from similar causes is occasionally seen. Treatment. — The treatment of stricture of the larynx by prolonged intubation has been described. Strictures of the cervical portion of the trachea associated with loss of the cartilaginous rings are probably best treated by plastic surgerj^ Avhicli aims at holding the trachea open by the transplantation of some rigid material. The success of the transplantation of cartilage for the correction of nasal deformity may open up a method of dealing with these cases of tracheal stenosis com- liinod with loss of cartilage. The treatment of low seated strictures of the trachea and of stric- tures of the bronchi is carried on along the same general lines as those employed for the treatment of strictures higher up, that is, the stric- ture is first dilated and then held open by intubation. Such strictures call for treatment because wlien they are small they interfere with breathing and expose the lungs to infection from the retention of in- fected secretions. Von Seliroetter, who has carried on extensive in- vestigations in these cases, first dilates the stricture with a sponge tent and then inserts a metallic tube so made that it is readily retained. It would seem that a mechanical dilator Avould accom]")lish the dilatation more speedily than the tent. THE REMOVAL OF FOREIGN BODIES FROM THE LARYNX, TRACHEA AND THE BRONCHI. Foreign Bodies in the Larynx. Foreign bodies lodged in the larynx in most cases are either coughed up after the initial spasm of dyspnea caused by them or drop into the trachea or the bronchi. Occasionally the foreign body is loosened by the coughing and strangling and enters the esophagus and is swallowed. Sometimes the foreign body becomes impacted in the larynx and if it is large enough it speedily suffocates the patient. Now and then the foreign body may be small enough like a piece of egg shell to remain in the larynx, or it may be of the right shape like a button or a coin to lodge in the ventricles. Examples of cases of l)oth kinds are found in the literature. When snch cases jn-esent themselves direct examination combined with the use of appropriate instruments is the best method of removing the offending foreign body. I,Ai;VX(i(>S((tl'V, mtOXCllOSCDPY, KSOIMIACdSCOl'V. KTC. 20.') The Removal of Foreign Bodies from the Trachea and the Bronchi. I'litil thi' ailxiiit (if traehi'iiscu|)y and liinni'liDSi-oiiy tlie ifiiKival of a foroiiin Ixidy rrnm tlit' traelu'a was aeconiijlishcd liy ])ei-f(>rniiii.t; Irachi'otoiny. WIumi a loose hody like a si'('(l was playinu; np and down ihf li'ai'hca seeivin.y,- to escape it was often lilown violently (uit of the wonnil liy llie first spasmodic expiration caused iiy eiiterinji: the tra- chea. Such an onteonu' w.i-; drauialic and s;ilisfactory. If. however, llic foreii^ii liody was not free in Ihe liadiea hut wa> impacted or was of a e;iii>ed the death of tiie p.aliiMil. It was a natural and great adxance in tin.' treatment of these cases when, instead of the hlind groping after foreign bodies in the trachea, the I'hysician lieiian to woi-k hy -ii;ht. Coolidge was th(> first to chi this in Ami'rica, in l^l'lf l'>y usinn' a female nrethroscoin' lu' located and re- moved a piece of a tracheotomy tuhe which had become detaehetl and had fallen into tlii' trachea. Killian was the first to demonstrate the feasibility of i-emoving a foreign body from the bronchus by nu'ans of a tube ])assed between the vocal cords. Killian dt'vised and first prjieticeil U)iper 1 UolU'l loscopy , later lie de\elo|ied loWel' hroncllOSCOpV. lOinhorn in I'.Hil' di'\ise(| an e>npliai;(i-cope jiaxiii^' an auxiliary tnbe in the wall of the main tulie. In tlie secoiidarv tulu' ;i light caiTier was iuseited tliniULjh which twci \\ire> lan to a >m;dl electric lamp on the end of tlie can-iei'. 'I'wii year,- later .l;icks(Ui iisi^d tin' mechanism of I'^inhorn on the Killian tubes ami ,-idded a second auxiliary tube for drainage ]iurpn>es. Later the >ame investigator lengthened the hron- chox-iipi' and used it for exploring the stomach, lie demonstrated the fea-iliility of iutroduciug a straight tube into the slomaeh and taught the medical profession throULili liis hrilliaut eases the \alue of the |iro- eedui-e. The Choice of the Upper or the Lower Route. Kxperience has |ini\e(| th.-it hiucr lunueli(i>ciipy i> >arer ami easier than up|ier bi-ou- cllo>ci]py. It is by all odds the safer JUdcedure for the beginner, lu infants and children nn a loose foicigu hod)' wliieii liv its \iolent excursions up and down the trachea has cau-eueh that it is impacted, for ex- ample, a beau or a pin, lower iironchoscopy is surer and safi-i-. If the 204 OPERATIVE SnUiERY OF THE XOSE. THROAT. AXn EAR. ()]ierator is skilleil, upper bronchoscopy may l>c tried with children over three years ohl. Tiistanees of success by tliis niethud are iiuil- tiplying. I'nh^'ss the ]ir(ice(bu'e is soon successi'nl. ho\\e\'ei', it sliouhl l)e abandoned for tiie lowi'r route. It is not so nuich the increased leniith of tubes required for n])])er l)ronchoscopy, Avhieh makes it less advisabh^ in many cases tlian h)\ver bronchosco))y — because the self -lighted tulie carries its light at the end and ineicase of length is not a serious factor — as it is the reaction of the larynx to the manipu- lations and the danger of cardiac arrest. (Crile.) The latter danger can be obviated or minimized Ijy the use of atropin. Killian has col- lected nineteen cases in -which after vTi)]ier bronchoscopy an emergency ti-acheotomy was reipiired. The gist of the matter seems to be that in the performance of upper l)ronchoscopy, a tracheotomy nuiy at any moment be called fcu'. Even after the successful outcome of the pro- cedure the same holds true. With infants and young children lower bronchoscopy is preferable. In a child of any age it is not good prac- tice to ])ersist in upper bronchoscopy unless it is soon successful. Indications. — Tracheobronchosco])y is called for in any case in which the presence of a foreign body is suspected. The dangers of the yjrocedure are so slight that even when tlie presence of the foreign body is not sure an exploratory hronchoseo^jy is indicated. This is especiallj' true in the case of children. The only contraindication to bronchoscopy is the presence of serious organic or systemic disease. Dangers. — The chief danger in bronchoscopy occurs in the iise of the ui)i)er rcnite. This danger, as has just been pointed out, arises from edema of the larynx or from reflex cardiac arrest. Ingals has reported two cases of death, one three, and one six hours after the suc- cessful removal of a fiu'eign body. These unexplained cases may have been due Avholly or in part to the second of the dangers just mentioned. Apart from these two dangers the most common one is septic pneu- monia, from the trauma occurring during the mani]mlations of extrac- tion. Another danger and nue wliich can be easily avoided is (hat of delaying the performance of tracheotomy when the ])atient Itegins to show signs Avhich call for it. The Danger from Leaving the Foreign Body Alone. — The dangers to which the jiatient is exposed hy lea\ing a foreign body in place are vastly greater than the danger to which he is exposed by the perform- ance of bi'onchoscopy at the hands of a man ])racticed in tlie art. The great danger incurred by a patient with a foreign liody in the lungs is pneumonia, or abscess and gangrene of the hmg. In most instances either complication is fatal. There are many cases reported in the literature of foreign bodies which have i-eniained in tlu' lungs a long i..\i;vN(;iisc()i'v. niioNciidsroi'v. Ksni'iiAnoscdrY. I'/ic. -H") liiiu' u host' ini'sriUT \\;is Unowii oi' uiikimw ii, .iinl w liicli liaxc liocii filially i-ouiihod out. But, .judiiiiiy even rimii the iiicniiipli'ti' litoraturf ot" till' rases of tlic ()|i|)nsitc natuii'. it i> I'miiitl tliat siirh furliinati^ toriuinatioUS are rare. Sllnuld the piiticllt rx-apr >c|i|ie |>lli'iillhilii;i ami llic I'lU'eiuii lindy ii'iiiaiii in llic luims, lie is r\|Mi>cil t(i tiilierciilar iiil'iTlidii iali'i'. Killian is aiillhnily I'm the stalniiriii liiat such eases not iiit"re(jiieiitly leniiiiiate in this iiiaiiiier. It should lie said in fair- ness, however, that soiiu'tiiiies the liiiiiis will tolerate a foreij^jn hody for a loiiij- tiiiic. 'i'lh' aiitiior lias in mind a ease in which Coolidtje re- moved a wile nail w hieh had lii'eii in the rii;ht him; of the son of a phy- sician i'or seven years. The synii»toms were only an occasional coiifjli. Another case oceurs to the writer. This patient was a nurse. For five years now and without any clixnmfoit she has hail a metal clasp pin in her Inny. The attempt to remove this jiin was made on two or more occasions, once hy Killian ami once liy Jackson. Till' decree of danL;rr wiiieh aerompanies the remov'al of a foreign liody nalui'ally \aiii'> with i1> iiaturr. shape and si/.e, its location and the e litidii (if thr patii'nt. luMindcil ohji'cts aiv liahle til lit a h)-cm elms ti,i;litl\' and to shut nlV aii- to the portion of juim- supplied liy it. Therefore they are mo>l lialilc to cause uaiiuii'iie and ahscess. A pointed object like a pin nr ,i n.iil allows air to jiass hut it jirodnces tranma by its excursions in the respiratory blast or prodnces erosion by lyiiiii' lon.<>' in one jiositioii. Hither condition leads to infection. Iiioiijanic substances macerate and decay. When this happens they may be coiiuhed out unless they have produced a fatal pneumonia before this take place. Seeds if uncooked do not macerate but swell on alisnibini;- moisture and liecome firmly fixed in position. Peanut.s, in this c(nintry at least. ha\'e pro\-ed to be vei-y fatal foreiun bodies to lodyc in tile luniis. The attempt at reino\al ortcii crushes thcni -.wm] scatters the fragments deep in the tertiary bidiichi. Koe collected 1,417 cases of foreiun liody in the air passa.u'cs. Tn 470 extraction was not attempted, and over 4()tJ died, that is, the nior tality was 27 jier cent. This is to be comiiared with !I4 cases of ujiper and lower hniiichnscoijy repoiteil liy .lack>oii in which the mortality was 3.2 per cent. If a foreif;ii body is to lie eouL;hed out this licuerally occurs in the first twenty-four iiours. .laidvson sums up the matter fairly wlien he says "we do full justice to our patients wIumi we tell them that w hile a foreign body may be coughed up, the chances of this are remote and it is very dangerous to wait: and further, the dilliculty of removal increases with each hour that the body is allowed to re- main." Results. < lui (if ii4 eases of In'onchoscopy the foreign body was removeij in s.") per et'iit. iJacksuii.) 20G OPEKATIVE SntCERY OF TTTE XOSE, TTHiOAT, AND EAR. Symptoms. — Cough is the most constant symptom of a foi-oion body ill tin' air i)assages. As the foreign body passes the larynx tiie cougli is paroxysmal. Later at every attempt of the air passages to expel the intruder tlie cough is again paroxysmal. Some minutes or hours may elapse between the seizures. After a time the cnugii be- comes more constant. Dyspnea is a very frequent sym])tom. It is usually iiis])iratni-y but it may occur on expiration. The dysiniea is worse during the fits of coughing and at such times the jiatient may become unconscious. It should be borne in mind that a foreign body in the esophagus may, by pushing forward the soft trachea of a child, produce dyspnea. The temperature is usually elevated. This might be taken as evi- dence in the doubtful cases against the presence of a foreign liody. In late cases in which i>iieuiiioiiia has set in naturally the teinpcrature is elevated. Chills occur when an aliscess has been produced about the foreign body. Hemoptysis is not present as a rule. It is associated with the aspi- ration of sharp substances. Pain is often ijresent but it is generally jioorly localized. Diagnosis — The fiuoroscope is not reliable in locating a foreign body unless it is very dense. An X-ray plate should be taken in all cases and interpreted by an expert. The physician who is not accustomed to reading jilates taken of the lungs is very liable to mistake spots of cal- cification along the main branches of the bronchi for foreign bodies. Unless there is marked dyspnea it sliould be the routine to obtain a radiograph. Metallic substances Avitli the exception of aluminum show well in the plate. So do pebbles and objects of glass. Bones unless they come in front of another bone like a vertelira also show well. Fish bones come out poorly in the ]ilate. Vegetable substances with the exception of some kinds of wood, do not cast much of a shadow. The same is true of peanuts and chestnuts Avitliout their shells. It is difficult to obtain a satisfactory X-ray of a young child unless it is etherized. Only in the case of a metallic foreign body when the plate shows nothing is it safe to permit the patient to go without an examination. Intermittent cough and dyspnea not to be explained in any other way and not associ- ated Avith fever is almost diagnostic of the presence of a foreign body. The Physical Signs. — The physical signs are of value in determin- ing the presence of a foreign body in the air passages if they are elicited and interpreted by a physician who ]iossesses a good and sufficient techiiic ill aiisciiltatioii and jicrcussioii. The ])hysical signs arc relied LARYNGOSCOI^Y. r.KOXCIlnscoPV, KSorilACOSCOPY, KTf. 120" \i])()ii iiKisl ill tliiisi' i-asi's ill wliicli ii pusitivc X liiy (•.•iiiiiot lie m'imiiimI. The followiiiu' paraiirnplis wliicli licar iipoii the piiysical si.uiis ami liii'ir moaiiiiiii' arc alislradod rroiii .Tat-kson for wIkhh llicy were writicii liy Boyoo. Tn tlio oxaniiiiatidii a ilisliiiction iiiiist It iiiadc lii'twi-rii tin' siifiis due 111 llie rnreiiiii Imdv and tlmse wliicli lire due 111 inll;iniiiia1iiry ciiii- ditions wliieli soon su])orveiie. A foreisi"!! body which is ohst nietiini a linun-liiis iiia> lead lo aielec- tasis of the luiiu,-. If so, the usual si,<,'iis are present. 'J'liis occurrenco, howovor, is not as froqiUMit as is yeiierally supposed. The most coin- mon findin.y is a marked Im-al diininuliiin nf the re.-piralnrv iininnnr with ]ires(>rvation or accent iiat inn of the nnrnial resoiianee. This may he called the typical ei nidi linn. W lien a I'nrei^n hiid,v jiartially nlistructs a hr(Uichus it may ^ixe rise to a i)eculiar dry r;ile, winch is easily dilVer- cntiatcd from that ;;iveii hy iiillaiiuiiator\ m tiilieiciilar thickeuiiius of the mucous meiuhrancc. These dry rales are limited tn ,i deliiiite ;irea and occur for hours at a time. Bronchitis is the commonest iiill;imm;iiiii-y cnnditlnii I'nllowinij tho inhalation of a foreiun hod\. The secietinii.- I'mm thi> arc soon - are imt ;is-nei;ited with a l'nreiL;ll hndy. Ill one case plural elVusimi resulted linm the presence of a foreign body and tli(> ])atieiit was twice tapped. ( Inuals.) Tulierculosis "without bacilli in the sputum, "' |iarticularly if the im:' in a )irim;ii\ hrnnchii-. i f'iu. l."i 1. i I 'in- and nails. hnwe\er. iint infrei|nentl>- fall into the smaller biniichi. hi ihe e\|)erience of the autlmr pins and nail.- frei|iiently Ind-e in the inner iirauch of the bron- 208 (ii^ki;a'I'i\k sriicKKV of tiik xo,'^ TIlIldAT, AMI KAi;. e\\u^ t(i the iiil'cridi- Icilu' (if the ri.uhl luiin'. SatVty ]iiiis. if tlicy nw uprii, of tlic foiccps can uiasp ii. The hook is passed flat until beyond the object and then liii-iieen iiii;- of a lu-oiiclius. In llic casi' of hollow foieimi bmlies expaiidin.n' forceps are of service. If the foicimi body i> jod-cd in a small cavity of the liim;- it may be uecossai> to dilate the opeiiiu- into the cavity before the for eiii-ii l)0(ly will come into view and peiiiiit extraclioii. Jackson has ilevised a dilator for lliis piii|io-.e. I'sually secretion is seen coming;' in which the foi'ci.Hii liody is lodiicil. Inllammaiory ■^w clliiiL;- nia\ indicate that the bronciius is imaded. A probe may be reipiiiccl to lociite the forei.nii body. A >nction apparatus is useful foi- reinoviiiL;- Iramueiits of seeds. The After-Eflfects of the Removal of Foreign Bodies. — Unless edema of the larynx follows the manipulations reipiired for the removal of a forei.i;-n l)ody, the after-effects of l)ronchosco])y are slij^lit. There may be some hoarseness for few days or a sliiiht locali/.eil l)idiicliitis. This is trivial and soon ilisaiijiears. 210 OPEKATIVK STT>(!Kr>V OF THE XOSE, TTIKOAT, AXD EAR. ESOPHAGOSCOPY. History. — Soon after tlu; iuveution of tlie laryngoscope attempts were made to see the opening of tlie esophagus by pulling the cricoid cartihige forward with apj^ropriate specula and then obtaining a view l)y means of a mirror held above in the ])harynx. These expei'iments led to no ])raetical results. In 1868 Bevan liy means of a tliiu s]ieculum, and two years later Waldenbnrg l»y means of a tuliular s])i'culnm 14 cm. long succeeded in seeing tlic mouth of tlio esojjliagus. The latter also made an ocular diagnosis of a diverticulum. Stork was the first man to pass a solid tube into the eso})hagus and to carry out direct esophagoscopy. Kussmaul (1868) explored the esophagus with a rigid tube and published his observations on the nor- mal and the diseased esojthagus, while his pupil Miiller established the important clinical fact tliat the normal esophagus should admit a tube 13 mm. in diameter. The observ^ations of Kussmaul, however, made little headway; later they were revived and i)oi)ularized by Killian. Stork and Kussmaul, then, were the two men who gave esophagos- copy its start. V. ]\Iikulicz, a follower of Stiirk, was the next worker Avliose results jjroved to be fundamental. By the year 1881 he had car- ried out most important anatomic and physiologic researches and had noted common pathologic changes. For the next ten years no s]iecial advances in esophagoscopy were made. Since that time this method of investigation has been pursued with vigor. The advances have l)een along the line of improved technic and new instruments. Anatomy. — The esophagus is a muscular tube which is the con- tinuation of the pharynx. It starts from the back of the cricoid car- tilage opposite the sixth cervical vertebra. At the mouth of the esopha- gus the lower border of the inferior constrictor muscle projects like a mound into its lumen and acts as a sphincter in a way similar to the action of the superior constrictor (Passavant's fold) in the upper part of the i^haiynx. Structure. — The esophagus has an outer muscular coat of two layers and an inner glandular coat covered with pavement epithelium. A connective tissue layer joins the two chief layers. The thickness of the esophagus is 3 to 4 mm. The outer layer of the muscular part con- sists of longitudinal fibers and the inner layer of circular ones. (Fig. 156.) The anterior longitudinal fibers are attached to the back of the cricoid cartilage. The inner layer of circular muscular fibers is a con- tinuation downward of the fibers of the inferior constrictor muscle. The upper end of the esoijhagus therefore is the lower end of the pharynx, so that voluntary musciilar fibers ])red()minate. From this I.Ai;VX(insl(irV. llKONCIIoSCdl'V. KSllIMIACIISCdPV. KTC. 211 ^^s?c**fc- it lia|i|K'iis that a l'(irci>;ii body anotfil at llic ciiti-aiicc of llic csoiiliii- ,U'Us is oftoii tlirowii hack into tlic pliaiyiis and into tin' inonti:. Lymphatics. — Tiic lyniiiinitii- nl' ihr fsopiiaf^nis cnlcr liotli llio nicdiaslinal and tiic ciTvical i;land> xi llial in susp(>ct('d caiHTr ol' liio oso|ilia,ii-us llu' glands at tiu' root of llir lun-k -lionid lie I'xamincd. Position, 'i'lif ('sojiiian-ns lia> tlir \ crti'lnal colnnm lirhind i) and llir irarlira in iVoiil, and lii's in tin' |io>ti'i-ior nii'iliasl Innni. .\t the fourth tiiorai'ic vortei)rii tiie arcli of the aorta makes a transverse oon- stric'tion in it and a vert('l)ra h)\ver down, the kd't main hronclins. at tiie fit'tli tiioracic, makes an (il)li(|Uo lim' across its front surface. l5cio\v this point the iicart lies on it lilve a wi'iii'iit. In llic liiwiT jiart. the rinlit and left ]incuninL;ast ric iicrxcs lie on tlu' sides of tiic csoiiha-ns. and hack of liic arch of tlic aoi-ta the thoi'acic duct crosses from ri-lit to left Ih^ hind it. on the fi-onl of ihc xcilchral cohinin. I j-'ii;-. l.'i". ) Direction. — The .■>opliai:iis is ph-iccd for tlu^ nio>t jiarl a litlic to the h'ft of tlie niiddh' line. .Midway in its coni'se. at the fourth thoracic vertebra, it swings to the central Fig. 15G. line. l)ack of tlie arch of the aorta. scctimi of the iium.in osophaRiis (Mod- hut at once f?OeS to the left a"-ain '^^■•ately magaifiecl). The sect;,... is trans- '^ verse, ana iro.n near the middle of the and entel'S the stomach lo the bd't gullet. (Quain'.s Anato.nv — Fro... a draw- an.l in fmnt of the ao,la. a1 the i"K by V. Horsley.) , n, i.l)rous eovenng; h, d.v.ded nlieis ol cle\-entli thoracic \er1elira. This the longitudinal muscular coat; e, trans- 1 , . ■ , ■ ,■ ,1 , , , verse muscular filters ; d, submucous or '■''^ '■■'""" ''""I ""■ '•'•liter do.'S not ,,„,olar layer; c. .nu.scularis mucosa;; /, interfere witil the passim;- of hou- '""cous memh.a.ie, with vessels and part of a lymphoid nodule: fl, la.nii.ated epi- fJH'S or tube> except at the lower Ihelial lining; h. mucous gland: i. gland . , . I .1 , • duct; m, stri.-ited muscular fibers cut part where tlie esopliaf,nis ])ierces ;n.r„ss. the diaplira laryngea ph.io'nfii'i Thyroid body Glandula lliyrcoidi Superior mediastinum Descending Aorla clcsceddcn Broncho- £sophageu3 muscle Pleuro- esophageus muscle Phrenocostal i diaphragm at ico • costal) supplemcQtal pleural Sinu5 phrrnictJco>ialis pk-iir Descending thoracic aorta Fig-. l.-,7. Showing the leljitioiis of tlie esophagus from Ir-IuikI. (From Tohlt.) Tlie Inmen of the esophag'us at tliis point is sul)ject to Avide variations which depend ni)on tlie relaxation or the contraction of the diaphragm. In addition to these two important constrictions there are two others. ()fl(Mi tliev are not seen unless closely watclied for, and they disa])]>ear I.AIIVNiUPX ii|'\ , 1. • t\. i.^wi ilACOSCorV, HTC. ui;: coiiiiilctrly il' Inriic tiilics ;uc u>^i't\. 'I'lic lirst >>[' tlioc iiiiiinr cniislrii-- lions convsiHinds to the :irch of llir anit.-i. mikI is rniiinl ;il tln' level loic ; 14, coronary artery; ];), splenic artery; l(i, Ifi', su|h'- rior mesenteric artery and vein; 17, inferior mesenteric artery; I.S, spermatic arteries; ]!), gall bladder; L'O, cystic iluct; 21, hepatic iluct : 22, inferior vena cava; 2:5, |)ortnl vein; 24, syinjiathetic cord. of the I'ninth lh(ir;icie \eitelir;i. 'I'lie hi>I third iVtiiii ;iii(i\'e c hiw iiw ;in L i,-- iii;i(le li\' lin iii>t riet imi. w hieii is tlic •i(i^>iiii; of 1 he lel't iiroll- 214 OPERATIVE srUCiERY OF THE XOSE, THROAT, AND EAR. chus in front of tlic esoplia^us. It oecni's at tln' level of tlic fit'tlt thoi'aeic vertebra. The Length of the Esophagus. — In men the distance from the in- cisor teeth to the bei^inninj;' of the esoi)liai;us is 15 cm. and in women 14 cm. The distance from the incisor teeth to the liifnrcation of the aorta is 26 cm. in men, and 24 cm. in women. In men the length of the esopliagns from the incisor teeth varies between 36 cm. and 59 cm., the nonnal average distance being- 40 cm. In women the figures are a little smaller, 32 to 41, the average being 38 cm. When flexible bougies are nsed for measuring 1 to 3 cm. should bo added to these measurements. Distensibility. — All the constiictions of the eso))hagus are dis- tensible. The ujiper constriction is less dilatable than the others, so that this is the one which gives the greatest tronlile in e80])hagoscopy. The normal esophageal Avail, according to Jackson, will stretch 2 cm. without rupture. At times foreign bodies stretch it more than this. Fig. 139. Under sinfjii'O of the liaphi-agm. E, Hiatus csopliagiis. Kote the direc- tiou of its axis. (After Jackson.) In infants a tube of 7 mm. should pass readily and in the adult a tube Avhich has a diameter of 14 mm. In infants a flexible bougie 8 mm. should pass and in adults one that measures 14 mm. With light stretching the transverse diameter of the esopihagus is 23 mm. at the cricoid cartilage and 17 nmi. anteroposteriorly. The diameter of the esophagus as it goes through the diaphragm is 24 to 25 mm. Two stomach tubes can be passed side by side. Briinings states that the esophagus at its mouth can be dilated to 30 mm. Avithont danger. At the lower end of the esophagus V. Mikulicz in his operation for cardiospasm stretched the lumen to 7 cm. so that the hiatus had a cir- cumference of 16 cm. L.\RYXnOS((il'\, lil;eginiiin,a,- at the level of the lii furcation of the trachea the esn|ihagus eolllrs to tile froUt ailil pUSSeS o\'er tllO desceiidiiiL;- aorta and iMiters the alnlo- iiieii throiii^h the hiatus or the opeiiini;- in tiie diaplirau,iii. This suliphrenic jiart of the esoiihauus vai'ies niiieli in shape according as the stomach is empty or distended. Tii ])ersons of spare liuild it has a lateral range of movement amount- ing to 10 or 1.") cm. (Fig. UiO. ) The Movements of the Esophagxis. — The esoidiagus is never twice alike even in the same individual. At the level of the fourth thoracic vertebra (24 cm. from the teeth) the throlihing of the ar:-li of the aoi'ta can lie seen if watched i \f^. 160. for and a little lower at the |e\r| of the ,s,.|K.nia sliowiiij; the ranse of seventh and ei-llth thoracic \ertehra (."!() """"'" °^ ^''° ga.stroa.-opo nt the mouth of the esophagus ami at the cm. Irom the incisor- teeth). The back- hiatus of the diaphragm. (After ward mounding of the heart an'us, due to the iircsciicc of two layers of imiseular tihrcs as described liy llyrth Acrordiiiii,- to .Jackson, the i)reseiK'e of this sphincter is not the chief agency tlirougii which the regurgitation of food is prevented. This oliserver maintains that the kinking of the esophagus below the (i|ieniiig of tlie diaphra.gm and the increase of this twist by distension of the stomach has much more to do with keeping the food in the stomach than the presence of the cardiac sphinct(>r. From a few anatomic findings which hav(! come to the notice of the aiitlmr he is inclined to think that dackson's posi- tion will lie sustained. Measurements of the Esophagus. — The following tables are com- piled from Stark. They are of use for reference. Diameters of the EsopirAcrs at the Foi'r Con.strictioxs. Constriction. Diameter. Vertebra. Cricoid Transverse 2:1 mm. (1 in.) Left liionclms Fiftli tlioracic. T)iii|iliv;i"ni Trniisverse 2.'i mm. (1 in. -(-) Aiiteroposlevior 23 mm. (1 in. — ) Tcntli tlun-Hcie. Length of thj.; Esophagu.s at Differext Ages. Length of Whole T >ctli to Cricoid. To Bit urcation. To Cardia Lsophagns Birth, 7 cm. (2% in.) 12 em. (4% in.) 18 em. ( (i% in.) 10 cm. ( 4 in.) 1 year, in cm. (4 in.) 14 cm. (•51/2 in.) 22 em. ( 8% in.) 12 cm. ( 4% in.) 2 veara, 10 cm. (4 in.) ^r> cm. (G in.) 2.3 em. ( 9 m.; 13 cm. ( uVs in.) .") years, 10 cm. (i in.) 17 cm. (0% ill.) 26 cm. (lOVi in.) Ki cm. ( 6% in.) 10 years. 10 cm. (4 in.) IS cm. (7 in.) 28 cm. (11 in.) IS cm. ( 7 in.) l.T years, 14 cm. (.'■>% in.) 2o em. (9 in.) 33 cm. (13 in. J m cm. ( 7V0 m.) A.lult, l.~) cm. M) in.) 2(> cm. ( 1014 in.) 40 em. (l.-i^i in.) 25 cm. (10 in.,1 For memorizing the length of the esophagus at different ages the following approximate figures are given: Birth, 7 inches; 5 years, 10 inches; 15 years, 13 inches; 25 years or adult, 16 inches. Add three inches for every five years. (Stark.) Diameter of Tubes for Differe.vt Ages. To 8 years From 9 to 1.5 years From 17 years 12 ti Adnlts 9 mm. 11 mm. 14 mm. 14 mm. (average.) LAr>VN(;(>si'opv. nitoxciiosi'oi'Y, Ksni'iiAdoscopv, kic. 1!17 Tlio (>S()iili;i,u:us Iti'.niiis () iiirlii's fniiu llic iiic-is(ir tcrtli, liacU of llic cricdiil rnrtilaiii' at tlio sixtli cervical vorti'hra. It is 10 iiiclics lonir, and uoos tlirou<;li tlio diaplirai!:!!! at tlu' tenth thoracic xrrf.'hr.i. K! inches iVdin the teetii. It is crossed l)y thi' arch of the aoi-ta hack nl llir iniiMJe i<\' till' lir-t jiiecc of tiie stcnuim, 10 inches rnim i he led h. 'I'lie nieasnre- iniiit> Id lie renieniliered in connection with it aic ihin. (1 ami 10. Contraindications to Esophagoscopy. 'i'he only contraindications to the |ierl'orinani'e ol' csoiihauoscoiiy aic aeutc inllainnialion as at'tiT the swallowinn' ot" coirosixc llnids, and aneurism of the aorta. Tiie clnet' danuer in tlie passage of tiic esoiiiia.iioscope is mi'tnre of the esojjhaijus. This almost always results in infection of tin' iiosterior niedi- astiuuni and death. Such an accidi'Ut should lie easily avoided l)y the selection of a tnhe of the iirojier size and hy adherinf; always to the fun- damental axiom of ail esojihaiieal examinations, namely, the exaniin- inj;- tuhe must lu-ver !)e advanced uidess the eye of the physician sees the ojHMi eso]ihai;iis ahead throuijh tlir tuhe. it i> \V( II. also, to remeui her that in old iiedplr the esophaii'eai wall may lie thin eiiouuh to rup ture of itself so that in the elderly smaller tnhcs and iireater care in usinii' them are neces>ary. It has dcvelopt'd of lati' years that there is consideralile shock from me.nipulalinns carrietl out in the esophaiiiis. Indeed, working- in the esoiihayus causes more shock than working:: in the trachea and Inonehi. Relatively children ihi not liear esophau:eal examinations as well as adults. When a patient is ])0()rly nourished, and especially if he is on the point of starvation from the presence of a stricture, it is better i)iactice to o])en the stomach and feed the jiationt through a gastric fistula until his resistance has been restored hefcu-e attempting any prolonged esophageal examination. Anesthesia. — The eso))hagus may l)e examined lunler local or gen- eral anesthesia. In Eurojiean clinics local anestliesia is employed for adults almost exclusively, ('hildnu ai'c examined under ether or ehlorcilni m. In this country many examinations are carried out under general anesthesia. The aiitlmr is \('r>' much picjudiced in fa\'or of a general anesthetic. H' the manipulations under coeain anesthesia are successfnl the operator gains his point, Iml if the examination is nega- tive no conclusions can he drawn from it and the case remains in doulit. On the other hand, if the examination has been conducted under ether and the icsult is negative liotli the jiatient and the ])hysician feel con- tidence in the tiinling. I'nder ether larger tulies can l)e used which means a better view iind a larger liehl for the maniiiulations. In addi- tion under such conditions the treatment callecl for by the case, for example the dilatation of a strictni-e, can be made imue efticieut. Instruments. — In exiphagoscopy all Inidgo must be crossed iu'fore 218 OPERATIVK SllKIEIIY OF THE NOSE, THROAT, AXI) EAU. the operator gets to tliem. In otlier words tlic pliysiciau iimst be willing to supply himself at the beginning of his work in this line witli a full set of general and special instruments. As everything depends upon light it is good economy to have two sets of tubes, one set being the self -lighted tubes of Einhorn- Jackson, and the other the extension tube of Briinings which is lighted by having the light projected through it from the electroscope. (Fig. 161.) Fig. 161. Jackson's esopliagosciipe. Tlie drnina^e tulic runs the whole length of the instrument. The list recommended is as follows: 1. One 7 mm. Jackson tube. 2. One 14 mm. Jackson tube. 3. One adult tubular speculum (Jackson). 4. One tubular siieeulum, children's size (Jackson) ; or one adjustable sjieculum (Mosher). 5. One Briinings ' or Kahlor 's electroscope. 6. One Briinings' extension esoi^hagoscope, about 7 mm. 7. One Briinings' extension esophagoscope, 14 mm. 8. Nine Coolidge's cotton carriers. Tliree 25, three 35, and three 50 cm. long. 9. One grasping forceps with three shafts — 25, 35, and 50 cm. long respectively (Coolidge or .Tackson) ; or one extension forceps (Briinings) with three tips — claw toothed tip, tip for grasping seeds, and a punch tip. 10. One esophageal dilator (Briinings, Mosher). 11. One metal probe carrying three graduated olives (Bunt pattern). 12. One set elastic esophageal bougies from the smallest size to No. 40 (French). The series should be complete up to No. 20. 13. One Casselberry 's pin cutter. 14. One Jackson's safety pin forceps; or one Mosher 's safety pin closing tul.ie. 15. One tooth plate cutter (Kahler or Mosher). 16. One metal staff having a perforated olive at the tip. A set of graduated olives and a flexible introducer (Mixter and Mosher). 17. One suction ajiparatus. Either a hand bulb, Jackson's secretion aspirator, or a suction apparatus run by electricity. When needed this last apparatus is a great luxury. The author does most of his esophageal work under ether and pre- fers to use as large a tube as the esophagus under examination Avill take. Accordingly he uses a large oval tube of two lengths. (Fig. 162.) i.AitYXcoscorv. luidXciKiscoi'v. i:s()niA(i()S((irv. i;ic. !l!) The tulie has a iiiaiidariii wliicli iirojcrls iVdiii llic I'lid an iiicli and a half. Thi' pointed end of tht- phniircr ivadily finds tlio opcninif of the oso]»hai;ns and pushes tlic ciicoid (•artih-ii:;e forwanl and alhiws the tube to sli|) by. The IuIm' h.is no seconchiry tnlie on the ontside eitlior for the liii:lit m- fm- -inliun. The tulie is liinefore snntoth. 'I'iic in- troduction of tile hwiiv lulies with secondary tnhes on tlie side is dangerous because the tul)es tend to cut. The autiior had one fa- tality due to this canse. Instead of the snction tube a short tube comes (iff froiii the main tulir near ils upper end. This is fur the intro- duction of air. The tube is titled with a iiMtal plui;- which has a ghiss end. When this wiiulow ])lu,ii: i>< in piaie the esnidiairoscope becomes essentially airti.iiht and the esopliaj;:ns may hf liallonned at will by closing- the tube with the window plug and then foreiny air through the Fig. 162. Moslior"s sliort longtii oval csopliaRoscopc. This tulio is 11 im-lios (::s ini. ) liiiiK. i>"il •>! '"'''> O'* ">">■) i" transverse diameter. Tlie cut slions the mcchaiiical device which loclis the lieaJ of the lifjht carrier into a nolch in the side of tlie tube. This arrangement holils the carrier firmly in place and allows the insertion of the air-ti)jlit window plug in the mouth of the tube. The lower end of the light earner passes through a small ring inside the oval tube and near the lower end. (See Fig. 163.) secondary tube. A stout foot bellows is used for tliis inirpose. The light carrier runs inside of the main tui>e. and as it is not incased in a small tube of its own it riuis freely id all times. (Figs. 1()2-1()7.) '^riie secondai'y tube fm- the light carrier is bitten and (h'lited i-on- finnally so that llic li.Ltht enters it ] rl\-. The li-lil of tlir o\al tube is incased in a lincnj. This protects it duriuy in^ertiun and while tin' tube is in use. Tlie liulit once adjusted in its Imud burns much Imiger than when it is exposed to the danL;< is of |iassiiii:' tlirongh the sec- ondary tube. p]ach tube is lilted with a see(uid oi' extra carrier so that the operator seldom has tin' aiiiioy.inec' of having to fit a new lamp diii-ing an examination. The General Examination of the Patient. A general i)hysical e.xaminaliuii of the patient should be maile Ik fore eso])hagoscopy is attempted. Aneurism should be excluded ami the condition of the heart ascertained. The i)atieiit'> ability to --wallow, the )daee where 220 OPERATIVE SnUlERY OF THE NO.SE. THROAT, AXD EAR. -A,- \ --\ \n \ °\ \ °-\ \ -x \ "\ \ -x \ ^\ ^:^ > -A \ - \\^^2 ~5> Fig. 163 Fig. 165. Fig 166. Fig. 16.'!. — Moslinr 's csopliagosoope (sliort lengtli). Tliis tulie is made in two Iriigtlis — 11 iiiclies (28 cm.) and 17 inclics (-13 cm.) Tlie lower tigiire shows tlie metliod of lioiding tlie lower end of t'.ie liglit carrier in place by J>assing it through a small ring on the inside of the niain tube. Fig. 104. — Hood or cap which protects the lamp. This arrangement of the light carrier the author has found more satisfactory than the acces.soiy channel on the outside of the tulje. The outside channel makes a rib which on larger tubes tends to cut the soft tissue. The outside channel is con- stantly becoming dented so that the light carrier runs poorly and the con- tact of the lamp is disturbed. When the light carrier runs inside the tube and is protected by the hood there is much less trouble in keeping the light in good condition. Fig. 16.5. — Long conical plunger for Jlosher's oval esophagoscope. This jdunger extends beyond the end of the tube ]i{) in. This plunger readily enters the esophagus and pries the cricoid cartilage forward and allows the tube to follow after easily. Fig. 166. — Window plug for making tlie esojihagoscope air tigi-i and ballooning the esophagus. Fig. 167. — Diffei'ent sizes of Moslier "s oval esophagoscopes. I.AlIVXCdSl'OI'V, KllOXCIIOSCOrV. KSOl'llAC.DSrol'Y, KTC. --I lie loc-ati's liis tnnililc. ami all tlu' tli'tails aliout ici;iir,i,ntati<)ii nr vmiiit iiii;: aio iiupdrtaiit to olitaiu. The coiulitioii i>t" tlic tt-ctli is olisi-rvcd and the pri'siMicc of crowns or lnidn'cs iiolcd and rcnicinhiTiMl. The examination ot' tlie month and pliaiynx sliotdd know the existence of nleeratioiis or sears and the iaryn,noseo|)e will iiive the condition of the larynx. If disease is present in the larynx it is often a ]iiirt of a similar process in the esophaji^us or a clew to it. An X-ray ])late is indispensal)le before many examinations. Tiie plate shows the lo- cation of metallic forei.nn IkhIus and pieces of lionc and Imltons; it >liows enlarnement of the arch of the aorta and i'nlar.i;enient of tiir mediastinal glands, and combined with the ingestion of bismnth it shows the position of strictnres, the size and location of diverticnla, and the size of the dilated esophagns. The old practice of passing a bongie into the esophagns shonlil l)o given up in most cases. If a foreign body is present the bougie may push it down or impact it or pass by and fail to locate it. If a carci- noma is present it will start Idooding and make the esoi)hageal exam- ination more dil'licull. Many palii'uts haxc been killed by forcing a bougie through the carcinomatous esophageal wall. If the i)hysician is dealing with a case of cicatricial stenosis of the eso|ihagns or a iionch, the bougie is safe and may iiive \alual)le data. The infoi'ination. how- ever, is much bettei- gained liy the esophageal examination with the tube. In speaking of the risks of esopliai^dsedpy it was staled that the greatest danger was the liability of peil'oraling the esophagus. This can liapp(Mi before the exaiiiiiiatinn, as well as dnrini;' it. Tf, therefore, a case pre>ents itself for exaiiiinat ion and the patient lias great jiain on swallowing ahmg the line of the sterniini. if the respirations are in- ci'eased. if fewr is pi-esi^ut. and there i- eiiipiiyseiiia of the skin, the physician should suspect that the esojihagns has ali'eady lieiMi pi^fo- rated and tliat an abscess is deN'eloping in the i Iia>tinnni. In ,-ui-h a case (Irainaiic of the nhscess is indicati'd. not esopliauoscopv. The patient >li(iul n\. P)runiugs has a long, thin longiu> dei)ressor with which he tests the sensiti\-enes< of the patient. The first introduction of the cotton swab in the preliminary application of eocain does ju-t as well auil s settles the (|Uestion as to whetlier or not the subject is an intolerahle gagger. The experienced examinei- always looks with anxii'ty at the patient 's neck and teeth. If the upper jaw does not )irojeet and if the teeth ai'e short, nr better Mill, if there ll'l OPERATIVE SURGERY OF THE NOSE, THROAT, AND EAR. are no upper teeth, if the ueek is long and thin and the lower jaw well rounded at the angle and freely movable the cliances for a favorable examination are good. When opposite conditions are present the ex- amination is often diffioult, sometimes impossible. Technic of Esophagoscopy Under Cocain Anesthesia. — By means of an appropriate applicator, that of Sajous is very convenient, a ten per cent solution of cocain is applied to the base of the tongue and to the posterior pharyngeal wall. After an interval of a few minutes, under guidance of the laryngeal mirror, cocain is placed on the tip of the epiglottis and alloAved to run into the larynx. After another interval of some minutes the swab is carried down on the posterior pharnigeal wall to the opening of the esophagus and applied at this point and to the region of the arytenoid cartilages. It is well to repeat this deep cocainization at least once. It takes from fifteen to twenty minutes to olttaiu a satisfactory cocainization. Position of the Patient. — The patient can be examined either in the sitting position or on his back Avith the head over the end of the table and held by an assistant. The sitting position is best adapted to short examinations. It is easier for the patient especially if he is old or stout. "Where it is essential to have the esophagus clean as in cases of spasm of the cardia with dilitation, stricture, or the presence of a foreign body, as well as with children or weak or sick ]iatients, the prone position is preferable. If the sitting position is adopted the patient sits on a low stool 25-30 cm. in height and an assistant stands behind him and holds the head. If tile patient is examined on a table he may be placed on his back or on his side. (_)f the two lateral positions the left is the easier because the physician works with tlie right hand. If the teeth are missing on the right side of the upper jaw the right lateral position is preferable. If the incisor teeth have been lost the i)idnc ])()siti(m is chosen. This position is selected also if the o])erator wishes to pass the esophagoscope into the stomach because in this position it is easier to bring the shaft of the esophagoscope to the right and to make the l^oint enter the hiatus of the diaphragm and to traverse the subphrenic piortion. In either the lateral or the dorsal positions the knees are drawn up slightly because the muscular relaxation caused by this makes the passage of the tube easier. The Introduction of the Esophagoscope by Sight. — The ideal way of introducing tlic ('soplKii;()sco]>c is (d insci't it under the guidance of the eye. The patient, anesthetized with cocain, is placed on a low stool, and an assistant stands behind him and holds his head. Care should be taken that the head is not placed too far back as exces- i..\i;yn(;i)si'(H'v. niioxiiKiscdi'v, l•;s(ll•llA(■.osl•(ll•^■, kit. -S.) sive bai'kwanl lu'iidiiii;- iiitcrt'ncs with tlir iiiscrtinii of tlio iiistnimciit. The room is darki'iiod and the upper pail nl' tin- extension I'soplia.^o- scope, if tlio r)riininijs tul)o is eiiosen. i> waiineil and smeared willi vaseline ami attacliod to tlio olectroseope. The operator holds tin- upper lip of the ])atient nul nf tlie \\;i\ with the thnml) and fore tinker of the left hand. Tlie liisl pint oT llic extension esophaiioscope is really an elongated tnluilar speenlum eiidiui: in a imiuted lip. It is. tiiere- forc, introduced like liie autiiseope. Thai is. il is introdueed into the month and .-leadied liy the tip n{' tlie thuinli i\\' tlie operator's left hand, is carried itack oxei- tlie h.i-i' of the tongue until the sunnnit of the epiglottis is seen ihrou-h the tiihe. At this jioiut the handle of the g"astroseoi)e is raised and the hiwci- end of tiie tube is pa.'^sed over the epiglottis. The shaft of the tulie is elevated nntil it lies snngly against the physician's forefinger which is guarding the incisor teetli or the gnms if these teetli are missiui;-. If the eiiiglottis is missed the point of the tnlie is alinn-t certain to liriiiu' nji against the ]Histei-ior pharyngeal wall much to the discomfort of the jiaticnt. After the tip of the epiglottis is recognized and passed, the end of the tuiie is car ried down until the avyt<>uoid cartilages are seen. These arc readily made out if the patient is a>kcil io plioiiate. The point of tln^ tuhe is now swung a little liackwanl to ch'ar tln' arytenoids and the tnhe is advanced a few ceiitiiucters to the opening of the csopliagus. Tiiis aji- pears as a transverse slit. The end of the tuhe is now hiought forward a bit in order to o])en the esojihagns. If this does not happen tlu' ])atient is almost sui-i' to swallow and wlicn he doo -o, the tn1)e slijis into the esophagus. Sonielimes the patient must he asked to swallow before the tube will di-op in. In diflicult introductions the jioint of the tube may l)e iilace(l di'ep in the left pyi'il'orni sinus and then swum;' round to the niediau line. As it docs thi> it pries the cricoid cartila-c forward. Once past the ci'icoid cai-tilai:v the prouress of the tube is easy. The tube is now cairieil down, adv aiicinu' slowl\. to its full K'liiith. the examiner all the while unidiiiL; the point by looking through the tidie. The tube must iie\er he advanced unless the esoiihagus ahead is o]icn to receive it. A\'hen the tube has been adxanced to its limit the second tube is inserted inside the lii'st one and can-icd down by si-ht. When the Jackson tubular >pcculuni is used foi- tlic introduction of the esoph- agoscojie the steps are the same a- for the lii-t r.iiiiiin-- tube, .\f1er the month of the esoidiagus ha~ hecii located and made to lemain open a Jackson esoi)liagosco))e is carried througii the speculum au'l into the esophagus. The speculum i< then withdrawn. The Introduction of the Esophag-oscope by Means of a Flexible Mandl-in or Bougfie. .\ heaked. ]iartiall\ open -peculum i.- carried 224 OPERATIVK STRGEHV OF THE I\"OSE, THrxOAT, AND EAR. down to the opening of the esophag'us and a snugly litting bougie is passed through it and carried into the esophagus. The speculum is withdrawn and an esojihagoscope is passed over the bougie into the esophagus. This ]irocedure, which often makes the introduction of the tube very easy, sIkuiM nevci' l)c used when it is the purpose of the examiner to determine the condition of the extreme upper end of the esophagus or when a foreign body is impacted in this locality. Another method of using the bougie as a guide is to pass a Jackson esophago- scope of the proper size below and behind the arytenoid cartilages and then into the opening of the esophagus. A bougie is then passed through the tube and finally the tube is pushed down over the bougie. The Introduction of the Esophagoscope Under General Anesthesia. — The patient is prepared for ether in the usual wa\'. lie is given an injection of one one-hundredth of a grain of atropin and one-sixth of a grain of morphin. The atropin produces a nearly dry esophagus ex- cept in those instances in which the esophagus is dilated and filled with food or a pouch is present and acts as a reseiwoir. A suction apparatus is not usually necessary, but is always a great luxury. The author is using it more and more. If the operator Avorks sitting, the table on which the patient is placed should be of the proper height to permit the surgeon to work at ease. If the operator prefers to stand the table should be placed on a platform large enough to hold not only the table but the stool for the assistant who holds the head and for the etherizer. The corner of the platform opposite the head of the operating table is cut out to allow standing room for the operator. During the examina- tion should it become advisable to lower the head of the patient the operator is not forced to work on his knees. An assistant holds the patient's head over the end of the table. His left hand supports the patient's head and his left knee sujjports his hand while his foot rests upon a sup]iort of suitable height. The assistant should so grasji the head that he can transfer it at any moment to the physician, be ready to receive the head back and to hold it in the new position indicated by the surgeon. Thus the ])atient's head is continually passing from the hand of the assistant to that of the o])erator. It is vital that the head should not be extended too far backward. If this is done the cricoid cartilage is held tightly against the sixth cervical vertebra and will not move forward before the advancing tulie without the applica- tion of great force. A rough introduction of the esophagoscope may cause sloughing of the posterior esophageal wall. This may have a disastrous outcome in a weak patient. The fonnation of the mouth of the esophagus calls for another word. It is bounded in front by the cartilaginous ring of the cricoid cartilage and behind by the body of the ^.A^.v^"(l()s(■()l■^ . hkonc ll(ls(■lll'^ , i.>i>ni.\i.ns('nrY. ktc. __ •• sixth I'orvical vertebra, (hily di: IIr- siilc wlicrc tlic px rironii sinuses load into it arc tlio walls fniniKi^nl of soft tissues. Tlie natural ciianui'l for food into tlio esopliaiius is liy way of the ))yriforni sinuses ami ex- perience has shown that the ]iyrifnnn sinus is the natural and the easiest channel tlirous>h whicii In |ia>s tin- eso|thai;'oseoi»e. If the tulie clKi-rii for the introduction into tht' isopliaii'us will not pass, ihc opiTator should at once select a smaller tui)c until one is fouuil which will enter without being forced. The tubes wliidi arc most useful accm-diui'- to r>runin!is are 10, 12 ami 14 mm. I'laitically every iiatieut will admit a tube of one size or another uiihss the Imdy of the sixth cervical vertebra is enlar,i;'ed, or the ccr\ ica! xcrtebra' aiv diseased. It is usually possible to pass the tnlie by sight aiul this methotl should be attemi)tee of the tootii lilate is just as imiinrtant I'or tlie later (•(iinj'nrt of the patient. In a hard introduction, no matter wliieh iii-trument is used, tile tooth ]ilate should be eiiiplo\i'i| until tiie tuin' is well in the esophagus because notwithstanding assertions to the contrary, teeth may lie nicked, bi-okeu or forced from theii- sockets. Patients do not I'cadily forget such an (H-ciirrenre. The teeth, then, ha\'e been pi-otected with a tooth plate and the a-sistant holds the head bent backward moderately. The jaws are kept slightly apai1 b> a gai;; pim-ed in the left corner of the mouth, ^fbe tongue is made to lie naturally and the end of the tubular siM'cnlum is cai-ried along the centiai I'urinw (\l' the tongue, and is piished foi'ward and downward until thi' tip nf the ejiiglottis is recognized. The tiji of tiie e|iiglotti> and then the body of the e])iglottis are ])icked up by tiie end of the speenlum in turn and drawn forward until the aivteuoids appear. Tiiese in tui'n are passed by inseiling the point of till' specnluiM hehiiid tlieni and Inrcii:- them forwai-lill further down. All the time the ojieialor is niakinu traction forward. When the liro])er depth has been i-eaclied the back of the cricoid cartilage is encountereliiii,Mis iiihUt ctluT iiiicsllicsia, lie profors to use for tlu' isopliairt-al i-xaiiiiiiatiou as larj^i- a luhc as tlii' esopliauus can lie iiiaiK- to take. Oval tuln's take iiji the slack of the csoiihauiis aloMn' anatomic lines lietter than round ones. For this reasim the writer eMiiilii\> l.-uuc n\,il tnhes. Thc-i' .nf iiiiulc in two lengths — an eleven-inch tnlic ami an eighteeii-incli tul>c. Sn niaiiy of the pathologic conditions of the esophagus arc fnuihl in tlic upper part and the eye strain is so vastly increased liy iDnkin^ thidugh a hmg tube that it is economy of eyesight to have luhcs of two lengths. Tiie short oval tulte is selected and jiassed hy sight to the right pyriforni sinus. At this ])oint the transverse axis of the tulie is Miaile to lie anteriorly by rotating the tube to tlie right. The tube will then sink further into the sinus. When the point of tiie tube is as far in the pyriform sinus as it will go without being forced, the tube is rotated tiack to its oriyiual ))ositioii with the lonu' axis airain transversi'. As this manipulation i- c-iiriiMl out tiie iel'l eoily of ilie eiieoid eaitilaue, thus |iushin.n- it lorwanl. and the tube enters tlie eso|iliaL;us. All tlnse nianii)ulations are seen by the examiner as he iiiiides them liiroiiiili the tube. The lield which the large tube gives is so -upeiioi- to tiiat allorded by a I'ound and smaller tube iliat e\-ery legitimate ell'ort >liouhl lie made to introduce as large a tulie into the eso]ihagus as will pass the cricoid cartilage. Even a large oval tube seems too small for the calibre of the esojihagus once the cricoid cartilage has been ])assed. The examiner gets this impression even in the noniial adult esophagus, to say nothing of the dilated esoi>ha<:us of e,ii(lio>pa>ni. The Passing of the Esophagoscope by Aid of a Mandrin or a Flexible Bougie. - In the earl\ (la\s of the esophai^dscope it wa- almost always intr()duee<| hy meaii> of a iHo.jectinL;- pluu,i:ei- or mandrin. .\1 lii>t the mandrill had a rii;id end: latei- IJeNiliie t i p^ were added. To all intent.- and piiipoM- ll h-i-lic hoii-ie i> a mandrin with a llexible li]) and is so u^e(| loihix. The niaihlrin is chielly em])loyed with the finger tip introduction of il so]ihai;dscopc oi- the gastro- seope. There is no great or \ital olije<-tioii to the use of the man- drin if the examiner is sure thai the ])atlioh)gic condition is well down the esophagus or if, as in gastroscopy, he is to i)ass the tube through a normal eso])hagns. The ]>roce(bii-e is cai'rieatieiit's )ihar\ii\. .\Iouii' the inner surface of the left f(M-eliniier of the examiuei- tiie esophaiioscope is can-ieil iido the right p>'i-iform >inus. ^\'hen the end of the in>trnment has ri'acheil this 228 OPEKATIVK SI'I!(;K1;V (IK THE NOSE, TilTinAT, AND EAIl. point a littk' twist of tlio end of tlic tiiKc to the left carries the tnbo into tlio csopha.nus. Witli a tiilio of iiKMlium nr siiiali dianiotor tliis nu'tiiod of iiitrddui-tion is the (|nic'kc'st and easiest. The disadvanta.iie of the prueedure need not be dwelt npon aftei' what lias 1)een said of the advantage of the introduction by siglit. The hirge o\al tube whicli is used by the author is fitted with a conical rigid plunger wfiicli projects iVom tlie end of the tube an inch and a half. The plunger is used in tliose cases in which the ocular introduction of the oval tube does not succeed. The oval tube is carried down by sight and the attempt is made to ]iass it by sight after the method which has just been described. If this fails the plunger is put in and gently forced home. The plunger is so long and ])ointed that it finds its way liehind the cricoid cartilage, dislocates it forward and allows the tul)e to follow on after it. The introduction of the esopliagoscope Avith flexible bougies is best adapted to round tubes. The bougie can first be introduced by the finger tip method or the tube can be carried to the entrance of the esophagus by sight and then the bougie passed through it and into the esophagus. The tube may tlien be sli])iied down over the liougie. Tlie impression may lun'e been given by what has been said con- cerning the introduction of lai'ge tubes that they should be used at all costs. This is not the impression which the author wishes to leave. If a large tube can be used, and it can be used under ether without danger oftener than is generally recogiiized, it should be employed. It must be remembered, however, that if the introduction of a chosen tube is not easily successful, that tube should be discarded at once for a smaller one. Obstinacy on this point will lead to disaster. The Appearance of the Normal Esophagus.— I ndcr good idumina- tion the color of the mucous membrane of the esophagus is a whitish pink like that of the mouth. Poorly lighted or when inflamed the color changes to a red of varying depth. After trauma, the mucous mem- brane soon becomes edematous. When examined with small tubes the walls of the esot»hagus are thrown into large longitudinal folds, and on looking through the tube they are seen indenting tlie circumference of the central dark area which represents the lumen of tlie esophagus. These folds are especially numerous at the mouth of the esophagus behind the cricoid cartilage. They make it hard in be sure of the pathologic lesions in this locality. Below the cricoid cartilage and in the cervical region the lumen is seen to enlarge with inspiration and to close down again, but not entirely, during expiration. When a large tube is used the examiner can often look down the esophagus a long way ahead of it. As the esopliagoscope reaches the first piece of the l.AKVNCOSfiilM . l!i;n.\( mix (IPS . i; slcnuiiii tilt' |iiils;itioii ol' llic jutIi of the aorta ran lii' srcii tliroii>ili tlic anterior wall. A littli- lower the heart iiioiuitls into t!ie anteritir wall on the left. The lieatinn' of the heart is visilile ami when thi' Inhe has jiasseil lievontl and the heart lies ajrainst it, the tnlie nlli n Fifr. ins. Fig. 171. Fig. IfiS. — ^The normal esophagus above tlie hiatus of tlu- diaiihragni, ami witli the tliaphragm contracted. Fig. KiO. — The eso|iliagosco|ie has been pushed througli the hiatus ol' the diaphragm and entered the snbphrcnic portion of the esophagus. The eliaraeteristic hmgitudinal folds of this part of the esophagus nie shoun. They converge to tlie left upon an ill-defined transverse slit whiih is the eardiac oiicning. Fig. 170. — The esophagoscopc has been carried through the cardiac open- ing of the esopliagus iato the stomach. The stomach appears as a funnel- shaped cavity. On the lower wall of this the rugic of the sfoniacli are seen. Fig. 171. — The drawing shows the esophagus just abnve the hiatus of the diaphragm. The patient was examined under ether and with an oval esophagoscopc. On the jKitient's right tlie rim of the liiatus is partially contracted anil mounds into the lumen of the esoiihagus. Later in the ex- amination when the diajiliragm became fully relaxed this ridge dis- appeared. Below and beyond the ridge the subphrenic portion of the esopliagus is seen. Tlu! characteristic longitudinal folds veer to the left and end in the cardiac opening. The cardiac opening is in a state of I niinvings 1 y the author.) vibrates in uniMin with tiic heart heat. 'I'lie hiatus of the esopiia.nns appears a.s a slit un a ru.~etle. The a.xis of this opening- throiiirh the iliaphra.ain is oblique, running- from linht to left, from behind forward. The subiihrenic juirtioii of the es(i)iliai;us usually shows no Iniiien. but 230 OPKKATIVK srn(lKi;Y OF THE XOSE, THROAT, AXD EAR. Fig. 17.: Fig. 174. Fig. 5;oscope. Fig. Fig. Figs. Fig. 172. — Normal esophagus during quiet breathing. Small csopha- 173. — Normal esojihagus during deep respiration. 174. — Stricture of esophagus with scars radiating from its lumen. 175 and 176. — Carcinoma of the esophagus. 177. — Fish bone in the esophagus. (After Stark.) i.Anvxr.osc'opv, nKoxciidsrnpv, KSdPiiAiiosropv. i/rc. 2.'}1 opoiis ;is till' Inlii' imsscs llinmuli it. Tlu' imi1niii;n-|i that it is lianl to tell whore tile t'soplia.mis I'luls and (lie stuiiiai-li l)t',i;iiis. Tlio iiiufous im'ml)niiKi of tlio stoniafh. liowovor, is a darker red tliaii that of tho ('S(i|iliaui-e of iiis liiidiiiKS. The difficnlty at tlie first place is due cliiofly to the folds of tlio mucous nu'uibrane. Those can bo strotclied out by ])assin,ii: the esophairea] ortion of the eso])lia- gus. a bougie passed through the esoiihagoscope ami into the sub- |ilii-iMiie |Mirii(iii will often guide tile tiibe into t lio stouiacli. Tlu" author relies upon ballooning the eso|iliagiis and thus finding his way. After the esophagus has been examined all the way to the stomach the tube is withdrawn and the whole of the esopbagi'nl wall is reexamined. THE DISEASES OF THE ESOPHAGUS. The chief symiitom of disease of tlie esojihagns is olistrut'tion to swallowing. Diseases of the esophagus, therefore, fall into two groups, those which cause marked stenosis and those which do not. Xew ■Jol: ni'KiiATivK srniiKr.v or tiik xosk, tihioat, axd eaii. UTiiwtlis foi'iii ail important sul),n-roiii). As elsewhere in the body a new iirowtli may lie heninii or mali.ii'iiant. Foreign bodies in the esoi)liagns make the linal inipoilant group to be considereil. DISEASES OF THE ESOPHAGUS WHICH CACSE STEXOSIS. Acute Inflammation. l*'ollo\ving the swallowing of a corrosive such as lye (washing jiowders), carbohc acid, or corrosive sublimate, the eso])luigus becomes acutely inflamed and more or less completely closed. Hough, ini])aeted foreign bodies also cause a local inflammation. This may be more or less general if the foreign body has caused extensive trauma. After the swallowing of a caustic it is better to wait for a few weeks, perhaps a month or two until the inflammatory disturbance has subsided before examining the esophagus with the esophagoscope or before passing bougies by the aid of the esophagoscope in the hope of preventing the formation of cicatricial strictures. This caution is especially necessary in dealing with young children. In such cases it is probably better to open the stomach without delay and to nourish the child through the gastric tistula until it has regained its powers of resistance and is once more well nourished. If a foreign body has caused the inflammatory stenosis of the esophagus, it must lie removed at once. Stenosis of the Esophagus Due to Cicatrices. Cicatricial stenosis of the esojihagus may be the result of opera- tion, i. e., removal of the glands of the neck, or excision of the larynx. Traumatic stenoses are caused by gunshot wounds and by swallowing sliarjj foreign bodies. Systemic diseases, which are at times associated with ulcerations of the esophagus, may also cause cicatricial stenoses. Sy]iliilis and tyjihoid fever are occasionally responsible for such stric- tures. Pneumonia may ])roduce the same condition, Imt cicatricial strictures are most common after the swallowing of some escharotic. When home-made soap was common, children drank it by mistake. Today they drink solutions of corrosive sublimate, which are kept to destroy vermin, or the ^'arious wfishing compounds containing caustic soda. It may be years before cicatricial strictures finally shut down. Adult patients not infrequently present themselves who give a history of having swtillowed some caustic in childhood and who have had only moderate difficulty in swallowing for years. The Location of Strictures. — Caustic strictures form most readily at the jioint where the eso])hagus is the narrowest. They are found. i,.\i;vN(;osr(ii'\ . itiKiNrimsi ni'\ . |■.sl)l■ll.\<;llS(•l>l•^ . kit. _.>.> lluTi-rori'. most cuimimiily at llir ii|'1iit m- Idw.T ohI d' the rsopliii.-^-us. (tccasioiially a strictniv is louml at tlif I.'mI i.f tlic> clav icli'>. Xol uii- i-onimonly t\u'\\> will he a strict uif at tlir lr\cl of tin- clavicles and a socoiid aiul lai,n>\' \\\r chief stricture Tlic esophageal wall al)ove a stricture is (lilatee of good size is used, the hnmii nf the stricture is I'asily made to come opposite the end of tiie tulie. (Fig. 17(5.) The Diagnosis and Treatment of Esophageal Strictures.— The best method of determining tiie i)resence of an esophageal stricture is to ]>ass the esophagoscoi)e. The larger the examining tulie the easier it is to find the constriction and to make the lumen of the stricture center with the end of the tube. The meie presence of a stricture can be nuide out with a small tube and the examination carried on under cocain anesthesia. The accuiate mai»ping out of a stricture, however, and its nmximuni dilataticm are possilih' only under genei'al anesthesia. For this i-eason tlu' author feels that time is wasted in examining a cica- tricial stricture under local anesthesia. Wln-ii. therefore, a ])atient is to l)e examined for a cicatricial stricture he shmdil be etlu'rized and placed on the examining talile with tlie head hanging oxer tin' I'dge and as large a tni)e intnuhiced as can be made to pass tlie cricoid cartilage easily. I'nder direct vision the tnlie is carried down to the stricture and the lumen of the stricture made to correspond with the center of the tube. The autliuiV e\]jerience has been that this is easy to accomjjlish. Occasionally ballooning the esophagus with air helps to find the opening of the stricture. After the dilatation of ;i -mall stricture has been begun the ballooning is an easy way of ki'ep- iiig the bl(M)d out of the mouth of the stricture. To retiini, after the -tiicture lia> been I'omihI and its npciiinu centeicd at the (.'ud of the tube, the lumen of the stricture should be tesleil with an idastic bougie of apjiropriate size. If it happens that the lumen measures 20 F. or is easily dilatable with soft bougies up to this calibre, the metal dilator (Fig. 178) is carried by sight through the stricture and the dilating mechanism exi>anded until marked I'csistance is fell. The dilator is kept exjianded for two or three miinites and then closed. After a 234 OPEKATIVK SriKIKlIY OF THK XOSK, TIIUOAT, AND EAU. short interval tlie stricture is again put on tlir stretch. By coaxing tlie (lihitation a marked ji'ain in the luiiicn of ihc stricture is soon at- tained. It is surjirisiiii;- Imw readily even old >ti'ictni'cs will yield. The author so far has not found it necessary to cut a strictui-e in order to make dilatation possible. No rule can be given as to how fast to dilate or how nmcli. lentil more data have been accumulated upon this ])oint the opei'ator nuist use liis best judgment. The aim is to get tlie max- imum dilatation so that a good sized bougie can be passed easily after the examination. In a bov of seven vears with a A^ear old corrosive '(■iim i;iiiimMiiinr;lnm »iiiiiir»iiiriiiiiiiiiriiiiii »rfriiiiriiiiimriiil linfin]riniiimi»[iiiiliiiiirnmmi[l»irir;miiiimTinimniirii Moslier's moclianical dilator, -(vith two tips. A, tip for use in strictiiie of the esophagus; B, tip with larger expansion for use in cardiospasm. stricture which would not admit a 16 F. bougie without ether and in whom under ether a 20 F. passed tiniily, I was content with a dilatation to 34 F. In a woman of forty with a stricture which had existed since childhood and which admitted without ether a number 20 F. bougie with difficulty, the dilatation Avas carried carefully up to 42 F. This was sufficient to allow the passage after ether of a 32 F. bougie. The dilatation was subsequently increased by the weekly passing of elastic bougies up to 36 F. Rapid dilatation under ether saves months of Modified Bunt's olive-tipped metal bouRie. This instrument is used for starting the dilatation of small strictures of the esophagus. time. Experience has proved that ra])id dilataticui is safe if carried out with ordinary caution. In the treatment of strictures in which the lumen is so small that the smallest elastic bougies will not pass, much can be accomplished by the gentle use of a staff carrying small metal olives (Fig. 179.) With the smallest olive an eighth or a quarter of an inch of the stricture is picked or teased open. After this an elastic bougie of slightly larger size is introduced in the lioi)e of inci'easini;- tin- dilatation. The use of I.AIiVXC.OSCOl'V. nnoXl'IIOSCdl'V, l.Snl'IIACdSCdl'N , i;i(. 235 tlic iiictjil .-live should lie iiKist ,<,niaril('(l. All tin- while llir (iiktmIci- iim>l lie ciiusfinus of lln' tnic Jixis oi" thi- csoiihatfus hccaiisc any ti-ietniv at tin' lirst sittiuy-. hocause exi>erieuee ha> |iin\cd tlial it i> helt.T in siieh cases to oiH'ii the stomach at once and to -el the patient propeily nourished heforc very tigld ov very long strictures are dilated. Wiii'U an emaci- ated, half-starved patient i)resents himself, and esiiecially in the case of children, it is hettei- snr-eiy to open the stomach at once and marked diHieulty in swallowing. Milk Ijeeame his only food. One day tliis would stay down, the next the [greater jiart of the milk would Ije reginjiilated soon after it was swallowed. A number Hi F. elastic bougie met with resistance at the lower end of the esophagus and would not enter the stomach. Under ether a stricture was found at the cardiac end of the esoiihagus, and a moderate dilatation of the esophagus above it. The stricture proved to be an inch long. It dilated readily with clastic bougies to 20 F. I'rom this measurement the dilatation was carried to 32 F. with the mechanical dilator. As wa.-; just said it was impos- sible to pass even a small bougie into the boy 's stonuich before the etherization and dilatation, but afterwards a number 32 F. could be introduced easily. The family phy- sician passed a number .■;2 F. bougie once a week. The boy soon became well nour- ished again. At the end of a year and half Ihc motlu-r of the clilM reported that he had no dilliculty in swallowing. Case Nimiber 2. — .\ woman in the forties gave a history of mariicd dilliculty in swallowing for two months, and of pain in the epigastric region. She was moderately well nourished and was living on milk and soft solids. The patient stated that when she was a small child a playmate offered her a drink of vitriol. Since this }ia|>pening she had had a moderate and stationary amount of trouble with swallowing. For the last month, however, the trouble had suddenly increased and she had begun to have jiain in the region of the stomach. A number 20 F. bougie encountered resistance at the cardiac end of the esopha- gus and entered the stomach with difliculty. The X-ray showed that the lower half of the esophagus was narrowed. The ether examination disclosed a stricture at the le\el of the cljivii-le. Tln> lumen of this was about .'50 F. This stricture was easily dilated with tlie mechanical dilator so that it permitted the passage of a tube measuring half an inch. A second stricture was found at the cardiac end of the esophagus. The second and lower stric- ture was dilated with clastic bougies up to 22 F. and then the meclinnical dilator was introduced and the stricture stretched slowly and at intervals of a few miiuites up to a linal dilatation of 42 K. At this point the resistance to the dilatation became extreme and it was discontinued. 23f) OPF.IIATIVE SriiCKItY OF THE XOSE, TIIItOAT, AND EAK. Fig. 180. Stricture of the esophagus. (Tracing fro)ii an X-ray phite, retouched aud reduced.) This plate was taken from a woman forty years old. At the age of four a playmate gave her a drink of vitriol. Since then she has always had to chew her food very !lne. Vor a month or two l)etore she came for cxamiuatiou she had been living on liquids. A Ko. 20 F. elastic bougie entered tlie stoniacli with difficulty, encoun- tering a stricture at the cardiac end of the esophagus. The X-ray plate shows that the lower half of the esophagus is narrowed. Under ether a stricture was found at the eud of the clavicles as well as at the cardiac end of the esophagus. This had a calibre of 28 F. The upper stricture was dilated first with the mechanical dilator and then the lower one. The lower stricture was dilated at the first e.xaminatiou from 20 F. to .'!2 F. I.AIIVNCOSCdl'V. KKdNlllOSrol'V, KSdl'l lACOSCOI'V, KTC. _■>( Tlic inslriiiiu'iilMliim wns not followi'il liy nny rise in t("iii|uMnliirc', liiit I'm (lays tlipre was an inoroasc of tlic c'l'ii;nstrii' pain, and for lliico or four il;i.vs ilir ability to swallow was Ipssi-iu'il. Hy tlic cnil of tlip wcolt tlio pain \u\t\ ilisaiiprari'd ami the pationt was swallowinj; lii-tliT than lu-foro the oporntion. At this time a niinilicr 30 F. olasti<- lioiigio passed without diflirulty. l'"or alioni a year afterwards bougies were passed on the avera;;e of every two «.■ ' l'.. iiv :i luinilier S(i F. jiasses willioiit dilli- dty and the woiuan eats everythia;;. This caso slimvs lliat wlu'iv tlicic air Iwu <>r iiiuir constriclioiis llio bougie liK-att'S only tlu' snialltT oiu'. I'lmn tin- ai:i' nf the lower strietiii-e and from its lirnmoss at the bofriimini; nf the er half of the esophagus wiis dilated and that llie stricture began as the Xray had sliowii. at the level of the .nipples. The lumen of the esophagus was reduced to a central opening about one-six- teenth of an inch in diameter. .V filiform bougie would just engage in this and then would enter no farther. Having gained this information from above an attempt was made to pass the stricture from below tliroiigh the gastric fistula, by using a small short bronchoscope. This was not successful. Then Dr. Coidiilge took the brondio- scope and worked from below while the author worked in the esophagus from above using a small esophagoscope. This double attack on tiie stricture made no gain and the manipulations from below were discontinued. The author .soon fo\ind that on using the small metal olives on the end of a metal staff tlie lumen of the stricture could be entered a short distance, perhaps an eighth of an inch. ICncouraged by this he persisted in the use of the metal olive using first the metal olive and then a small ela.slic bougie of slightly larger size. The result of the first day's work was the ungluing of about an inch of the stricture. Xo reaction followed the manipulations. Two weeks later the lioy was i-tlierized again and the same manipulations repeated. A second gain of nearly an inch was secured. During this sc'i'oiid session at the stric- 238 OPEKATIVK SlKCKilV OF TJIE NOSE, TIIKOAT, AND EAK. ture the ballooning allaclinient was employed from time to time in onlei- to clear the blood from the lumen of the stricture and in the hope that .some of the air might find its way into the stomach. Air finally did enter the .stomach and could be detected com- ing out of the gastric fistula. This haii|iruiii;4- was must comfortiu};- and encouraging. It proved that the metal tjlive was following the riglit line ami that tlic lower inch of the stricture was pervious to air. Without the confidence which this finding gave the author might have given up the attempt to pick apart so long a stricture, because if the line of the stricture was not adhered to closely the olive would perforate the walls of the esophagus and convert the case into a tragedy. After a second interval of rest, about two weeks, the boy was etherized for the third time. The gain made at the other exam- inations was found to be retained. Air still could be forced into the stomach, and after a little manipulation the olive also entered. This wa.s followed by soft bougies until the lumeu of the .stricture was increased to 20 F. The mechanical dilator was then put in and expanded at intervals to 28 F. The umnijiulatious ended by carrying into the stomach a thread and bringing the ui>i)er end of tliis out of the numth and fixing it over the ear. Three or four days later the perforated metal olive on a long staff was carried down on the thread into the stomach. The boy began to drink milk. It was soon pos- sible to pass the olive through the stricture mthout using the string as a guide. This was fortunate because the thread was vomited after a few days. The further treat- ment of the case consisted in passing larger and larger olives at appropi'iate intervals until a final dilatation of ?,6 F. was reached. In this case an absolute stricture three inches long and a year old was opened up piecemeal with a final lumen of 36° F. The previous treatment of the case along general surgical lines had faih^l. This fortunate case, therefore, shows in a striking mannei- the possibilities of the treatment of strictures by tlie esophagoscojie and by apjiropriate insti-umeiits used through it. The Use of a Thread as a Guide in Esophageal Strictures. — The procedure of having the patient swallow a thread was a great advance iu the general surgical treatment of strictures of the esophagus. It is mentioned in coimection Avith the use of tlie esophagoscope because occasionally advantage may be taken of this procedure in connection witli the use of tlie tube. The swallowed thi'ead may be used to guide the esopliagoscope to the lumen of the stricture, altliough as the oper- ator becomes accustomed to the use of the esophagoscope and resorts to ballooning, he will find the swallowed thread less and less necessary. The chief use of tlie thread is its employment as a guide for the metal olive after the rapid dilatation. When used in this way a yard or two of stout wa.xed thread is wrapped about a small button and tlie button is carried into the stomach through the tube (hiiing the examination and after the stretching. The upper end of the thread is brought out of tlie mouth and fastened over the ear. Generally the use of the thread as a guide for the metal olive and its staff is necessary for a few days only, because the operator soon becomes orientated in regard to the lumen of the strictui-e and finds that the metal staff allows hiin to turn KAivVXciosciti'v. ltl:(l^■(•ll()S('lll■^ . r.soi'iiAiiosi'tn'v, v.rc. 23!) the (ilivr ill .lirrclcllt (rnccliuli> ;in.| Il' iiicrcasiiiii si/.r may he passt'il uii till' iiu'tal siial't until the tliiatatiun (tf tlii' stricture is such tiiat the passage of elastic hougies is i)ossihle. (Fig. LS-"!. ) lusieail of forc- ing tiio ))erforate»i olive ddwn the stall" and thr can lie (pl)taiiied Ky ( ni|ih>ying the >)iii-a! wire carrier. The llex- iiile |iu>her Imckh's aw ay I Vdiii the line of 1 he iiiaiu si all', aud mi at times refuses to push a .-^nug olive thidugh liie stricluri'. Tiie spiral w ire car- rier, on the otlier lumd, lings the guiding staff clot^ely and gives a direct push nn tlic nlive. When the (dive is in p(isiti(ni against the stricture if liie (iperatdr puts his linger in tiie palieiil "> piiaryiix aud pre>>es ddwn- ward on the sjiiral staff, he can exert great pressure on tiie olive below. In fact, tiie antiior found tluit tliis method of forcing an olive througli a 24(1 OPERATIVK SUKCKUV OK THE MISK, TUllOAT, AND EAR. sti'icliii-i' was si'v, UKdNciinscniM'. l•■.sl(l•ll.\l;l>s(■(ll•^ . i/rc. L'41 Cardiospasm. ('iiiirHis|)asiii is the ii;iiiir a|i|p|ic'i| tn a <-(iii(liii(iii of spasnioilii' closuiv ol" tin* csoiilia.n'us a1 the carcli.-u' ii|iriiiiiL; n\' tlir stoiii- acli. The iiaiuo. liowovcr. is used in i-ouiu'ctioii with spasiiiodic closure of the esophagus at auy other point. This eonditiou is one of the most important i>athoKi,uie alVectious of the e--oiihni:us. Its ctiohjiry is still ohseure. .Taekson holds tiiat the cai'lia i> not a true -iiliiiicter in siiite Fig. 1S5. Cardiospasm. Retoiiclied tracing from an -X-ray plalo. The osoiiliagiis is filled witli bismuth gruel, and is narrowed to a very small lumen. Alxive the narrowing it is dilated. (Author's case.) nf tile circular liliers nl' II \ it I, Inn iiiaintnin- t li;it t iic hiatus is an actual spliiiictei-aiid acts a> nnc in .•;iidiu>|ia-iii iliciv aiv t \vn i-hief I'eatui-es, S|)asm of the eardia and dilataliun ,,r tlic c>(,|i|ia-ii>. In the majority of the eases there is atony of the inuscular wall as well. The conditions which are responsilile for these chaii-cs have heen hehl by various writers to l)e a coii,<,'eiiilal derecl. a piiniary neurosis, or an esopha.y-itis. In some cases the atony i^ piimaiy lo the spasm anso|tlia,iiUs. W'lu'ii initatiiin' lluiils siicli ;is very Imt iw seated diverticnlnm of the eso])liagus may be present. Alucli light is often thrown on a case by filling the esophagus with bismuth and then taking an X-ray plate. The Examhiatiov r^rler Local Auesthesia. — A large sized elastic bougie is intro(hiccd into the esophagus and tlie distance of the obstruc- tion from the incisor teeth is found. In a case of cardiospasm the bougie will occasionally pass through the cardia easily or on gentle pressure, at other times much pressure is needed to force it through. The esophagus is washed out and the throat cocainized. Then the eso- phagoscope is passed and a careful examination is nuule of the esoph- agus. The condition of the mucosa and of the esophageal walls is noted. It slioulil be ascertained whetlier the walls are firm or flaccid and whether tlie esophagus is normal in size or dilated. Ulcerations, diverticulum and new growths are excluded. AVhen the tube reaches a proper depth tlie cardia is seen as a slit with the long diameter lying obliquely from the right posteriorly to the left anteriorly. This is not the cardia strictly speaking, but the hiatvis of the esophagus, though many writers use this name for the constriction of the esophagus at the ])oint where it goes tlirough the diai)hragni. Tlie liiatus ap])ears either as a slit or as a rosette. In s])asm it is usually like a rosette. It has been compared to the montli of the cervix uteri. (Fig. 168.) The eso))hagoscope cannot be passed in cases of cardiospasm into the stom- ach without first cocainizing the hiatus. As soon as the hiatus gives way the tube is carried into the stomach and then withdrawn. On the withdrawal the esophagus is examined again in order to confirm the negative findings. In a complete examination the next step is to determine the capacity of the esophagus. An esophagometer is xised for this purpose. Lerche has devised an instrmnent of this nature. It consists of a rub- ber bag which is inserted into the esophagus and tlieii tilled with air. A recording mechanism reyisters the amount of air necessarv to make I.Al:v^■(;(lS(•(n■^•, iii;oxciinsc(ii'\ . i:sni'ii.\(iiiS('or\'. irrc. L'4.) tlk' \>i\'j; assiiinc tlii' saiiif (lilii(;itii>ii .•iinl sluipc iis llic (•s(>])liii.i;iis. An X-ray i)ictur«' may l>f taUni with the liau in jilarc Tliis will iloiiioii- stratc tile sliapc t>\' the (liiatimi iiioif sli:iiiil> than tlic I)isinu11i <;i-iicl. 'PiiK Thkatmknt atient. The stretciiing of tiic cardia with the mechanical dilator is nmch simjilcr than the use of the iubl)er bags. There is oni' diawl)ack, howe\ci-, tn the examination mider ether. All spasm of the esophagus is done away with and the cardia itself nuiy so be relaxed that unless the examiner bears this fact in mind he may feel that lie has not found the cause of the condition for which the examination is undertaken. After the ether examination in cases of cardiospasm and the dilatation of the cardia the author has been in the habit of leaving a tlireail in the esophagus and in the stom- ach ami of jjassing the olive tijjped staff on the lliiead I'or a few days until it was possible lo i)ass the staff nnguided. ( )n tlie staff metal olives of increasing size are jiassed for a time and then the unguiiled clastic bougie. Finally the patient is taugiit to i)ass the bougie for him- self. This he does at intervals according to the ])ersistence of the spasm. The relief of carilios])asni is easily broiighi ai)out. The ])aiient's s>ini)toms lessen almost immeiliately. Measuii-ments show tinit the 246 OPERATIVK SrUdEIlV OF TlIK XOSK, TliltOAT, AND EAR. esopliaiius soon contracts unless llici'c has Ixn-n cxtcnsixe weakening of the esojiliageal Avails. Cases of lliis kiml, altliou^h they ol)tain niarki'cl relief from st I'etchiiii;- of the cardia, iialiu-ally still have a certain amount t)f residual tr(jul)le on account of the slowness with which food passes the weakened esoplia,iius. Cases of cardiospasm Cardiospasm. Ki-oin a iirint of an X-ray plate, showing a dilated esojili- agus. The esophagus narrows to a point in the shadow of the iliaphragni. (Plate b.y Dr. F. H. AVilliams.) I,Al;v^■(;(lS(•()I'^•, iiKoxriioscoi'v. losoniAUdsroi'v, irrc. 24V ail' aiiiuii^- tile iiio>t (liainatic of siir;;i'ry. Tlu' follow iii^- case is an example: A yoiinii' woman liad lircn ro.srni'.ifitatiii.si: her food for llftoeii years. Slie wh'mI from ]ili>>-ici;m lo pliysiciaii. Slie was conslaiitly eatin.ii" but was always limiui'v, ami c-niisniiu'ii (•noui;li footci| away. Wlicii slic lay down, I'ocxi reiiurnitated into lu-i- mouili or her nose. This and a constant eon.i'li kejjt her awake. In a slu)rt ether examination histinn' alioiil the same number of minutes as she liad been ill yeai's the cause of tlic trouble wa-; discovered and praetieally cured. (Fi,ii:. 1^7.) Phrenospasm. — Phrenospasm is the name api)lie'Us cannot be enleted. I'nder ucneial anesthesia the s])asmodie closure of the hiatus di>ai>|>ears. This characteristic disa])])earance of the siiasni together with a normal mucosa establishes the diagnosis of ]ihrenosjiasm. Almost invariably the <>sophafius is dilated above the hiatus. .Jackson mak"es a clear distinction between spasm of the cai'dia and sjiasm of the hiatus. Many authors do not, but >peak of sjiasm of the cardia when in reality they mean sjiasni of the inatus. Then again the tei'ui s])asm of the cardia is u>eil to mean s))asm either at the cardia or at the hiatus. Jackson's termiuo|oi;y h'ads to cK'arness. Benign New Growths of the Esophagrus. Benign neoplasms of the esophagus occnr but are imt comuKUi. AVhen it becomes the routine to examine all caility more lienii:n new growths will be discovered. Edematous polyps and pedunculateij liponiata are |irol)- ably the commonest of the benign growths. Fibromata also occni-. These benign growths are found chiefly in the u|i|>er pai! of the esophagus. Their pedicles allow tlu'in to pia\- up and down so that they ajipear at one examinatiini and ma\' disa|ipear at the next nv the> are present when the examiner lii'st looks into the throat witli the mirror and they disappear when the |iatient swallows. I'edmu'U lated lipomata ha\'e a fashion of dropping forward into the lar\nx and of causing cough and intermittent hoarseness. Treatment of Benign New Growths. — P.enign new growths shouhl be removed with api'idpiiate ura-pinu or cutting forceps. An elfort should be made to ohtain a~. niucli of the pedicle and its ba.se as is l>(>ssib!e. Sometimes the maniimlations ciin be carried out through the tubular Sjieculum, whereas at other times the esoiihagoscojH' is 248 oi'Ki;ati\k sn:(;Ki;v ok tiik xosk, tiii;oat, axd ear. necessary. Tlie accossihilily ni' llic urowtli and the lolci'ancc of llie patient h^ettle tlic (|iiestioii of llic use of local or ,i;ciicral ancstliesia. With the cxeeption of lipomata all supposcilly heiiign growths are looked upon with a certain amount of suspicion. In any given ease time alone can settle wiicthcr m not this snspiciim is well founded. Malignant New Growths of the Esophagus. Any persistent diftienlty of swallowing in a ])atient of the cancer age ought to lead to a prompt examination of the esophagus. Only in this way can malignant disease be detected early and the cases Avhieh are fit for operation sorted out. Cancer of the esophagus often gives FiU. ISS. Section of iiovmul esophagus (liOW power). but slight symptoms for a number of years. It is not uncommon to have patients give a history of tioiiJ)le with swallowing dating back three or four years. The horrors of cancer are nowhere greater than in cancer of the esophagus. If for no other reason, therefore, these patients should be given the benefit of an eai-ly examination and of an early diagnosis. Malignant disease may start in the epithelium of the esophagus, or in its muscular wall, or outside of it. In late eases no conclusion can be arrived at as to origin of the disease. Periesophageal disease, when not far a .liicUsKii. (Icsrrilics tl:c iiiipciiin >>\' f.iii'ii- of the I'soplia.uus uiiiItT li\i' licnU. I. 'I'lii' I'soplKLUcal wall -lin\\> 1 liicl;ciicil wliitisli |ia1i-lii's. 'I'licsc wliitf itatclu'S alternate with patdir- of liri^lil ivd. II. TIkto is a riiii: liki' naridwiim ol' the luincn of the esophaiiiis. 'I'his is called the ammlar l'..i-iii. At some puiul in llie riii.i!,- tliere is usually iileeratinii. i-"rei|iiciil iy the esopha.iius is iliiateil al>nve the eonstfiotiim. ."!. Careinoniatous iuliltratidii wliieh is iii>t only annular in l'(nin Init l'niinel-shai)e(l. 4. Canlirtower masses snrronntliim the lumen ol' tin' csophaiius 5. Papillomatous veiietalious. In the author's oxiterienee tlie most eonmnm tVu-ms an' the lii>t, second and the fourth. Syphilis may stiuudate any of the live forms. Tile mieroseoiiie examination of a specimen condiined with the thera- ]tentic and the Wassermaiin test will rule imt syjihilis. Cancer of the esopha^n- oei-urs urteiiest at the upper or the lower end. It is not nncomnKni. Ikiwcmt. tn liml it located ahnut half way ilowu the esojihauus. Symptoms of Cancer of the Esophagus. The chief sxnipiom of cancer of the esophagus is (lifli<-ulty in swallowiuii'. This symptom may lie slijjfht for years. Associated with the dilhcnlty in swallowiuii", if the .growth is located in the upper part i>\' the esniihairus, there is pain radiatini;- to the ear of the arfected -idc ( M'teii the cervical ii-lanl rncliun heeaine marked and emaciation niiticeahle. TIh-h a IkiU'.;:!' was passeil, an iili>t rncl inn was found ami the liongie lirnui^lit up Mndd. Tiiday this is antii|nated surge|-y. to call it liy im hai'dei- name. The liy tiu' open "V liiliular speculum, rallialixe t re;ii imiit j.s also hest carried out llirough these instruments. The renioval of a specimen foi' microscopic examination may seem a lri\ial affair in such an ul;1> disease, but the snrgi<'al satisfaction which cdines from it is not to he (h-siiised. 250 OPEnATIVR SrRGlillY OF THE NOSE, THROAT, AND EAR. If the cancer is well advanced and liapjoens to be in the njiper part of the esophagus the tubular speculum gives a splendid view and enables the surgeon to remove a generous specimen quickly and easily. Good biting forceps are necessary for this procedure, and care must be Fig. 189. Carcinoma of the esophagus. taken to pierce well into the tumor. (Fig. 189.) If the mucous mem- brane over the suspected area is unbroken it may be questioned whether or not it is justifiable to cut into it. Unless this is done, however, the I.AItV.VCnSCiPl'V. HKONl'imSt'OPY, KSOIM I .\( loSCI )rV. KTC. 251 case must be k'l't in ilmilil. If llio cxjiiniiiiitioii is cMrriotl out uiidcr othex" and the jrrowtli is situatcil at oi- iicir tlic mouth oi" the csoplia^us, the open s])e('uhnn, ,u:iv('U a t'avoi-alilr neck, al'fonls a f;:ood view and enables the operator not onl\ to iiiikivc a si)ecimen but to i-Kar away a great part of tlic fuuijatiii.u- .urowlli. In (•;iiicci- ln'Iow the nioutii of tlie esophagus, if it is of the caulithiwcr \y\>r, cari'Tid riiretting will ^i! ir-,,%. Fig. 1!)0. Soelioii of careiiioiiiiitoiis urea (low power). (Sco Kij;. 1S9.) remove tlic i)l)sli'ucliiiL;- masses and ii'ston' ihr patient's alijlity to swallow soft food. 'I'lie aiitlior lieliexcs from lii^ ivsidts that this pro- cedure is.jnstiliaiile. 'I'he eu ret tin- ma>- lie repeated two or three times. (Ings. 190 and ]!)1.) Tlie examination of a case of cancer of the esophagus is not ideally complete uidess the lumen of the cancerous stricture is ascei-tained and tlie |ire>eiice of a se.-ondai'y gi'owth lower down i< rest ol" llu' osdiiliauiis. It is iiol always Jios- sililc 1() ilo lliis. iic\frlliclcss the allciiiiit >liciulcl Ih' ma'li'. !K Cancer of the esopliajjiis. lU'toiiclied ti:icin<; from X-ray plate. (Laloral view.) Tlio esopliajjiis is lilled with bismiith gruel. At the point wlipre tlie (growth is the esophajjiis ends in an irrcyfiilar eone. Hpjashe.s of bismuth which have passed througli the stricture are seen below. i.\nlhor's case, i W'licii llic wall.s of till' csniihaiiu- air sni rniiiidcd with liiiiuatinii' mas.ses of cancerou.s .UTOwtli it is iianl In tril w hnv ilir Imiini ,<\' \\\r esopliagus is placed. Ta siidi a ca-r if ilir .-(iiili.i-iis is haliooucil 254 OPERATIVK SURGERY OF THE NOSE, THROAT, AND EAR. with air the displacemont of the cancerous masses reveals the site of the esophageal ojiening'. If no opening is found but tlie air enters the stomacli, pressure on the abdomen will force the air back and as it bubbles upwards through the structure the lumen can be located. In extensive disease of the esophagus the esophageal lumen can l^e saved for a time by intubing the carcinomatous stricture with a small elastic webbing funnel after the method of Mixter. It is justifiable to dilate a cancerous stricture with bougies or with the mechanical dilator only by using these instruments through the esophagoscope and under visual guidance. Even with these safe- guards the procedure must be employed with exti'eme care. What eveiy physician hopes to find in a case of cancer is that the new growth is located at the upper part of the esophagus, that it is not extensive and that it is of a low grade of malignancy. Such cases offer a chance of cure if the larynx is removed and the diseased por- tion of the esophagus resected. Patients who might liave been saved by this method have gone to their graves without any attempt having l)een made to relieve them. Such cases exist today, but they will ncA^er be found except by the roiitine use of the esophagoscope. When hope- less cases are encountered, and they are still in the great majority, an early opening of the stomach will save the patient from starving to deatli. The author cannot understand the reluctance of some sni'geons to giving the iiatient the benefit of this operation. Compression Stenosis of the Esophagus. Structures whicli border on the esophagus may push ui»on it and cause compression. The conditions which are commonly found to do this are glandular enlargements, cervical or mediastinal tumors, aneurism, phxral effusions and spinal deformities. The esophageal examination in these cases shows only a nar- rowed lumen. The general jjliysical examination supplemented by an X-ray i)late are the most efficient means of arriving at a correct diag- nosis of the cause of the compression. In an aneurism the pulsations may be seen through the fluoroscope. DISEASES OF THE ESOPHAGUS WHIC'H DO NOT CAl^SE STENOSIS. Inflammation and Ulceration of the Esophagus. In acute inflammation of tlie eso])hagus the usual signs shown by an inflamed mucous membrane are present. According as the inflamma- tion is general or local there is a small or an extensive area of redden- ing. Later the mucosa becomes edematous. The vessels of the miicosa i.Ainxcosropv. mtiixciMisi'oi'v, KsoriiACdscopY, etc. _;);> :irc not as a rule xisililr. Acute iiillaiiiiiiatinii of the rsoplia^Mis, if severe, is a coul raimlicat imi to the passaii'e n\' tlie (•soi»liaf;:()SCope. Wlu'ii. luiweviT, it is eauseil liy tlii' preseiiee of a I'lHeij^n body tlie iii- tlamiuation should bo disrogarded ami the roroign body removed at once. In acute inHaniiuatiou where im cause is fouiul. aTi uuderlyiim: earciuouia sliould be suspected. Chronic Inflammation of the Esophag:us (Chronic Esophagitis.) — Chronic iullainiuati(Ui nt' the esii|iliai;us may I'lillow acute iullamuuitioii but as a rule it is tlu' ri'^ult of tiie long continued irritation of ])us or food. These are held in the esopluiii'iis by spastic or anatomic strictures, or by diverticula, rncoinplicaleil chiMiiic catarrhal inthim- inatiou of the esophagus is seen most often in ahoholics. Here it is (hie chiefly to the irritation of the local iiiitaui. The esophagus is usually a dirty gray or a pale red, at times motth'd ami with the vessels showing. Tenacious mucus covers it. Ulceration of the Esophagus. — Ulceration of the esophagus occurs in two forms, ulcer> located above the hiatus and ulcers below it. Fig. J 94. Forceps witli iiuiioli tip for direct worlt upon the larynx or esopliagiLS. Tliis force])S is niadc in various Icngtlis so that the punch can lie adjusted for any length of esophagoscope or bronchoscope. (Pfau.) 1 Icerations ;ilio\'e the hiatus may he dui' lo any of the causes which in'oduce acute iutlammation of the esophagus, i. e., to infection or Irauiiia. The ulcers occurring in typhoid Fcmt aie caused by throin- Imsis of the vessels. Deep painless ulcei-atious occur in syphilis. The same is true of the; ulcerations which occur in tuberculosis. Tiie greater part of the esophagus may be involved in tuberculosis without the lesion being suspected. Tuberculosis of the esophagus usually is sec- ondaiy to tuberculosis of the lungs and is due to swallowing s]iutiim. A tuberculous lu-onchial gland may ulcerate into the esophagus, though this happens but rarely. ITcerations of the eso]>liagus below the hiatus bear a strong re- semblance to pepitio ulcerations of the stomach. They are often as- signed to functional insufficiency of the cardia. Jackson believes that the closui'e of the upper end of the stomach is due to a kinking of the esophagus at the hiatus and that the kinking is caused by the pressure 25fi OPERATIVK srncEr.Y of the xose. threat, axi) ear. of till' coiitcnls oj' till' stoiiKich at tin.' I'midus anil liy tlu' stnu'tiircs alioul till' hiatus. The coulciits of the stoiiiacli, liowcxcr, rrcipu'iitly iinaili' till' lower part of the esophagus. I'lcerations of the esophagus at this jroiiit have a resemblance to ulcerations of the duodenum and may have the same pathology. Codman has made the ol)servation that duodenal ulcerations are often associated with tissures of tlie cardia. He made the further observation at autopsies that fissures of the cardia were not unconnnon. The analogy is at once suggested between fissure of the cardia and fissure of the anus. Where an ulceration cannot be explained the ])resence of a Imried foreign body should be consideieil. The treatment of ulceration of the esoijhagus consists first and chiefly in the removal of the cause. After this is accomplished the topical application of nitrate of silver, argyrol, or tannin is useful. The same iirocedure is advocated for the i)eptic ulcer. The ulcer is cleaned and then dusted witii bismuth powder or touched with nitrate Fig. Ift.j. Mosher's eurette for use in examination by the direct method of the upper end of the esophagus and the larynx. A simihir but uiuoli longer curette is made for use with the esophagoseope. In dealing with inaliguaut diseases those instruments are indispensable. of silver. There is no danger of perforation or of heniorrhagi' if the maiii])iilations are carried out gently, and always under clear vision. Neuroses of the Esophagus. Sensory Neuroses of the Esophagus. — The diagnosis of a sensoiy neurosis of the esophagus should be made with great care. Since the advent of the esophagoscoj)!" the number of true cases of sensory- neuroses of the esophagus has been niaikedly diminished. A routine examination of such cases will icveal a large number of instances in which the symptoms have a real anatomic or pathologic basis. The old diagnosis of globus hystericus should never pass unquestioned. A trifling anatomic |)eculiarity like a partial band at the mouth of the esophagus, can readily cause these cases. The writei- feels that further study of the u]ii)er end of the esophagus will show that such bands are frequent. Small ulcerations from trauma could cause such partial bands or adhesions. Whether caused bv trauma or bv some slight T.Ai:vN(;(is(()i'V. ni;(iN(iinsci/..>il liminic uudcr the old iiiolliod nl' licahiiriit would liicak tlir Imiid aiisc(i])c luust bo passed lii'l'oir lln' liiiui;ii'. Truo si'iisiirv inMimso include li> |icii-i hrsia of lln' I'sojiliauus, anostht'sia, and paresthesia. Thi' patient gronps his symptoms uuiKt the head of a feeling- ol" eontiaction ol' the n])per part of tiie tiiioat and dillieulty in sAvaUowiiiij, or as a sensation of itcliin,i>-, jtrickinfi' or gen- eral uneasiness. Kxeej)! in eases of true hysteria sensory neurosis of the esophagus is xny ran'. The aiipiopriatc trcatnicu) i> aloiiL; m'lii'ial lucdical liin's. Paralysis and Paresis of the Esophagus.— In eases wheie the iu nervation of the esophagus is iulcrrcrcd willi. all solid food is swal- lowed with diflieulty. fluids are usually ^waliowi'd easily. .\t times, even fluids may yo down wiili diflieullv and ouiy iu snudl ipiantities. After eatin,i>- there is pain liai-k of the >ternum and regururitation of niueus or food. Contrary to eX]ieclatioU llle esopliati-oscope. e\-eu witllo\lt ether, readily enters the esophaiius and i)asses easily into the stomach. Tlu' case with which it passes establishes the diagnosis, because iu spastic stenosis spasm occurs if no anesthetic is used, and if there is an anatom- ical stricture this persists even under ether, 'fhe iiai-nlysis may be deinoiist I ated by Stark's pill expeiimeiit. W'itii tlie aid of the esoplia- goscope and forcejjs a pill or capsule is pL-u-ed iu the esophagus 27 cm. from the incisor teeth. If tlie peristalsis is normal the pill will l)e car- ried into the stomach; if the pill remains wheiv it is placed a paralysis or an abnoiinal feebleness of the esophageal wall exists. Tile chief causes of paralytic couditious of the esophagus ai'e cen- tral uer\e lesi(Uis, till' most commou beiug bniliar jiaralysis. and the neuritis which follows alcohol, diphtheiia, and lead poisoning. When a paral\tic coudilniU of the esophagus is suspected a iieuro- loi;ic examination is called I'oi-, and if sucii a condition is proxcd the treatment, of C(uii'se, is almig general lines. Congenital Anomalies of the Esophagus. Congenital anomalies of the esophagus occur occasionally. The esophagus ma\' be bilid uv douiile or it may end iu a blind jtoneh. Children iia\-ing these deformities sc'Idom lixc foi- any lcnL;th of time. Rarely, a fistula Joins the trachea and the esophagus. Cases of this kind ha\'i' been reporteil and the patients have survived. This was 258 Oi'KIlATIVE srP.tlERY OF THE NOSE, THROAT, AND EAll. possible for tlic reason that a valve-like fold of imicDiis iiu'iiiliraiic prevented food from getting into the trachea. Congenital Stricture of the Esophagus. — A little girl about a year old \vas referred tn the autluu' with the history that she had swallowed a "pacifier," and had liad almost complete obstnictidii to swallowing since the accident. The baby was very jiooi'ly nonrished and it Avas found on questioning the parents that from liirth she had contiiuially thrown up her food. It was supposed naturally that the milk was not of the proper kind. Both the milk and the physician were I'epeatedly changed. The baby just managed to survive up to the time when it made a meal of the "pacifier." It speedily vomited the rubber nipple which was on the end of the "pacifier." Notwithstanding this it could not retain any milk. A local specialist passed an esophagoscope and thi'ough this introduced a liougie, but could not make it enter the stomach. At this point in the case the author saw the child. The X-ray showed a small round body apparently in the esophagus and at the level of the bifurcation of the trachea. This Avas supposed to be a bit of bone from the "pacifier." On examination under ether this bit of bone was neither seen nor felt, but instead a stricture Avas found. This was at the level of the bifurcation of the trachea and readily ad- mitted a No. 16 F. bougie and was easily dilated up to No. 20 F. Sub- sequent dilatations carried the lumen of the stricture to '26 F. After a few days the baby began to retain milk. A second plate showed that the bit of bone which gaA^e the round shadow in the first plate had disappeared after the examination. The stools Avere searched, but it Avas ncA'er found. The folloAving seems to be a reasonable explanation of this case. The child had a congenital stricture and she forced its discoA^ery by SAvallowing the rubber nipple fi'om the "pacifier" and perhaps a bit of bone from the handle. The first examination pushed the piece of bone through the stricture and the second pushed it into the stomach. The second examination determined the presence of the stricture and led to its dilatation. Diverticulum. — A diverticulum is a pouch-like off-shoot from the esophagus. The so-called traction diA'erticulum is the easiest of ex- planation. It is caused by the contraction of sear tissue, arising from a suppurating gland in process of healing. This ucav tissue exerts a pull upon a circumscribed part of the esophageal Avail and makes a pouch. In certain animals pouches and dilatations of the esophagus are nonnal; for instance, the crop and the dilatation of the loAver por- tion of the esophagus in birds. Something of this tendency to A^ariation in form maA' be retained in man. In one of the author's cases the l.\i;yxi;osc(ii'v. I!^,()^•('lH)st'lll'^ . KsdniAciiscoi'V, kit. 25?) iiioiitli i>\' till- csiiplmyus \v;is \fry wiilc ;is if llif |ili;iiyii\ rxtciiilol 1h>1o\v the cricoid cartilauv and had tlnTr :ii iriii|itic| in mnki' a doiililc (■so])lian-us, tlu' iinsucccssfid atl('iii]it Kfiuu ilir iniiicli. nivcrticula arc ciicouiitci-cd iiiost dl'tfii in tin' ii|i|iri- part nf tlio osoi>iiag'ns near the cricoid cartilaiic In cvciy csopiiaui'al cxaniinalion the i>ossil)ility of Hndinn' a pouch must he hoi-ne in mind and its exist- ence ruled out. S/niipidiiis. — Tile symptoms ol' a small pouch arc not iiiarki'il (■iioui;li to make tlie examiner do moie llian sus])ect it> prc-cncr. The cliief sjnnptoms are slight dilliculty in swallowing and soon after eat- inj; the regurgitation of a small amount of undigested or putrid food. Where a poucli has existed a long time and has dissected its way downward between tlie nmsi-h'> of tlic neck and pci'haps into the rlicst tlie symptoms, although of tiie same general ciiaractrr, are much more marked. It is imjjossihle from the .symjitonis to din'crenliate such a case from one of phrenospasm and dilatation of tiie est)phagns. Diafinosis. — If the ))resence of a ])ouch is sus|)ected the ]iliysician may give the patient lii>nMitii and then lake an X ray; oi' he may give the patient bird shot to swallow and then take the plate; or he may jiass a bougie. The bougie on its iirsi introduction meets with an obstruction high n)i in the csopliagns and then if it is withdrawn and reintroduced it (■ntcr> llu' luini'ii of the esopliagns and cmitinues on into the stomach. .\o one of ihcsc three methods is as satisfactory as the diagnosis of a diverticnlnm by sight. An .X-i'ay ])late of an esophagus tilled with l)ismiitli often gives the impression of a pouch where muie exists. This is dne to spasm of the esophageal wall. llriinings lias a 1)eaked tubular speciiliim the lower half of which has a slit in the side In using tliis the atti'mjit is made to mm'age the beak of till' spcciilimi in the o|ieiiini;' of the esopliaL;u- and after this has been locate(l. tu liiid tlir dpciiiim ul' thr ponch hy examining the esophageal wall tiii'oiigli the .-lit in the >idr of the instrument. In the search for diverticula the hailodning attachment I'nr the oval esophagoscope is of the greatest sei\ ice. There is usiiallx- no trouble in lindim:" the pinn-li. as the esophagoscope goes into it most ivadily. ••nee in the pnueli, the exaiiiiiK/r sees iio esopliageal imiien ahead. instead theri' is an iinlirokeii wall. ( tii attempting to readjust the Itiiig axis of tlie tiilie to eonl'orm to tlie lung axis of the esophagus -till 11(1 limieii appear>. If imw the window plug is inserted and the poucli disteiidi'd with air the Faei that ti iid nf the esophagoscoi)e is in a cIoscmI cavit>' liecdines clear. .Xni unly tin,-, Imt the size of the pimch can lie made out and the Cdiiditiim of its walls. The bottom of the |)ouch is found in many cases to he thickened and inflamed from the 2G0 OPEKATIVE STRCEKY OF THE NOSE, THItOAT, AND EAT.. rotontioii aiul niaccrjitiun of food. When the |ii)iicli has lu^i u outliiKMl in this way if 1 lie csoplia^'oscopc is shiwiy w i1 hoin'li, at the nionirnt when tlic end n\' ihc csopli- ag'oscope leax'cs the mouth of tlic pimcli and is ojipdsitc the (ipfuinsi,' of th<> osoplia.ii'us t\\() (ipciiing's will he socn throiinii tlic luhc Tlie new o]ieniiiy will proNC on oxaniination td lie the lost opening;- of the esoiihagus. This is l)y far tin- hcst nictluid of dctcnnininii' the in'cscncc- of a divertieiihim. Treatment of EsophnjicaJ Direrticuhi. — If the ])ou('h is large onougli and not too large, that is, if it does not extend into the chest, it may be dissected out. This is the treatment advocated at the Mayo Hospital. Small and medium sized pouclies may be cured symptomati- cally by dilating the esophagus at the point Avliere the pouch leaves it. This is done by first finding the pouch and cleaning it of food and then stretching the esophagus with the mechanical dilator. After this a thread is passed through the esophagus into the stomach and allowed to engage in the upper part of the intestinal tract. As soon after the ether examination as the thread has become well anchored, the metal staff of Mixter with its perforated olive is carried down on the thread and olives of increasing size are forced down on the staff. After a week or two the metal staff will find the esophageal opening unguided by the thread and the thread may be allowed to pass on. The physician soon finds that he can pass elastic bougies also of increasing size, through the esophagus. Lastly the patient is taught to ])ass a bougie of reasonable size for himself. This has to be continued for an indefinite time. Mixter, who has had much experience both with excision of the pouch and with the symptomatic cure by dilatation, favors for the general run of cases the treatment hy dilata- tion. Some day it may seem feasible to cut the common wall between a small pouch and the esoiihagus. When this procedure is attempted it will be carried out if it is to be performed in a surgical fashion, through the esophagoscope. The writer tried this in a rather hesitat- ing manner on one case, and is waiting for an appropriate ease to try it again. The results were mediocre, i. e., no better than dilatation. Dilatation of the Esophagus. In dilatation of the esophagus the whole structure becomes en- lai-ged and acts as a sac instead of a tube. The most common form is a spindle-shaped esophagus. From certain obsei-A-ations the au- thor is of the opinion that a dilatation of moderate degree of the I.Al;v^■c;(lSl•(l|•^ . iiiioNciKiscdrw i:siii'ii.\iii)stni>\ , i;ic. L'lil IdWrr tliinl ol' till' csdiilia.nus is <'<)iiimiiii. if iml ikuihiiI. It i> n rt.iinly not umisual in ilissi'ftiii.n" I'odiii Ittulics. Tilt" lower part of tiit- i'so|iliay:iis is tin.' part most ol'tcii I'lilarniMl. Tlif ililatatioii is dm' citlicr to an anatomic siriftnrc or to a spastic closure at some point. Tiic forms of striclnie have licm discnsscd. Spastic closure, as has been said, is due a> a rule in -pasm of (lie hiatus of tlio esophagus or to spasm of Ilie caidia. l>ilalali(Oi of the eso]>lia.a:iis is spoken of at this i)oint under a separate lieadiii.u, and after diverticula of the eso|tlia.nus ha\e lieeii discussed, hecause the two conditions have to he dilTerentiatcd. The diaiiuosis is made hy examining; the liiiuen di' liie esophaiius through the eso|>ha,uoseo)H'. In the norma! esophaiiUs the wells Iiujj: the exaniiniiiii' tube and are seen to he continuous with the end of tiie tuhe foi' some distance aliead. If tlie esophaitus is dilated the end of the esophajioscojje linrls itself in a laiiic, dark cavt'iu, tlii' walls of which become clear only as llie tube is umvecl slroimly from side to side. The ojieniui;' of tlie esophanns lielow the dilatntinu may not be in the center of the dilated portion, but eccenliii-. Not uidy this, but the dilated jiortion may sa,y below the level of the esophancal opeuinii' and make a deep moat about it. Most often the sa,a:.i!;in cxaiuiner to swin.a: the ]ioint of the olive to the hit and to lisli siic<'essfully for the ojienins" of the eso))lia,uus. I'>allnnuiim the isnphayus smooths the folds and makes the lumen stand (Mil deailv. The treatment of dilatatidii nf tl suphaun- i> to treat the con- <1ition which causes it. This ha- already been i;i\-eu. Foreign Bodies in the Esophagus. Jackson bejiins his diapler on j'oreiiiii bodies in the csopha,i::us with the followiiiii' sentence-; "( (lusiderim;- the iuillianl achiexfinents of esojihas'oscopy in the renii>\al nf l'cireii:n Imdies t'lipiii the esophaiius. it is time to proiioiiner the |n-e\alent use nl' tiie sdund, the x^erlcbrated forceps, the coin calclier, the bristle ami spuniic probaniis obsolete, dan.Jrerous, unsuru-ji-al and uttei-ly unjust iliaMe. There are numerous cases on reemd nf fatal re-nlts from tlii'ii' u>e, and thei-e aic many time^ as many cases that lia\e ni'\ei- been i-ep(iited. " This laiiiiua.ire 2G2 OPEKATIVE SURGERY OF THE NOSE, TIUtOAT, AND EAR. is none too strong, especially when applied to the use of these instni- nients in cases of rough or sharp foreign bodies. Foreign bodies lodged in the esophagus fall naturally into two groujos, smooth foreign bodies and rough or pointed ones. In tlie tirst class are penny whistles, buttons and coins. Prominent in the second are pins, needles and safety pins, fish bones, chicken bones, meat bones and, lastly, partial or complete tooth plates. Coins often lodge for a while and then go down, although there are many cases in which coins have failed to jjass into the stomach but have remained in one position and ulcerated into the aorta or trachea. Pointed and sharp objects as a rule lodge and finally perforate and generally prove fatal. Ordinarily patients come to the physician with the history that they have swallowed a foreign body. This is not always the case, however, because it sometimes happens that they come simply for difficulty in swallowing. In infants regurgitation of food may be the only symptom. Older children may swallow liquids but not solid food and there is a persistent cough. Patients often think that a sharp foreign body is still in the esophagus when in reality it has passed downward. The scratch or abrasion caused by it, and this is especially true of fish bones, for some days makes the patient feel that something is wrong and he interprets his abnormal sensations as the continued presence of the foreign body. Witliout an esophageal examination it is very hard to disabuse the patient of this idea. Patients seldom localize the position of the foreign body accurately. Places Where the Foreign Bodies Lodge. — Foreign bodies in the eso])hagus lodge most often l^ack of the cricoid cartilage. If they are dislodged from here they stop again at tiie lewl of the inner end of the clavicles. Anatomic narrowing is said to be responsible for this. Once beyond the clavicles smooth foreign bodies almost always find their way into the stomach and any smooth foreign body which gains the stomach as a rule can pass the pylorus. It is astonishing Iioav large an object can do this. The author has known a flat, mother-of-pearl button one inch in diameter to pass from the stomach of a one-year-old child into the intestinal tract and to l)e recovered in the stools in twenty-four hours. Procedure to be Followed in Cases of Foreign Bodies. — Tlie his- tory of the case is taken and the parents or the friends of the patient are instructed to bring a du]ilicate of tl:e foreign body if it happens to be a nail, a pin, or a button. The physician can probably furnish a duplicate if the foreign body is a coin. Unless the case happens to be desperate from pressure upon the trachea an X-ray plate is taken. LAinxcost'opv, nnoxriroscoPY, ksopiiaooscopy, etc. -('>'■'> This (letiTiiiiiu's tlio piisitioii of tlic forciiiii body ami in casL- its iialuiv is not known often disc-losi'S it. Xoxt, apiHoiiriatc instrnnu'nts for the extraction of tlie foivi.nn l)oily are selocti'il or nlitaiind. Sin-ci'ss in tho ivnioval of foroiyn liodics loilned either in llie liailna or in the csopli- a.uns depends nimn two things, tiie nieclianieal sense ami inuses are examined in turn. Imiiacted ccmcretions in tlie supratonsiUar fossa often give the sensation of a foreign body. If a good view cannot be oljtaineil after cocaini/.ati(ni and if the foreign body liaiipeiis to lie small like a lish bone or a iiin. the base of the tongue and the jiyriform sinuses are explored with the tip of the finger. Should the foreign body happen to be a coin this maTii]inlatioii is not einiiloved for fear that the gagging caused by it might di-lodge the coin tVinn the grasp of the inonfli of the esophagus and stai't it downward, for tlie same reason .-(nin and liougies are not passed. Choice of the Anesthetic.-jAfter the cxainination of the mouth and pharynx has proved negative the operatnr decides whether tlie examinaticm with tlic tnbuLir siiecnlum is to be caiiicd cmt nihlci- local or general anesthesia, ^fany successful extractions of loiei,:;ii bodies, notably in the Gennan clinics, have been performed under local anesthesia. Kven partial tooth plates have been so removed. Some allowance must be maile for the temperaineni of the patient ICA OPERATIVE sriKiEin OK THE NOSE, THKOAT, AND KAU. ami also for the tciiiperainnit of tlic operator. Tlie aiitlior lias re- ])eato(]ly expressed his indixidiial preference for general anesthesia. If the operator pi-efers the sitting position ami cocain aiic-tliesia, well and good, provided that the resnlts ai'e good; if, (in the other hand, he should prefer general anesthesia and the pnnic ]iosition of the patient lu^ should not be rnled ont of court. Coins and Buttons in the Esophaorus. — Coins and buttons and for- Fig. 197. Penny lodjieil in tlie uiiiier part of the esophagus of a child. The penny is well aljovc the level of the clavicles, that is, it is just ))elo\v the mouth of the esophagus and oppiosite the cricoid cartilage. (X-ray tracing retouched and reduced. Drawing made by the author. From the throat clinic of the Massachusetts General Hospital.) eign bodies of similar form usually lodge behind the cricoid cartilage. These cases usually occur in cliihlren. The first thing which the physi- cian should remember when he encounters such a ])atient is to keep his finger out of the child 's mouth. ( Fig. 1!I7.) If the X-ray ]date shows that the coin is sticking behind the cricoid cartilage and the pjatient is an infant or a young child, it is wrapped in a blanket, placed on its back on the examining table and the head is brought over the end of i,.vi;vx(i(isfSed lllhlel' its own ilhuninatiiin or undtT the illuniinalioii of the head iiiirnii' - and no illumination cfjuals that of the head mirror for short distances ■ — until tlie i)oint of the s|>ecnluin is en,i;'a,i::e(l hehind the i-inij- of tlie cricoid oartilasi;!'. When the cricoid cartilage is lield forwaiil it is l"ossil)le to see down the hiinen of tlie esopiianus almost to thi' level of the clavicles. Coins and Inittons lie Hat a.iiainst the vertelual euhiniii, so that the operator sees only the upjier eili^e of the lini dI' the coin. This appears as a dark, transverse line. The ed.u'e of the cnin heiny- in view it is a simple procedure to jiass a jiair of aiimilar fmceps and rt'move it. The tuhidar s])ecnlnm can lie eiiiploNed in the >aine wa>. It does not, howe\'er, ,ui\'e siu-h a wide lield I'm- opeiatiim as 1lie adjust- able speculum. If the coin is hehiw the reach of the speculiiiu an esopliaii;oscope of a|iprcipriate size is iiitrn'us and carried down care|'nll\ uiilil the foreii:n limly cdiiies into vi(>w. As lar.U'C a lllhe simuld he used a- po-siMe, liecailse it is liUinilialillii' \ ct true, that a small bromdioscope may pass a coin witluint tlu' exam- iner seeina,' it, or detectiuij' it by striking- it with the cimI of the tube. A manipulation which will occasionally biiiiii the cuin to \ iew is to elevate the handle of the tube stronnly and to press the point a.i!:ainst the vertebral column. This saved the author on one occasion from the embarrassment of defeat in the case of the child of a ]»liysici,in. When a button or a coin is lodi;ed in the thoracic poiliou of tin' esopiia.srus as the examinin.ii' tube approaches it t he lumen of the esophai; us chanji'es from the customary rosette to a transverse slit. In this dark trans- verse slit tlic foreii^u body is lodncd an' it has g'one into the stomach. If before or during the examination the patient vomits, examine the voinitns. The fori'iiiii body may be found ill this. (V]u: lOS.) The Bristle Probang". The use of the biistle probant;- is allowalile only in case a bolus of meat or a sinootii foreign body like a coin or a button is lo'l.iicd In-hind tin- ciicoiil carlila'_;e. Its use in siicli cases is often successful and is without daiincr. A more surgical procedure, howe\-er, is tn use the speculuin. When munii foreiiz'ii bodies lilce lisli in- chicken bone- oi- pin- aii- tn he .|c;ilt with the n-e of tile lii'istle 2(i(; >i'i'',i;A'rivK srncKr.v oi'- tiik xosk, TiiitoAT, Axn eai;. ])r()l)iiHi; is riiiiti;iiii(lieato(l. lu the rare cases in wliicli the use of tlu' tubular s|ic(Miluin oi' tlie esophas'osrope fails to disclose^ tlie foreiiiii Ijod)- the bristle i)robang comes a,i;aiu lo its own. If a min di' ;i liutlon caunot be found ajid extracted it is a y-ood ]iracticc, at least ti-oiu the standpoint of the iiatient, to push it down. ( )pcuiu,L;' the sidf of the neck for the removal of a smodth fdi'ciiiii body of this nature is obsolete surgery. Pins in the Esophagus. — When a jiin is lodged in tlu' csojihagus, esp('i'iall>' when its point is turned downward, it does not as a rule Fig. 198. Penny whistle in the uj)por pait of the esopliagus of a seven yeai' okl chihl. The whistle lodged just below the mouth of the esophagus and behind the crifoid cartilage. This is the favorite place for foreign bodies to halt. The wliistle was removed under ether with the author's open speculum and angular forceps. Such eases are best managed with the tubular or the open speculum. (Author's case. X-ray tracing retouched and reduced. Massachusetts Charitalde Eye and Ear Infirmary.) give much trouble in the extraction. When, on the other hand, the l)oint of the ]iin is ujtpermost and embedded, its removal may be very difficult. Casselberry's pin cutter which divides the pin and holds the fragments is practically indispensable for the proper management of such eases. LAUVXCOSC'dl'V, liKdN'Clinstnin. i:sol'll.\(i()S((lPY, K'l'l". L'(i7 Safety Pins in the Esophagus.— ( Ki.n-. 1!>!*.) An open siitVly pin, jioiiit lip. is one (if tile liiiriji'st (if rorciyn Itoilics to rcniow frdni tlic t'sopliiiiius. Tlio Jiiin of till" opi-ralor is to close the pin. Tiiis ac-coni- piisiuHJ, the oxtrju'tion is cjisy. Coolidi'V, sonio (•i,ii:ht yoars a,i;(), was tlio Hrst to romovo a satVty pin runii tiu' csopiia.uns. lie used a satVty pin elosor doviscd liy tin- aiilliur. Since the time of this case other methods ha\ e lieeii devised lor sucressfully ch)sinfj: a safety pin. Within the hist year ,laciin tnl)o the aim of whieh is to dost' the pin and to extract it without lirst pnshing it into the stimiach. .\ few years aRo the author oiiiiinated an instniiiieiit ( l-'ig. :-'<>•_') for closing an ojien safety jiiii, point up. The de\ ii-e consisted of a double broiichdscopi'. one tiiiie iieiim placed within the other. The outer fnlie liad a slit in the side which eii.iiaued the pointe«| shaft of the I in. liotation of the inner tube closed the pin. The de\-ice has been ^illlplilied liy discarding tin' inner iniie. The present instnimeiit is 268 OPERATIVE Sl'lUiEKY OF THE XOSE, THROAT, AXD EAR. made as follows: It is the usual self-liglited bronclioscopo. There are two sizes, the smaller one for the trachea and the larger one for the esophagus. The end of the tube is bevelled on the side. Fi-om the apex of the A' a slit runs upward about two inches. At the summit and at the side of this there is a second smaller and connecting slit. A pointed tongue sei^arates the two slits. Suppose for the sake of illustration that the point of the pin is up, and imbedded in the i-iglit esoi>hageal wall. Tlio tube is used in tlie T'iff. I'OO. .Tackson 's forceps for graspiiis; and pusliing open safety pijis into the stomach for turning. A, illustrates point of foreeps; P., ilhistiates method of procedure. FifT. 201. Schema showing Jackson 's method of removing an open safety piu from the esophagus by passing it into the stomach, where it is turned and removed. The fir-st illustration (A) shows forceps before seizing pin by the rings of the spring end. (Forceps jaws are shown opening in the wrong plane.) At B is shown the pin seized at the ring by the forceps. At C is shown the pin carried into the stomach and about to be rotated liy withdrawal. D, the irithdrawal of the pin into the esophagosco|ie wliicli will thei'cby close it. (From the Laryngoscope.) LAKYXCOSCorY, UltOXCI lOSCdPY. KSOPUAGOSCOPY, ETC. 2G!) followiiiic inanncr: It is I'arrii'il into the csopliajjus until tlic iiood of till' ]iiii can Ito scon. Tliis is irrasiiod witli forci'its and steadied wliile liie slit is turned so that it eu,ii:a,ires the jjointed shaft of the ])in. Then llie tuhe is ]»ushed (Uiwanl until the top ol" tlie slit hrini^'s up aixainst the ci-dteh of the safely pin. This stiiijc i<\' tin' niaiiipninliiins icached the tube is carried a little fnrtlicr down in oiilcr to free tin' point of tlie pin from the esophageal wall. This accomplished tlie liood of the pin is again hcM motionless by the forceps wiiile the barrel of the tulie is rotatetl to the right. By tiiis mani])nlation tlie shaft whicli bears the l)oint of tlie i)in is made to lie in line with the accessory slit. The pin is now ])ushed straight down Die tube. As it descends the acces.'sory slit, wiiich of course is closed Im'Iow. acts as a riiiii' and sliiits tln' pin. Fig. 202. ^^osll('l•'s safety |iiii r<'mo\ iiijr tube. 1, eml iif safety jiiii clo.siiipr tiil)e. 2, Iiood of ]iiii ^.'rasped tlirou!;li tul)o. .'5, tube carried d(i\vii until main slit brinuM up asainst llie crotcli of pin. 4, barrel of tube rotated to the riglit in order to brinjj jdn in line willi secondary slot. .">. ]iin pushed down and closed. The tube and the i)in are withdrawn logi'tiier. A moment's practice out.side of the body \vill show tiiat tliese niaiii|)uhitions which seem com]tlicated when descril)ed are in reality very simple Iliil)bard lias (levised a useful loop gniiic(Tssfiill\ fdi- the closing and removal of a safety pin. Tooth Plates in the Esophagus. Toot 1 1 pi.ites. especially partial I'iates with prong.s, have the unpleasant distiiicti A' being the hardest foreign bodies which the i)liysiciaii is called upon to remove from the e.(ii:r;Y of the nose, tiikoat. and ear. been recorded. (Fig'. 204.) it is an axiom in dealing witli these difficult cases that unless tlie exti'action is fairly easy and is soon acconiplished tlic foreiu'n bodv should lie i-emox'cd li\- an incision tln'ouuh tlu- side Fife. 203. Moslipr's safety iiiii for< of the neck. It shonld he remem- bered, however, that the mortal- ity of this procedure is 12-20 per cent or ten times the mortality of esopliayoscopy. Eough manipu- hilion is not jiermissible. The chief difticulty presented by these eases is the locking of the prongs of the plate in the tissues. Some- times the plate can be tui'ned by careful manipulation so that its short diameter may lie in the direction of the esophageal axis. Killian accomplished the as- tounding feat of cutting a plate in t\vn bv galvauocauterv. Rather Fig. 204. Tootli plate in the esophagus. (Plate b}' Dr. W. J. Dodd.) tliau attempt to tni-n tlie plate it is lietter sni-gery, unless the turn- ing should prove to be easy, to cut tlie plate. For tiiis a power- ful forceps is necessary. A cut- ting forceps has been devised by Kahlcr. The one devised by the author is illustrated in Fig. 205. The tootii plate should lie at- tacked er.rly, before tlie irritation set up by it has caused the esoph- ageal wall to become inflamed and edematous. When this has occurred it is hard to get a good view. Briinings has invented a dilating esophagoscope for use in these cases. LAKVXliOSl'OrY. miOXCimSCdl'V. KSOrilACOSCOPY, KTV. L'71 After all i'SO|ilia,ii«'al cNaiiiiiiatioiis. and ('s|icciall\ aricr tlic iiiaiiip iiiatidiis lu'ccssary tor tin- dilatation of a stricture m- Im- I lie iciiKival (•!' a I'oii'ijin hody, tin- patii'iit cimiplaiiis nf a sore tliroat. Soniclinics lliis is si'ViTi' and niaki-s tin' swallowinu; of i'liod dil1ic\dt Tor a IVw days. After the stretchini;: itf a stricture tiifri- may Itc pain aluiii: the course of the esophai^us and shar)) ]iain in the epiiiasti iuui. Also there may he a rise of temperature fema of the side of thi- neck. These unpleasant symp- toms, whieh, put in persjieetive, must he reyai'ded as trivial, soon dis- apjiear under sim]ih' treatment. Fig. 205. Mosliei-'s iiistninuMit for outtinjj a tootli )>lat(; or hiiKo pieces of lione. A sniiiUcr instniniciit of tliis same jiaUi'm cua In- liaiil)le aad extracting flicni. GASTROSCOPY. History. — In ISSl ^likuliez. who did so niueii pioneei- work in osopha.i;oscopy, decided after e.\|)erimentation that the .na.strosco])e must 1)0 rigid. The men who had attacked the problem of irastroscopy liefore this time had used instruments whieh were juinlcd. Mikulicz, however, jdaced a hend in his ^astroscope in order thai it uiiiilit accom- modate itself to the curve of the vertehral column. His instrument was clo.sed and the picture of the gastric mucosa was jji-oduced by pi"isms after the fashion of the cystoscope. Hosenhcim al>i) worked with a rigid tnhe Inil he discarded the bend. Tii tlu' construi-tion of his tube he also nuulc u>r u[' lenses and prisms. ll remaiueil for Jackson, using a straight instrument without optic apparatus, to make gastro- scojjy feasible and comparatively easy, lie elongated the esophago- scope of Eiuhorn and adtled a drainage tube on the side, lie dem- onstnited tluit such an instrunu'nt couhl be i»assed into tiie stomach readily, and laid down the axioms of modern gastroscopy, namely: The gastro'^cope must be passed by siulil. The stomach should be examined in the culhipscd >tati' In pciiiiit cleiiniim nf ihc nmcosa by mopping, and \<< ( naiile the operatoi- to palpate the walls of the stomach with tile en>\' llir laMc is alx.nt I'.d <-ui. lii.u:lu'r tlian tln' foot. The assistants are jilaeeil a- in lii kcpi wiilc oiten. The jaws are kept a^iart by a i^ixii placed in the left corner of the mouth. The assistant who holds the head also keeps the fjjag in place. The patient is drawn toward the operator until his shoulders are clear of the oi)erating table by four or six inches. The ixivj; is inserted on the left side. The assistant sits on the right nf the jiatient on a studl. His right leg is held in the kneeling iiositinn while tlic left foot is sup- ported on a stool L'li inclifs lower than the tdp nf the table. The assist- ant's right forearm is jiassed beneath the neck dl' the patient and supports it. The right hand grasps the ninutli gag and keeps it from slipping. The left hand of the assistant rests on his left knee and gras])s the to)) of the patient's head and at the sanu' time bends it baekwaid and upward. The exact amount nf backwai-d bend and of n))ward pressure reipiired is detennined liy experii'Uce on the indi- vidual case. Passing the Gastroscope. — The gastmseopo should be ])assed gently. If tlie tube does not advance readily its position i- w iohl;- and it should be changed. The tube Jiuist be well Inbriealcd with vaselin. The gastro.scope is grasped and held by the right hand of the operator after the maimer shown in Fig. 207 (Jackson). The forelinger of the physician's left hauil is inti-odnced into the right ijyriform fossa of the jialieut and tlm end of the gastroscojie is carried down with the finger as a guide. As the tube descends a cer- tain ainouiii of upward leverage is made with it on the base of the t(mgue and the epiglottis and finally on tlir cricoid cartilage. The linger of the physician can si-ldoin feci t lif ciimid carl ilage in the ailult. This is inmiiiterial because once the end of the gastroscope is well in- .serted in the right pyriform sinus it 'litly, the obturator is \vith(h-a\\ii aixl the eiineiit I'm' lightiiiii- is turned on. From now on the tube is ]jassed by sight. Tiie csoi)hai;-eal hnneu must be made out ahead of the tube befoi'e it is a iiiti odm-tion of the gastroscope, vicwrd riniii alii.vc liv tlir operator looking dowiiuard. (After Jackson.) observer sees a central rosette-like opening ahead of the tube. The esophagus leading down to this is smooth. (Fig. 169.) The end of the tube is plac(>d against this opening and then a little in-essure or a little -deepening of the anesthesia allows the tubt' to slip througli into the abdominal portion of the esophagus. The picture seen through the tube at once changes. Instead of smooth walls as before, the esophagus is now thrown into long, thick folds which center at the left of the field. (Fig. 170.) No regular opening is made out, but if the end of the tube is crowded to the left and advanced slowly the folds part and the irreg- ular dark slit suddenly bursts open and the tube is in the stomach. If the cardiac opening of the esophagus is in a state of spasm the long longitudinal folds of the abdominal esopliagus swing fi'om left to right and radiate from a small circular o[)cuing which is placed in the left (piadrant of tlie Hehl. i.AnvNi;osc(t!'v, itKdNciioscdi'N', i;s(pi'iiA(;iis(i>i'v, etc. '-i-> In order to juiss tlic ;iliilniiiiii;il rsopliiiuMis it is iici'i-ssiiry smiictimi's to hi'iul the lii'iid Mild lU'ck of tin- luitifiit lo tlu" ri^dit. Full JiiicsUicsiii is iiocossary for passiiiu: llic liiiitns, tlic siiliplirciiic imrtiiiii of lln' oso])li;i<;ns and the cardiac (ipcninti'. Wlicn tiic irastroscopc has entered the stomach it is necessary, owini;- to the small liehl yiven liy the tulie, to liave a system in the examination. Then- are two plans of exjiloration. First the gastro- scope is carried straiuht down to the greater cnrvatnre. inspecting on the way a strip of the anterior and tlie posterioi- walls. If the stom- ach is not snlliciently collapsed one wall must lie taken at a tinu'. After the (irst strip has been gone over the end of the tulie is moved slightly to one side and brought up an e\;nnine(l strip hy strip. Tiieii the second nietiiod of ixaniination is iiraeticed. This consists in passing the tube down to the extieme li'ft of the greater curvature and then swinging it along tlie line i>\' the ureati'r eurvatiire to the rigid. Having reached the right limit t ln' 1 iiln' is \\ il hdraw ii a litt Ic and sw un:^- hack like a iiendnluni. In this way, id re.-itini; steji hy step ami swing- ing the end of the tube hack and forth fr(im rii;lit \t> left, the examina- tion is continued until the cardia is ii'acheil. Tln' examination is greatly aided by hax'ing an assistant manipulate iiy palpation the unex- plnicd p(irli(in> (if the stomach in fmnt of the end of the tnlie. For this jiuriiose the patient may he tnined lir>t on one side and then on the othei'. During these niaiiipiilat ion> liic tnln' is withdrawn into the esophagus and then jiushed into the stomacli again when the new jtosi- tion of the patient has been ad.jnste*!. if the patient begins to retch wjien the Inbe is in the stomacli it is w it lidiaw ii into the esophagus above till' diaphragm. The vertical diameter of the stomach is deteimined by nieasure- nieiit. The distance from the teeth to the caidia is ascertained and then the gastroscope is iiu>lieil down to the urealer eiir\alni'e and the distance from the teetli determined auain. The diffeieiiee between the two measurements is the \-ertieal diameter ol' ihe >tomach. in these manipulations it is necessary to ;i\-oid pn^llinu the greater eurxaturc cm. (fourteen liichiv- ). The end of tlu' tuhe tend- to drai;- the stomacli walls along with it. This can be avoided by withdraw iim the tube a little and then carrying it down again. The average time i(M|irnc(| to examine the stomach is thirtv miiniti's. _'(() OPKIIATIVE SriUiKllV OI' T 1 1 K .\(.)SK, TliliOAT, AM) EAR. The Area of the Stomach Which Can Be Explored. — Vertical and iiiraiitile stomachs afford the greatest ranye of ex|iloratioii. The more liorizontal the stomach the less the range. The lateral movement of the hiatus makes it possible to examine the stomach over an extended area. This lateral movement varies with the individuah It is greatest in feeble, elderly and emaciated patients. Also the deeper the anes- thesia the greater it is. The anteroposterior mobility of the hiatus is of but little use. If the diajjliragm were rigid gastroscopy woidd be much limited. ( )wing to its flexibility the end of the tube can be made to pass at the hiatus through an elliijse the small dianu^ter of which is 5 cm. and the large diameter 15 cm. The long axis of this ellipse is placed laterally. The full range of the thoracic aperature is made available by shift- ing the iiead and the neck to the side. The pivotal or rocking i)oint of the gastroscopc is in the thorax not at the lieginning of the esophagus or at the hiatus. As a rule the tube can be made to ijoint in turn to either superior spine of the ilium and the greater (nir\atnre can be forced down to this level. Any anomaly or disease of the esop)hagus may render gastroscopy dinicult or im|iossible. Contraindications. — Tlie contraindications to gastroscopy are tho usual conditions Avhich make the giving of an anesthetic unsafe. Dangers. — The dangers of gastroscopy in careful hands are only the risks of the anesthesia. The observations of Boyce show that the blood pressure falls when a rigid tube is introduced into the esophagus. This, however, lasts only a short time. As esophagoscopy and gastro- scopy are done by sight there is less danger than in the passing of a sound. Difficulties. — Any physician who has had a training in the use of the microscope can look through the gastroscope and see tlie j^icture which it presents. If he has not had this training it takes a little time for him to teach his eye to see. Lordosis, Potts' disease and other diseases of the spine make gas- troscopy impossible. The Stomach as Seen Through the Gastroscope. The Normal Stomach. — The folds of the stomach arc constantl\- changing so that no two views are alike. When the gastroscope enters the cardiac opening the folds extend straight on from the mouth of the tube and a small tunnel of open stomach is seen. As the tube is carried down through this the folds take a lateral bend. Finally, the tube brings up against the stomach wall. This appears as a flat surface l.AKVNtiiiSl'dl'V. lilloMllnsCiil'V, l.snl'l I AfiOSCOPY, ETC. -(i wliifli IS soiiictiiiii's iiiciltlril. s(iiiu'tiiiu-s sli.iilitly rril. Tin uri-atcr \vs tin- tiilic lo piisli it (lowiiwanl sonic in ini. iict'orc it resists. ^Viu'Il tin- tiilic is witlulrawii tlic sluiiiacli wall, wlii -li lias 1)0011 flattoiioil a.yaiiist it I'ttilows tlio tul)o uiiwanl tn the ii(i>itinii wlinc tiio tubo lirst oiioountorod it or a littlo liii-lior. As yot not fiioii.uli is known aliont tlio aiTaiijicnionl ol" llio folds to atlonipl to ^loui) thoni. Tlio imu'osa of tlio osoplia.mis and that of liio stuniacli at tinios are strongly contrasted in color. The color of the esoiihagus, however, is more constant. Tlii> osoiiliamis is a.-enornlly a pale ])iiik wlicroas tlio mucosa of the stoiiiarh \-;iiir- fi-oiii a similar |iiiik In a (lri')i criiiisdii. .lackson considers that tlio color of the oinpty stoinacli varies i'vmw .1 pale red to a jialo jiink. The nincosa ajjpoars moist and iili stoning Init loss transparent than the iiuirosn of the esophagus. In the walls nf the empty stomach vessels arc unt usually visible. The i>ylorus is, of course, found mi the rinlM cxticmity of tin' greater curvature. As the lube appniadics the folds guardin.i; il. il seems like a slit. Tliis gives way wiien the tube has fully icaclicd the opening, and a round opening appears soiuowhat like the rosette made by the esophagus at the hiatus. The oiiservci- makes sure that the opening is the jjylorus by advauciiiL; tin' tube iiitn it until the small annular folds of the duodenum come into \irw. If bilf mlored Huid escajjos njjward at this ])oint the hieali/alimi nl' tlie pylmii- opeuing is determined 1)eyond a doubt. The Movements of the Stomach. — Beside tiie ordinary peristaltic movements nf the sloiiiaeli thei-,' arc movements associated with the heart and with re>piratinn. The movcnu'iit^ transmitted frnin the heart are best seen just as the tube enters the cardia. They come from the heart and the descend- ing aorta and are syuclii-nnou^ with the beat of the heart and the Idood wa\'e in the aorta. The respiratory movements in the stomach are loss maiked than in the esophagus. Just as in the oso]iliagus, there is, in hirii, a nega- tive and a |io>iti\<' in-essurc 'i'liis alteration causes an iiillow and an (jutflow of air. Tltc Peristaltic Moroiioits. — The piiistali ic ni(i\-eiiieiits of the stomach wliich result from the aelion nl' \\~- own lilnes can be fre- quently si'oii. These, however, are not as iiiarkeil as the antiperistaltic movements. The latter are of two kinds, the rovorst-d ])crislaltic movement, which is seen mostly at the I'undus and causes vomiting, and the antiperistaltic movement of the ilnmlciial \aiiety which is confined to the region of the pylorus. Tlie pvloric third of the -toinacli is the nio>t unstable part, .lack- 278 OPKRATIVE SURGERY OF THE XOSE, THROAT, AND EAR. son's descriijlioii of tlio a])ci-tui-e seen tliroun-li tlio tube as it cii)proaches tile pylorus states that in (Hie instaiici' the pylorus was surrounded by a rosette of annular folds. In anothei', the folds were larii,er. These curved in ahead of the tube and then Avere pushed aside by it. Fiiudly, one large fold was encountered and when this was thrust aside a slit came into view. Tliis chaiiiied at once into a rounded opening Avhicli was the entrance to a shoi1 tunnel in the lumen of which there were numerous small folds. From this ui)ening and the tunnel beyond some bile-like fluid welled up. Gastritis. — Jackson tlms describes the gastroscopic findings in a case of gastritis. The walls of the stomach were covered with a thick past}' secretion and tlie folds were thickened. In another case the secretion was in patches. In still another case the color of the mucosa seemed darker red than the normal. In only one case did this observer find dilated capillaries such as are seen in chronic inflammation of the esophagus. Peptic Ulcer. — Jackson has had the courage to examine the stom acli in cases of ulcer. He reports his findings as follows: The first ulcer was a dirty grayish-yellow and was not i)unched out. The ulcer of the second case was punched out and had slightly infiltrated edges. In another case the ulcer appeared as a longitudinal slit. In still another the bed of the ulcer was dark and rough. Malignant Disease of the Stomach. — Malignant disease of the stom- ach gives a \arying jiieture in l<).i;>' i> >■'• inilis- tiix't by reason of the (.'vidciit-o ["nniislu'il hy tlu' slu(]y of this sul),iL'ct that there is some (luestioii as to wliere it riiiiitt'iiUy belongs. It is tlio <-onviction tliat tlie larynuohigist and otologist have the greater elaini tliat impels tlie author to treat this subjeet from the sjieeialist's stand- ]ioint. The otolaryngologic surgeon is l)etter (|uali(ied to do this work simply because he is so Avell informed on the re(|uirements of these structures from tlicir anatomic characteristics and their physio- logic functions. Cosmetic considerations do not constitute the sole reason for the performance of these o]ierations. The deformities or malformations which call for ])lastic i)roced ure may lie real or imaginary. The latter comprehend slight devia- tions from the iiDinial, \i ry much exaggei'ateil liy the imlixidnal, on account of wjiich the jiatient liecomes the ))ati-()ii of the lieaut\ doctor. The ]isychiatrist would he of moi'e serxiee. ()iily real (leri.iiiiities or nialfornuitions are consicleicd in this eliapler. Kach case is a law unto it'^elf as to the teclniic, ye] many \arieties and iiiodilications of meth- nds must be descrilied. Tlie jmrpuse here i- tn illustrate r;itliei' lli;ni to give e.xtensive deseliptidUs nf (lelinite nietllnds. History. — Keconsti'uetive snri^ery with special rcferenci. id i-hiim- plastic operation dates back tn llie piiMications of Tagliaco/.zi in l.'ili? (Figs. 208 to •2-22) althoimh earlier repoils of |)lastic surgery of the face were said to have been inade hy lleiiedietus in 14IL'. Taglia<'ozzi "s work, however, \\a~ nnt taken np \er\ entlinsiasticall\ nntil about the eighteenth century, when a large numbei- of snr-cons ivc(igni7.et. I'.nck. Andrew-. I'linc. i;,,herts, Koenig, Israel, .loseph. I.an-enlieck. Olliei-. Xi'lalon, Kee-an, h'oe. 280 OPERATIVE SURGERY OF THE NOSE, THROAT, AXft EAR. V\iX. I'll. ^i-. 1^1. 'l. Fig. 215. Illustrations from Tagliacozzi 's work. Fig. 216. ri,.\>iii >i Kcr.itv oi' TiiK xosi', and kau. 281 Siiiitli. Kolk', lu'ViTtliii, Wolt'i'. KiMiisc, 'I'lilcrsrh. (icrsmiN, Li'mt, ( \-ir) I'xck ami many otlu'is. Indications. In i-onsi.li'i-iiiL;- thr in.ii(;iiinii> Im- pl.-istic sii !•;••(-• ry of llu' iKisc ami llir car, \vi' liavc in iniiid llir curiii'lidii nl' defects; first for tiio ro-i'stalilislmiciit nf ccrtaiii riiiifli(iii>, sin-li as n-sjiiratioii, plioiia- Fig. 21S. Fig. 210. Fig. 220. Fig. 221. Fig. 222. Appliances and instninicnts cmiiloycd liv Tagliaoozzi. tioii, de.iJ^liititioii, audition; and sci-ondly for cosmetic reciuirements. Of tlie. liy far llie most im|)oilaii1 from the operator's point of view, bnt llic latin- is oft.'ii of -icalcr interest from lliat of the patient. At the same lime llie eosiiielic iuilication must not lie undervalued, as by reason of deformities and malformations many unfortunate individuals arc s and prixileu-es in life 282 OI'KKATIVIO Sl'KtiERY OF THE NOSE, THROAT, AND EAR. w itli their fellow-inaii. It can l)e stated uiiliesitatiiigly tliat even wlieii the licst results are obtained cosmetically, the patients are still much liandicapped by their appearance, since such results still leave them ol)jects of curiosity and comment. This of course is more especially true of extreme deformities of tlie nose and ear. The so-called better classes are annoyed by certain minor deformi- ties, malformations and blemishes which injure their jjride, ])nt which otherwise are of little consequence. However good a result is achieved by the operation, the patients are never entirely satistied, and persist in their desire to have more work done. These unfortunates mostly self-centered and neurotic individuals become the prey of the so-called "beauty doctor," and many bad consequences result from the unscien- tific surgery of the latter. It is best to attempt to discourage them from having plastic oiiera- tions performed; furthermore, great care should be exercised when operating on them to have the patients or their immediate family as- sume all the responsibility as to the cosmetic results. As a preliminary to the performance of plastic surgery it is neces- saiy in order to obtain the best results to ascertain whether or not some general or local pathologic condition, such as lues, tuberculosis, general anemia, malnutrition is present. These are among the most frequent causes of failure. A local chronic skin infection, as eczema or graniiloma, will retard or ju'event healing even if the plastic has been perfect. Important Factors. — Since there are so many varieties of deform- ities there are naturally a great many procedures for their correction. After all it remains for the individual operator to use his judgment as to the selection of a particular type. Again, frequently a plan must be changed during the operation and an entirely different i)rincii)le ap- jdied, or perhai)S a combination of diiferent principles ov operations must be adopted. It is of great help to know the condition and position of the struc- tures previous to the deformity. If this has existed from birth, the normal condition of the parts should be known. This is especially im- portant in nasal and ear plastics. For instance, in constructing a nose, the surgeon is veiy fortunate if he can obtain a photograph taken be- fore the deformity was acquired. Sometimes photographs of the closest relative who is known to have resembled the ])atient before injury, are of great service. To make a nose of the Roman style when, as a matter of fact, the patient had a short stubby, thin, straight or bulbous nose before, would be ignoring an inqiortant jirinciple. iM.ASTic sri;(;i'.i;v oi iiii: nosk anh i;,\i;. •JS3 Tu cm- |iliist'u' tlic ()|i|Misitf v:w niny lie used ;is a inmlcl. In tli.' in.ijiiiity 1)1' iiistaiK'cs. Tlir selection of the inellm.l .if npeiatixc procetiuri' is iiiituially (if "■Teat iiniiortance. A ilelinite rnle canndl always l)e laid down since, as has boon saitl. each case is a law iinln itsell'. and ihe dpi ratiiMi indi- cated varies Avitli the a.iic, condition, and \dcation of the |iatient. A rule Avhioli tlio writer has rolloweil is to ein|iloy at lirst a inethoij in volvini;- ni) loss of tis>ne, ane of I'ailnre. in other wcii'd-. it i- hot to foiiii the na>al >tiin-lnre liy employing- traiisplaiitalion method- in prelereiiee to n>inL; llaps from the face or I'orcdiead. Similarlv intranasal are to he preferred to external methods. Flajis should he i'i-operl\- ,-electeil and pn'paied. 'I'hey >honld he niea-nred ont previons to the operation, one third larizer tliaii the de- fect, and made very plastic, that is, with not too niucli UHilerlying tissue. Making' them too thin or devoid of suhcnlaneous tissue is even a lii'eater mistake, since their iionrishmeiit is thns likely to he affected. It is necessary in make their pedicles eoiit'orm to the hlood -apply: that is, to construct the flaps so that the i; renter diameter of the vessel is in the jK'dicIe and not in the jieripheiy. If the pedicle is too ifreatly twisted sti'annidatiou of the Haps may occur. While jierfect cleanliness or asejisis is practically impossil)le in inisal surg'cry, uii'at care vlnmld he taken not to introdnce foreiu'ii micro(">r' form and si/e of defect in the skin may he co\-ered with- out causin.ii- a marked deformity in the i-e-ion fmni which the tissues are taken. 1. Defects may he coxcred hy makin-- incisions in certain direc- tions and unitiiiu- in the op|iosili' ilirection, thns hioseuin<>- the tissues ami uuitinii- them in the iiest |iossilile manner so that the tension is the sli.i^htest. Connter incisions, to relax the tissues ami to facilitate easy approximation of the skin, are also freipiently employe.l. I^'ii;'. 223 dc nstrates various shapecj defects and the method ,,[' co\-eiini;- them. The arrows ins. 'S 1 1 1 1 1 r Fig. 223. Incisions and flaps for closing defects. (Celsus.) ri.Asiic sii;i;i:i;\ ni rm; nh-i-. axp KAn. 285 by iiu'.ms of ;i iict'dlt', snip it olT w itii kiiil'c nr s<-is>iits jiihI jilacc it over tlio |irci)ariHl irramilatin.y: siiri'ari'. (Fins. ■_'"J4 and -'2').) (B) TliiiTSfh n'rafts arc ohtaincil citin'i- from llif ar • ii'ii' (fvoTn i)arts containint;- little iiair) hy placinu- the >ltirti-li and em])h)ying a very ici'i'n razor or special knife, i h'iL;. I'l^il.) With a steady side to >ide nioxcuH-nt, tlu' epidermal layer is ciil off and foldc(| on the knife. Hy means of this knifi' the uraft is carried over to th<' granidatin.!.;- area to he eo\-ere(l, and liy the aid of a neciHr it is laid and spri'ad out on the liefeet. I'articnhir attention is paid to the nnirtrins of the nraft. so that tliey arc thoron^ldy spread "\\\. and noi i-oHeil in. Tliis should he done as carefnlly as when piepaiiiiL; a niiei-oscopie s]ieeinien. The next uraft shonld not lie applied too idose to the lir-t. Fig. 224. Making; Rcvenliii yrat't. Revcidiii i;ralt apijliiil. ami so on, since the cpidcimis yrows (piite readily from tlie mai-.uins and liiiis hridi^'es o\-c|- iikh'c easily than when the grafts are |ilaeed too close to one another. The ui-afts shonld not he loo lariie, since those do not snrvi\-e as well a- small ones. Aftci- the entire defect is covered, the lirafls ;ii-e held to liii' l; I a 1 1 iHa t i n i; sniface hy means cither ol' strips of paralhn oi- of riihber tissue in the f(n-m of lattice work. (('I Wolfe oi- Kranse nrai'ts are transplantations ol' the entire skin, that is. of .■pitlndinm and coi'inm. These slioidd he devoid of very nmcli snhcntaMcniis fat and -honid not he toe. lari;e. since their vitality is nineh interfered with when they ai'c of more than one half inch in size. These particle- uf skin nia\- contain hair w he|-e such is re(piired, as f(n- the foiniatiim of I'yi'hi-ows or on the n|ipei- lip in the m;de. to form a ninstache. 286 OPKItATIVK SmUKItV Ol' THE XOSE, THROAT, AXD EAl!. (D) Epitlit'lial (Aussaht) Spread. Hy moans of a i-a/.m' tlic sur- face e))itlieliuni is scraiied until a slight oozini;- of senim (Imt not lijoiiil) occui's, and then this sciapod oil' cpilhclinin is siiicaicd mi llic i;Tanidatin.n' surfaces in a xcry thin layer. It is liest eux-iTcd witli a thin layer of paraffin before covering' with gauze and bandage. Recording Cases Before, During and After Correction. — As has Ix'cu stati'r than il' tin' face is IM-dtniilinL;-, nv dt' the prnn-natlmus lypo. Aii'aiu. if llic face lie nl' the luui ]irntni'iiiiu' xarirty, cu-tlioiriiatlunis. a short ikisc is licst suited to it. I li'of. 1 i'lie next stop is lo ol)taiii a very (k'taileil liistory and to iiiako a thoi(iii<;li local and goiu'ral examination. Intranasal and pharyn.iical inlianiniatiny and ohstrnctinji' conditions ninst 1)0 noted as ■well as tlio local patliolotric cliai\ucs that may Ite ]iresent on the external nose or ear. As to tiie i;ciiiTal ciiiiilil imis cxistinu'. syphilis, t ulicrcnlosis, severe anemia, and maliiiitritinn iiiu>t ircrixc tln' stiidi'sl recognition. Fig. 227. Stereoscopic pliotograj)!! of plaster cast. A nnmber of i)hoto.irraplis from every angle should lie taken. The author is now accustomed to take stereoscopic piiotogi'aplis, which are avast iiiiproxeiiieiit ii\ei- the siiiizle exposure, since they liring out much more clearly the \arious tlelects, liowever small they may be. Plaster casts (Fig. 227) are excellent positive records of tlie con- dition i)resent. Tlu' rollowiug method is used i'oi' making casts: Fill a one-half pint howl iialt' full with tepid watiT and plaster of Paris (dental) until the latter is submerged. I'onr off excess water and stir to proper consistency. When one desires ipiick setting of the jilaster, a piucli of table salt is introduced into tin' warm water before th(> plas- ter is added. Before a))plyini:- it to the lace a line iayei- of vaselin is spread upon the skin ami the anteiior nare> or tiu' nasal apertures are plugged loosely with cotton. A small rubber tube is kejit I'eady to 288 OPERATIVE SURGERY OK THE XOSE, Tlli'.OAT, AND EAlt. plnco into the patient's mouth at tlic hist nionicnt, just before tlic jihis- ler is put over the mouth, in or(h'i- thai the jiatient may breathe whiU' the ])hister hardens. The mask is begun by phacing the plaster in tliin layers a!)out the forehead over the closed eyelids, cheeks, lower .jaw, nose, u]3per lip, lower lip, and closely about the tube. This tirst layer is reenforced with a goodly quantity of plaster and the mask is allowed to liaidcii. The subject should avoid any facial movements, in fact he should lie jterfectly still until the plaster is set, which takes usually from three to five minutes after the mask is finished. The removal of the formed mask is now veiw carefully manipu- lated so that it may come off in toto. If it should unfortunately bi-eak into two or more parts, it is carefully placed together and cemented, as is done by the dentist in making jilaster casts. In fact this whole procedure is so much like the making of dental impressions that the author would recommend that a dentist be emiiloyed for the ])urpose. To make the positive from this mask is the next procedure, and this is accomplished by painting the inner surface of the thoroughly dried cast (mask) with separating fluid and pouring into it plaster of Paris until it is thoroughly filled. This is now allowed to li&rden and di'v, when the mask is carefully picked off from the positive at the i)ink line of demarcation of the fluid. The chips and defects on the positive cast, caused by this tedious process of picking off" the mask, must be repaired with plaster. Secondary casts and photographs, showing the eff'eet of treat- ment, are of service as additional records, while stereoscopic photo- graphs are even better than plaster casts. Rhinoplasty. Classification of Nasal Deformities. I. According to Roe : Hoiiy j'Oiticni portion Convex Ouncavo SiiatuUiteJ Deflected Tip Willis Collapseil Expaiidea lOx.-essive (leliciciit tissvie Deflection from median line n.ASTic sn;(iKi;Y ok tiik nosk anh kai;. 2Si> rr. AccuKMNi; 1,1 Kill. IK. (Ill ilftici.'iirics ]..i rt Iciiliirly rt-ri-ralilt' tn p.-iralliii iujcctiiiiis. ) 1. AnU'i-ior Xasal |)i'lic''n'iii'V Superior one l liiiil. Middle oiu'-tliinl. liifcrior oiu'-tliinl. Superior ono-Iialf. Inferior one-half. Total. Total 2. Lateral Insunicieiicy 3. Lolmlar Iiisul'iicieney. 4. Iiiterlnliulai- lii^iirru'iency. ."). Alar I )i'rn-ii'iicv ) I'liilateral. I P,i lateral. riiilatoral. r.ilateral. Ck SiiKM.iilal hcli.-ieiK'V ) i'artial. ( Complete. 111. -Vutlior'.s (.'lassilicnlinii. A. Eliulogy. — Traumatic, Luetic; t'oiiiivuital ; Tubercular and Lu- pus; Simple infectious, as abscess; i\n-iclioiulritic; Atheromatous, or Acne Rosacea: Xeojilasiiis, ninliii'iiaiit and lieiiiuii: (Iross liiiai;"inati()n. (ii- \'auity. Ii. Funii. 1. Larue liunip nose. 2. Twisted nose. .'.. Kinked and doiilili' kinked. 4. Sa(ldlel)aek. kinked and witli wide alu'. ■"). i*iu(^iK'd pointiMl, \\iili c'dllap-ed ahe. (J. Flat or squasheil, witli lar.ne ak-e and lai',L;i' xcstilinles. 7. Xotchcfl. 8. ("ou.^'enital aiisenee u\' |ii-eiiia\illa am! cnlniiieliar cartila.n'o. 9. Pushcd-in nose. 10. .\bseuce of external nose and septum. 11. Unilateral defunnities. 12. Hare lip nose. l-'k ( '(niiliinalioii of nasal and fa'^e dermiiiit ics. 14. I'nmiij III- liyperl nipjiir nose. 290 OPEItATlVE SURGERY OF THE NOSE, THROAT, AXI) EAR. Methods of Procedures in Nasal Deformities and Malformations.^ T. Gonnan or French method, iiichuliny skin <;raftin,i4'. TI. Italian or Ta.si'liaeozzi's nictlind, witli niodiiications. HI. llinihto or Tmlian method. IV. l)oid)h' transi)hintation method (toe to hand, to nose). y. Finder method. \'T. ( 'lavicde metliod. A'ir. Tm])]antati()n method (parathn, etc.). A'lII. Reduction method. IX. Artificial method. X. Ortho})edic method (Carter's clamp, i)ins, etc.). XI. Intranasal method. XII. Miscellaneous and combination methods. I. German or French Method. (Facial.) When a subtotal destruction or an unilateral defect is to be cor- rected this method gives excellent results. The transposition of the newly-formed parts may be accomplished by sliding or pedicle forma- tion. Small defects may be covered by rearranging flaps from the nose itself as shown in Figs. 234 and 235. The nasolabial fold offers the best place for pedicle flaps. Flaps for building up the jironunence of a nose as well as for forming an epi- dermal lining of the nose are frequently formed from the cheeks and turned outside in, as shown in Figs. 228 and 229. Columellse may be made from the point of the nose, from the outer part of the middle of the lip, or from the mucous membrane of the lips, and passed through in buttonhole fashion, as shown in Figs. 252-2(50. It is most im])or- tant to loosen the parts thoroughly and to effect perfect adaptation of the margins. Portions of the nasal bones, nasal processes of the superior maxilla or of the premaxilla and the floor of the nose, are utilized for support of the nose formed after this method. (Figs. 286 :and 287.) Other materials for support are cartilage from the septum resected from other jaatients, or, clavicle, and bones from the toes, Angers, and the anterior surface of the tibia. (Figs. 307-314.) IM.ASTIC SIIICKIIV or TIIK NdSK ANH KM!. 2f)l C'UHRKCTKIN 111 r Ml.Al'l'.l! \I. A Nil PaIIIIAI. I )|.I ICI K.NCI I'.S (IK TIIK XdSK. Legg's Operation. 1. .M:ikc ;i sili.-lll Idlimii' sIi;i|mmI |1;||i. with il- lliimv |irilirli' .'it tllC iiiisohibial .-ivaso. (Fii;-. lil'S.) -. Tiini ovor witli skin surl'aiH' iiitu llic \ fsliliiilc. .iml .-uliiii' all aliout tlio niarit'ins ol" tlio ala. wiiicii have licon rrt'siiciicii u|i. aihl close <'ivatod di't'wt on tlio cliook. ( Fii!. i'l'!>.) Fig. 228. FiS. 229. Lefis's (iperatidii for poirection of unilateral and pr.itial dcru-icncics oi: (he nose. (hn WrrI: Lahr. •'1. Sl'vit the iiodicio aiiil irmljust, lln'ii siilurc to ihc ri'inainiii.n .liar iiiaru:ins. -!. t n\i'i- the llap Willi a tliin TliiiMsrli i^raft. Koenig's Operation. 1. Make ;i >iMiiiliinar iiH-isiiiii tiiinimli llic ala rrniainiii,ii' and dis- soct the niariiiii away. ( l-'in. I'.'lu. ) 2. Take a Wolfe -i-ari iVuin ihc ihick skin nf the hack of the nrck and iiiiiilant into the alar drfcct. I l-'i.n'. 'I'M.) Von Esmarch's Operation. 1. ]\rake a tlap in lii.. n.-i-uh-ihial Inhl. i Ki.i;-. 'i:!--!.) -. 'rnni nil ii> |irilicic with the skin outwards and snlnre. {V'wx. •2Xi.) '.'). Mveiit iiaii\ >c\cr till' |icdicli' nnc week later and readjust jiarts. 202 OPEKATIVE SURGEHY OK THE XOSE, THUOAT, AND EAR. Fij;. 2-M. Fig. 281. Koenig's operation. Fig. 2:^2 Fig. 2 ^'ou Ks^iuaic-h 's operation. Pig. 234. Fig. 23.5. Von Liuigenbock's operation. ri.AS'i'ic sri;(;i:i;\ m iiii. nosk and i;ai!. 293 Von Langenbeck's Operation. 1. Frcslii'ii up till' surfarcs on llic dcrrc-t. -. MaUc a flap on tlic lioaltliy siilr «\' tlic imsr with llic prdidc over the sid.' of tlio (li'tVct. (Fii--. •2:U.) .'!. Pi-SL'ct this flap loose and stitrh inlo ihc pivjiaivd dciVct, luiiiiii^ ill the lowiT niariiin of tlu' Ha]i so as to make tiio nosfril have a dciinal snrfaco. (V'liX. '2'.\').) 4. Covor llio nowly-foniird delect eillicr with si Syme's Operation. 1. 'I'wd l;ilri;il Maps arc iiiadr. niic to each -iilc of llio defect, cxtciuliu.i;- to tlic lateral puiti if llic luisc ami \n \\\r clicok.s, botll tlu'se Haps liaviiii;' a c dl' the nasal ili'lVcl. .".. Sntnre the two Haps loucthei- in the niekin ,,r the check ami hriii- it close to the lateral tiaps and suture. Any defect rcniainin.t;- may he eo\ercd liy skin g'rafts or he allowed to granulate. 7. Tubes of stiff rublier are ))!aced iu each in-imitive nostril. 8. Subsequent rurniatitm nl' the cuhiiiiclla iVuin the upper lip. CoiiKiccTKi.v or TdiAi, Loss. Helferich's Operation (Frencb Method). I. .Make a i|ua(_lranj;ular llap iVdin (Hic >idc n!' the cheek with its liedicle on the side of the nose, for the imrpuse n\' support and to line the nose with skin. (Fig. '24:^>.) 20G OPKKATIVK SnuiERY OF THE XOSE, THROAT, AND EAR. Fig. 2J2. S\nnc's operation. PIASTIC Sl'KGKKY OF Tllli NOSK AXP EAR. 297 /r- Fig. 243. ^ Fig. 244. Helferich's operation for total loss of nose. 298 OI'KltATIVE sriKIKIIV OF TTTK XOSE, THROAT, AND EAK. 2. ?il;il<(' a sdiiicwhat obloiit;- Haji rnmi llic ntlicr clicck with its ])e(iiclt' jihu-cil towards tlic inner rorncr of tlic eye, for tiic inir|)ose of' covering llic first fiaii, and reconstruct the nose. (Fig. 24."!.) 3. Dissect and turn the quadrangular fiap across tlie naval ih'fcct, and suture the previously freshened margins of the nasal defect, facing its skin surface into nasal cavity. (Fig. 244.) 4. Dissect oblong Hai» and bring it in contact with tlie denuded surface of the first flap, and suture in i)lace. 5. Close, by sliding and ieadaj)ting the skin al)()nt the cheeks over the newly-formed defects. One Week Later. G. Sever pedicles and readajit the ]iarts to a smoother healing surface; secondary (i]»eration upon the aliv and columella. Roberts' Operation for Sunken Bridge With Upturned Lobule or Tip of Nose. Fi(!. 24."). 1. A transverse incision is made into the nasal cavity, the tip of the nose being ])ulled down so that the nostrils ap])ear horizontal. (Fig. 246.) 2. An inverted V-shaped incision is made between the eyes up to the forehead. (Fig. 246.) 3. The skin ancj subcutaneous tissue l)etween tlie first transverse and the second V incision are dissected thoroughly. 4. This dissected skin is brought down, the ]»oint of the Haj) dis- placed as low as possible, and the lower defect broadly sutured. (Fig. 247.) This fonns a good prominence over the fonner depression. Dressing should be retentive so far as to hold the tip of the nose down. Roberts' Operation for Sunken Saddle-back Nose. 1. Sever the lobule and ahv from their bony and cartilaginous attachments at the deepest ])art of the saddle. 2. Draw the lobi;le and al;v down so as to Ining the nostrils into an almost horizontal plane; this leaves a conical defect into the nasal cavity. (Fig. 248.) 3. Make two small skin flaps from the cheeks with their ])edicle towards the root of the nose. (Fig. 248.) 4. When these flaps are dissected, they are turned with their e]n- dermal surfaces toM^ards the nasal cavity and are miited one to the other as well as to the upper portion of the newly-formetl defect in the nose. This brings their raw surfaces externally for granulation formation and subsequent sui)i)ort for the newly-formed skin flaps. PLASTIC SURliKltY OF TIIK NOSE AND EAR. 2!)f) Fig. 2-1.- Fig. 246. Fig. 247. Robert's oppriilidii for sunken bridjic with upturned lobule or tip of nose. 300 OPEKATIVE SUKGERY OF TJIE NOSE, THROAT, AND EA Fig. 248. Fig. 249. Fig. 250. ■ Fig. 2.51. Robert 's operation for sunlcen saddlobaok nose. PLASTIC sritdKItY OF TIIK XOSK AND KAI!. 301 'riic (U-rt'i-ts in tlu" I'lu'oUs iTcjitc.l li\ tli.'sc ll;i|.s ••nc at mic-.' united. (Fig. 249.) 5. About one wct'k to ten days lat.T. the irregularities aliniit the base of tlieso ehoek llaps are eiuiceted liy iuci>itins and |iro|ier sutures so as to olilain n sninntli surface. (i. When all the inllaiiiiiialnry ivaeiinii lias disajipearod, usually in about three to lour weeks, an inverted \ -sliaped ineisiou is made down to the bone. Correspoiulin^ to this ineisiou .just al)ove the margin of the nasal defect, which is now covered by the iuvertetl skin flaps, a similar ineisiou is made excejit that the leirs of the V run more hori- zontally. AVhile \\n' k-i-s of the npiier ineisinu Irniiinale below the eyes, close to tiie inner corner. \\\r lnu ei- eouie nut lint lirr on t he cheeks, .iiiviug greater plasticity td tlir lla|i>. The ajiiees nl' the two in\'ei-ted \'-shaped ineisiiuis are now joined liy a vertical one iiinncilialely over the crest of the nose. (Fig. 250.) 7. Those two flaps, rhomboid in form, are dissected very freely from the underlying tissues and the cicatrized surface of the skin flaps covering the defect freshened by gently scraping with the knife blade. One flap is turned so as to fit its extreme point or tiji into the opposite extreme point of tlii> defect and is anchored li> a suture: tlim the sec- ond flap is brought above llie lirst so as to till in tiie defect to i he great- est extent, and is anchored. This will leave a somewhat triangular defect at the root of tlio nose and lower portion of tiie forehead which is closed by three or nioic sutures in a \-ertical line. The two flaps are noAV sutureil to the \arious nuirgins and to themselves as sliown in Fig. 251. FoliMATIOX (IF A XeW ( 'oLT-M EI.I.A (Fko.M TliK I'n'Ki; Ijl'). Dieflfenbach's Operation. 1. Two ]iarallel ineision>, sei)arated about one foiuili inch, are made through tin- entire thickness of the upiicr lip up to the margin of the nasal floor. (Fig. 252.) 2. Turn this tongue-shaped llap >o thai the skin surface looks into the nasal cavity and nincons incinhrane externally, and locate a lioint wiiere the free end of this llap will toueii the nasal tip without undue tension or twist of tiie iiase of the llap. .'J. Denude this located area of skin. ( Vlu:. 252.) 4. Remove the mucous membiaiie from the tip of the t-ue-shai)ed flap of its dermal covering as the hair wouhl suhse- (piently irritate the interior of tlie nose. Fig. 252. Fig. 253. I)ieff'i.'nli;ich's iiporatioii t'cir fiirmation of new c-dUiniella from the uyiper )i[). % ^ •^2::^- Operation for forniatioii of new colunicllu from tlie dorsum of the nose. (Hindoo method.) yrom the Dorsum of the Nose (Hindoo Method). 1. An oblong flap is made, the pedicle being at the side of the ala running to the tip of the nose. 2. A defect is made at the jnncti(ni of tlic upper lip with Hoor of the nose. (Fig. 254.) ri.A.-ric sriiGF.nv or tiif. xosk and ear. ■M) ;i Till' ll.-i)! i- luninl iliiu iiu ;inl ;inil sutured into this dcrcct. ( Fisr. 25").) 4. The (Irfi'ct (111 (liiis\iiii 111' iinsf is siiliircd or ;i skill uT.-it't is lls,.d. ."). Any sli,«:lit irri\n'iil;iritii's mc \i< \>r cdni'ctrd at a siilisi'i|ii('iit tiiiif wlioii tlio jx'diflt' is severed. Vv,^ ,01111 III FiR. 259. Fij;. ;;(i(i. Lexer's operation for tin- formation of coluniella from tlio mucous nu-ni- loanc of tlio up|u'i' lip. Lexer's Operation for the Formation of Columella (from the Mucous Membrane of the Upper Lip). 1. Cniistnict a toiiii'ue-sliaped llap with its hase towards tiie lofiiiuival iiiaruiii on the under snrfaci' u\' ihe u|iiiei- lip. made up of inucou.s iiK'iuhram' and smiie uiKh'ilyiiii; suhniucdiis tissue. (Fi.ii'. '27A).) 2. Disisc'ot it loose, and eldse to its liase remove tin oiiithelial surface of a small transverse snip whirh will snlise(|iiently he witliin a huttonliole of the upper lip. i l-'iu. L'.'iT. ) ."!. Form the fhip in a soit of a nil!, siitiiriim- tin' iiiaryins. (Fie:. 258.) 304 OPERATIVE SURGERY OF THE NOSE, THROAT, AXD EAR. Fig. 261. Fig. 262. Italian or Tagliacozzi's method. ri.ASTu- siT.cKnv or tiik xosi: and kah. 305 4. .Makr a luiKoiiluiK' in tin- n-iitiT al tlio jiiiu-tidii nl' tlic u|i|ut li|i ami Hour of tlie nose, throujjh tlio thii-Unt'ss of tlio lip, in rront nl" the iH'dirlc (.!' tli.' tlap. ( Fi.ii'. 'J.');).) Also iiiak.- a iiulcli at (lie tip of the nosi'. 5. Bring tlio Map throuuli aiul suture into tlit- notch at the tip of the nose and also at the bnttonholo. (Fig. 260.) Fig. 263. Italian 01- Tngliacozzi's method. II. Italian or Tagliacozzi's Method. This nictlioil, w hicli is the oldest, is not einployetl to any groat ex- tent at the present time, as the patient is verj' nineh inconvenienced by having his arm held in a very constrained position for such a long nnCi Ol'ERATIVK srR(iKi;V OF THE NOSE, THROAT, AND EAR. pci'iod. Tls ]iiii']K)si' is to olitaiii ;i f1a|i IVuni llic ai-iii as shown in Fi.n'. •-'(11. 1. 'I'lic fla]) may be allowed to l)ecoine iinti and of ])roper size l)y jihu-ini;' niliber tissue, Cargile meinbrane or anointed .nai^i^'^e between the deimded surface so as to pre\('nt it from reuniting'. The flap should always be made one-third larger than the surface to be covered on account of the subsequent shrinking. 2. After the parts about the nose are freshened and loosened ui) the tla]) is sutured for about two-thirds of the distance, holding the liand over the top of the head and fixing it by means of adhesive plas- ter as in Fig. 262. The jjedicle should not be twisted too acutely. 3. A complete immobilization plaster cast is put over this jui- mary adhesive fixation, care being taken to protect the eyes whih/ it is being applied. After it has thoroughly hardened, spaces or win- dows are cut out so as to ex])ose the Avouml, the eyes, ears and mouth, as in P"'ig. 263. The wound is eovei'cd by a separate dressing. This cast is allowed to remain until the parts have healed, the stitches being removed usually in one week to ten days. It is then time to sever the attachment of pedicle to the ann. The remaining portion of the defect about the nose is freshened and loosened up, the ])edicle trimmed to fit the pai'ts, making allowance for a columella, and the external parts of the nose finished. The skin defect on the ai'm is cleansed, the margins are freshened and loosened u]> and sntnrt'd. ({rafts may be used, or tlie defect may be aUowed to heal 1)y granulation. Israel's Operation. Instead of olitaining tlie tla]i from tlie arm, one is made- from the forearm, and the arm and forearm are so placed as to make the patient most comfortable, as shown in Fig. 26-1. The retention of the arm is tlie same as in the Tagliacozzi method. 1. Make incision in left forearm synnnetrically on l)oth sides of the ulnar edge, and form a trapezoidal skin flap. The small part of the trapezoid Avhich points towards the wrist should be 4.5 cm. from the styloid process. (Fig. 265.) 2. With a chisel, outline a bone flap from the ulna in connection with the x^artially dissected skin flap 0.75 cm. wide and 6 em. long. (Fig. 265.) 3. With a fine saw this bone sliver is severed from the uhia, care being taken that it remains attached to the skin flai) and to the ulna at the upper end. Iodoform gauze is interi)osed to prevent reunion. A Few Days Later. 4. Break the lione bridge at the point where the tip of the nose is rr.ASxrc srnoKRY or tuk xosk axd f.ah. 307 Id lit' t'(iinu';irts for aiiollu'r tlirce Id li'iir i\:\}>. 5. Tninsiilaiil Hap to nasal tk'tVct ami lix at tlie side as shown in Fiy. l2(i4. Innnohilizo by tlii' usual nu'thod of plaster of Paris jaekut. 'lira Weeks Later. G. Sever the Imny and skin pcdirlc^ and fradju^l p;irt> to I'drni a nose. The hone should lie iniili'd with ilir nasal spiiu' at the tlnnr of the nose and the skin >nlnicd aliout thr >idi' of the nose. 7. Form the colnincjla anil nostril from the icniainini: skin tlap that was iMirposcly tnki'ii lni- tlirir formation. 30S OPERATIVE SinuiERY OF THE NOSE, THROAT, AXD EAK. Dieffenbach's Operation. 1. ()iitliiie a train'X.oidal Hap above the elbow on the inner sur- face, one-third larger than the newly-formed nose is to be. 2. The heavy lines in Fig. 266 show the formation of incisions and this skin flap is dissected freely. 3. Tnrn in one-half of this flap so as to bring tlie skin next to the Fig. 266. Fig. 267. Dieffenbach's operation. Fisr. 268. raw surface of the arm in order to prevent adhesion and also to fonn the so-called roll of the dorsum of the future nose; fasten by two sutures. (Fig. 267.) Six Weeks Later. 4. Sever the upper part of tlie flap and turn downward. Eemove the two stitches and lay the flap open partially. (Fig. 268.) 5. Freshen up margins of the nasal defect and suture in this new flap as in the usual Italian method. PLASTIC SfnCKIlV ni- TIIK \OSK. AXU F-AH. 309 run Weeks Ldfii. (i. Sever tlic inMlirlc ;iiul readjust the jiarls to rmiii the nliv ainl eoluiiii'lla. Nekton's Operation. 1. I'"iinii a iii'ilicli' lla|i rrmii llir rorcaiiii and attacli t<> tlii' mar- gins of the .h'ffct. (Kig. •2i\[).) Fig. 269. N<51.Tton's operation. Tna Wcck.^ Later. 2. Sever the pedicle. 3. Fonn two flaps from the oiitfr inaiLiiii nl' the alar niiciiin.us outwai'd and downward as low as the inriiinr iiia\illa in llic naso- labial fol.l. (Fig. 270.) 310 OPKUATIVE SV'RCKnV OF THE JTOSK, TTIKOAT, AND EAR. 4. Turn tlicse so as to make skiii-liiicd nostrils and also a coln- luclla ni- septum support for tlu' new fm-mcil tlap, whicb. should also iuchidc a small flap for tlu' formalioii nf a double ooluniella. ( l''i^. .1. Suture these flaps to one another and close the defect in the nasolahial fold. (Fig. 271.) Tiro Weclv ruriiR'cl of llif skill and part nl' its iiinlcrlx iiiL;' i-iniiH'c-tivi' tissue only, or tlioy may contain the ]icriostcuni ami even a portion of tlic cxtiTiial tal)k> of till' frontal l>on.'. The frontal .Id'eets thus createil liy the turn iu<;- of the Haji ina> he eoxcred in several ways. I^y loost'iiini; up the I'iiT. :J7L'. Jliiidoo or liiiliaii iiicthint of ll;i|i formation. Fi-. ■27:;. niicTscirs oi.r.rali 312 (lI'EliATIVIi srK(;KllV OF THE NOSE, THROAT, AND EAR. margins and di'awing the parts together as far as possible, the granu- lation may be encouraged; a Thiersch skin graft may be used, or the entire area may be covered by skin graft (Thiersch, Wolfe or Kraiise). After union takes place the pedicle is severed and the stitches are removed. It requires usually about eight to ton days before the pedicle is cut off, and it is frequently very thick and large, so that it must be trimmed off and adjusted to the still existing defect between the eyebrows and root of the nose. Thiersch's Operation for Total Loss of Nose. 1. ]\rake two small quadrangular fiaj^s from the cheeks at the lower portion, forming their hinge at the side of the nose where they will constitute the inner sui"face of the nostrils and ala of the nose. (Fig. 273.) 2. Dissect them loose and turn them with their dermal layer towards the nasal cavity. 3. Suture one to the other in the median line. 4. Make a frontal pedicle flap and suture into the freshly denuded margins on the side and loAver part of the nose (Fig. 273.) 5. Cover newly-formed defects by Thiersch grafts. Nelaton's Operation for Total Loss of Nose (Indian Method). 1. Expose entire length of costal cartilage of the eighth rib. 2. Excise. 3. Trim down to a size 2.5 cm. long by 3 mm. wide. 4. Cut a notch where the point of the nose is to be formed by this cartilage, that is, about 0.75 cm. from the end nearest to the base of tlie forehead pedicle. 5. Outline the forehead flap. 6. Incise the base of this flap down the bone for about 0.5 cm. and make a tunnel to fit the cartilage strip. 7. Introduce cartilage strip with its notch towards the skin in- cision so that it is between the frontal bone and its periosteum. (Fig. 274.) 8. Close skin-jieriosteal incision. Tico Months Later. 9. Make an incision about the nasal defects in such a manner that two lateral and one iipper central flap will resi;lt. (Fig. 274.) 10. Turn these over so that the skin surfaces will look into cavity of nose. 11. Stitch with catgut so as to retain them in position. PLASTIC SURGERY OF THli XOSK ANH EAR. 313 Fig. 274. Fig. 270. Fig. Xclaton's operation fnr total loss of nose. 814 DPEnATivK srncKr.v of tke xose, thiioat, and eak. 12. Cut t'orclu'jul H;i|i with its jicdiclc towards tlie ()i)])osito iimcr t'oi'iu'f of tlif ('\(\ oNcr wliicli till' tia)i is situat('(l as sliowu in I'M;;'. '27'). Tliis fia]) contains the pi-fxiously inlroduccil cartilauc with its under- lyinii,' ])enostenm. I.'!. Turn the Hap (h)wnward, ovci' the jireviously tni'iied flaps made i'roni tlu' niar^in of the defects. The flaji shonhl be fashioneil into a sort of a ti]) of the nose by bending the eai'tihige where the notch had ))( en <'nt in it, so as to make a proper eohimelhi. 14. Stiteh in ])laee. (Fig. 276.) 15. The defect in the forehead is closed ))y skin graft or sliding flajis. [Antlior's comment. — This forehead defect can be covered mneli better l)y sliding the skin and making counter release incisions in the liairy i)ortion of the seal]).] Our Wfi-Ji Later. 16. Cut pedicle, trim it and imidant in existing defect at tlie root of the nose. Koenig's Operation (Indian Method). 1. ]\rake a transverse ineisiim across the depressed i)ortiou of nose into the nasal cavity and dissect loose the tip of tin- nose, so as to bring- it into a more horizontal ijosition. (Fig. 277.) 2. ]\Iake a strip-shaped flap from the root of the nose straight towards the hair line, all tissues being severed to the bone. (Fig. 277.) 3. With a small chisel cut through the external table along the course of the incision made in this strip-shaped flaji. 4. Take off this layer of external table, periosteum and skin and turn it downward into tlie newly-formed defect, bringing the upper- most margin of the strip-shaped flap below the lower margin of the defect and stitch it. This causes the skin surface to look into the nasal cavity wdiile the raw bony surface is external. (Fig. 278.) 5. Break the curved bony bridge of this turned down flap so as to give a curve to the nose. 6. Make a lateral frontal flap and turn it down in the usual man- ner l)v twisting a iiedicle covering the denuded bonv surface. (Fig. 277.) ■ 7. Subsequent trimming of the pedi(de at the root of the nose, with read.instment of the newly-formed irregularities at this ]wint must follow, that is, excision of the skin between the root of the nose antot:il loss of .nose. pr.ASTic sriUiKiiV ni' niic XdSK an'h kau. :;i!i ."). A similar prorodiin' is pniotifcd on tlii' iiasiil Ixnifs, whii-h aic usually dcpn'sscd. Tlicv arc sawed nr ciiiseli'd otV I'niui tlie nasal jirocossos of till' su|ii'iini- maxilla and cli'vattMl, Icaviii;; tlicir attacli- iiioiil witli till' fi-unlal \>n\\r us a -(Hi nf liinii-f. {V'lii. "JS?. ) t). l-'iinii a iHdiM'i- lniclir;id Map and ftiM-i thi> iicwly made lioiiy siippiwt. and -nlui'i' in llic n>nal nianiMT. Schimmelbusch's Operation for Total Loss of Nose. ]. ( 'ul uut a rliunilniidal >liapc(i llnp IVcnn llii' Inivhriid with thr lu'oad jiart aliovf, im-asnriui:: '2 to o cin. lictwccn I lie niari^in- lifldw nnd (i 1(1 7 cm. at its upper part. Its leuiitli should depend mi the len-tli of tiu' nose to he <'o\('red. This incision includes the perio>teum. Fig. -W!. y^ii- -'^'i- Von Laiificiiliecli 's operatidii fm ciilhiiiscil luisc: niakinji .siii>i)orts, especially when soft parts are wanting. 2. By means of a broad cluse! a thin plate of liouc is taken away with tliis flap; in most instances it will he in several jiieccs, altliouij;li endeavor should he made to keep the perin>teuin attached. (Fig. 288.) .'1. Turn this skin hmie ll;ip down and in order to prevent these hone plates from I'aliini;- olV. a sort of lattice \voii< nf -ilk thread sliould he passed abont this flap and co\ered willi -au/.e to allow i;ranidation to form. 4. Cut out two curved skin tlajis as shown in Fi.u;. 2SS, to allow the slidiiif^ forward of the lateral skin flap for the closure of the frontal defect. 320 OPERATIVE SrELIEl!V OF TTIE NOSE, THROAT, AND EAR. Fig. 289. Fig. 290. Sehinimelhuseh 's operation for total loss of noso. pi.ASTK" sri!(!i:i!V (H- iiir. misk an"i> r.Ai;. 321 5. Contiinio iiioisioii up to tlio pcriiistt'inn in a cuixd liiioar nian- nor bai-k of llio car ami looson the t'liliiv latoral Hap. (Fijr. 289.) 'riiis is done on liotli sitlos. ti. Slide tlu' two lali'ral Haps so as to inaki' tlicm iiicct in tlio center of the forehead and also Join the sUiii where the two little flaps were removed. As a result there will l)e two small ilefecls on tlio side of the head, which can he aUowed to jii-amdale and can lie eoi'i'ected subsequently. Four to Si.r Wrels Later. 7. I\v means of a saw divide tlie Ixmy pdilinn of ilie nose to lie formed, and shape it in the form of a Ironuh. In the event tliat tiie pedicle is a.aain ailherent at the loot of tin' nose, it should he thor- oughly loosened and tlie flap Ini'ned with its dermal surface ontwanl. (P'ig. 289.) 8. To form the eolmnella, dissect off from each side t)f tiie ])yri- foiTu aperture two skin flai)s and unite them as shown in Fig. 289. This will leave their pedicle attachment at the usual insertion of the columella and their free end is to be attacheil to the newly-fonned tip of the nose. Three Weehft Later. 9. Freshen up the lateral )ioi1Jon of the defect, esjiecially at the apertura pyriformis and dissect away the skin so as to lay hare the bony margins of the defect. The good result of this iiroce I'.AK. 323 till' thread liitticc work to prevent tlie (lislodnciiieiif of tlie Ikhh' ami w ra]) the w lioU' thi|) in gaii/.e to alhiw the hone to ,u,ranuhile. Oil,' Jl'.r/, L,il, r. I!. Make a vertical incision in the middle of the hri in snch fashion as to give a roof like appearance. (Fig. 291.) (i. To insnre healing, trim off the dermal layer of the frontal llap where it will come in contact with the ti-.-ne> ahont the apertnra pyri- formis. 7. riace the frontal llap in jiosition lietwcen the dissected lateral skin mariiins of the nose ;ind lirndy aL;ain>t the apertnra pyriformis, where an anchor >ntuie may he pl.-iced ;iiid lironght ont at the onter corner of the ahv. (Fig. -Jii-J.) One Week Lnfcr. 8. Sever the pedicle at the lotit of the nose in snch a manner as to utilize as nuich of the tnined over skin as ])()ssihle to lit into the still remaining defect hetwcen tiu' eyes, whore the two lateral parietal llap> come to-ether. and then sntnre. 'J. h're^hen nji the lateral skin margins of the nose and hring' to- g:ether over the middle of the nose. (Fig. 293.) Sir Watson Cheyne's Operation (Indian Method). 1. An inci-ion i> made in the median line (if the nose o\-er the cartilaginons portion, (h'ig. 2114.) 2. Two transverse incisions are made at each end of the lirst in- cision, forming two lateral flaps when dissected, like an open door. (Fig. 294.) 3. Dissect thesi' lateral Haps and take along any fragments of nasal hones or periostenm that ma\ he .ittached to them. (Fig. 29.").) 4. Sever the cartilage finm tlie hcmy poition of the external nose and cnt into the septnni so as to jmll dow n the point of the nose in the pioper shape. .'). Two \-er(ical incisimis arc now ma' aiio\c the root of the nose and aliont \('rse incision nnites these 324 OPERATIVE SITRGERY OF THE NOSE, TIIKOAT, AND EAR. Fig. 294. Fig. 296. Sir Watson Cheyne's operation. (Indian method.) I'l.Asiu >ri;oEr.Y of tiik xose and ear. 31'") Iwo viTticiil OIK'S at llu' liiiir liiu'. Tlicsc lliri'c incisidiis dixiilc nil llic structures dowu to tlio liono. (Fiir. 'JiU. ) 6. Insert a narrow cliisi'l alniiii- tin' margin of tliese tliree in- cisions and sejiaratc ,i iKnliiiu >,{' thr cxiii nal talile of the frontal bono, Ii'avinu' it attached lo tiir iicriostcniii and tin' remains of the lla|i. (Fisif. 7. This whole tlaji is now turned downward so tiiat the skin i< looking into the nasal cavity while the outer surface comprises the denuded bones. S. Shave olV the epidermis at tlie voot of the nose as well as at the uppermost jMiitinn nf ilii> tnrin'e of ihi- iljip and the tension thereby relaxed. (Fig. 296.) 10. Unite the defect on the forehead. 11. The lateral flaps are now replaced and united over the raw iiony surface of the forehead flap, also above and below. (Fig. 297.) Ticd or Tlnce Weelis Later. 12. Tlu' jiedicle is cut, tnrned back to liil up tln' defect and any irregularity trimmed down and corrected; an.\' graimlating surtace may be covered by skin graft. Von Hacker's Operation (Indian Method). 1. <)utliue the usual llap iVoiii forehead with pecjicle at the root of the nose. 2. Dissect tin' skin on the three IVee margins of the llap to a point iu the median line mea>ni-int;' s mm. in width an portion i> to form the ^uli>e(|nen1 bony support of the innvly-fonned nose. '•i. The dissected skin is now sutured temporarily iu tiie median line by two or three interrujited sutures and a few small ))ins driven into the bouc-periosteal flap ( Fig. 29S) in order to facilitate its dissec- tion. 4. By means of a chisel tliis lioue periosteal skin llap is now severed up to the root of the nose, where the pedicle only consists of skin and jieriosteum, in order to be aide to twist it easily. (Fig. 299.) oL'G (IPKIIATIVE rtl'EGEKY OF THE NOSE, TIIKOAT, AXD EAR. Fig. 300. Von Haeker's operation. (Indian mothod.) IM.ASTIC sri!(iK.i;V OK TIIK NOSK A N I • K.AI:. .._( .J. lirciik away the iMitiic llap ami lutati' dnw iiw aid iiiln tin- |iropor ])osititiii, liaviiii;- in'cviously |prc|iari'(l llic cldVct I'm- iininii l.y rn'shciiiiiti' up llic iiiaruins ami tlir i-ciiiaiiis nt' the si'iitniii with wliicli till' lioiiy luiiln'c is tt) roinr ill (•(intact. This lniii>' strip is iirnkcii at the hiwcr |iciitiiin and a |ii(i|ici' iminl of ihi' misc i- InrnKMl. It is siiturcil iiilii the llimr oi' the iidx' ami a ciilnniclla aiui ala' arc i'liniiod from tile skin llaj). Kiildicr tuhcs arc inserted into nostrils to irive siiiii.e to them. (Fi.l.) '2. Form a forehead llap, takinj:; care to make a loiiiier median llaj) lor tlie fonnation of the colnmella. ;'.. Freshen up tin- na>;d ddVet. 4. I.rini;- down rnmlal llap and -ntnrc in lalcrally. and to f(U-in the columella snturc central llap to the little llap iVdUi the lip in such a manner that there is skin surface externally as well a.-> in the nose; in iitlicr wiirds. one on top of the other. ( Fiu. 'M)'2.) IV. Double Tran.splantation Method. A skin Haji )nay first he made fi-om the chest or ahdomcn and at- tached to a part of the hand or forearm, and after it li.is healed un and 328 OPEUATIVE .SUIUiERY OF THE NOSE, TIIIIOAT, AXD EAR. good circulation has been ostablisslicd, it is severed, and tlicii attached to the nose as in tlie Italian method. Or a toe from which the nail has been removed is implanted into the palm of the hand, and after it is thoronghly healed it is severed and made ready to use in constructing a firm support for a nose. Bone which has been removed from an am- putated leg and formed in the shape of a nose, implanted under the forearm below the periosteum of the ulna, is prepared in the fonn of a pedicle after it has united and remained viable and is then sutured into a nasal defect, as in the Italian method. A similar method is em- Fig. .303. Steiutlial's oporation for total loss of nose. (Double tiniisiilaiitntiou iiiotliod.) ployed in implanting pieces of cartilage under the skin and periosteum of the forehead Itefore making the frontal flap. Steinthal's Operation for Total Loss of Nose. 1. Make a tongue-shaped flap from the sternal region with its pedicle towards the sternal notch, measuring 5 cm. at its free end and 3 cm. at the pedicle end, the length being about 12 cm. The flap is com- posed of skin and periosteum. Suture the defect over sternum in part. PLASTIC Sritl'.KUY OK TlIK XOSK AXI) KAlt. 329 •J, Make an incision tliroufjli tin- sil ami ever llii' radius to accoinniodatr llic I'lcr cinl dt' liic ahovo Ilap. ;;. SulUl-r ill tlli> tVrr iMld cif lllc tlap I'"!- >U I im 'i | llrllt t I'a n>| ila II 1 a - liiiii. I Fiir. •■!i»:i.i 4. Ai)|)ly inmuiliilizin^- plaster of I'aris jai'icct. 'fivclre Days Later. 5. Sever pedicle from stcrnnni and Icavf it nnal larhcd in allow ]ierfect circulation to he estal)li>ii(d in thr tlap I'm- \\\>> m- three days. Fig. 305. Via. -MM. Kaiisch's operalion for collapscil ikisc. (Double liiinspiairtiition motlnHl.) (i. |-'re>lle|i |||> the Slirl'aei' at the nasal defei-t. 7. Suture free iMid (if Map situati'i! ni\ the forearm to this prc- jiaivd siii'faer almiit the iia>al defect. (I'^i-'. 'M)4.) s. Appl\' aiiain a retention |ila>ter of i'aris jacket for aimut one week or ten days. 9. Sever the Haj) from the foreaim and sntnrc in ahoiit the re- mainintr nasal defect to form a jiroperly shaped nose, inclndintr columella and alar slsin liniuLT. Kausch's Operation for Collapsed. Nose. 1. li'eiuove tin- iiail nf the fourth toe of the >ame >ide as the hand tJuit is to lie employed. A portion of ihi' skin from llie tip of tin' toe is tui-iied hack to olitaiu a uond law >urfai'e. 330 oi>ei;ativk srnciERY of the nose, throat, and ear. 2. Make an incision in the tlicnar cniincncc of llic palm of the liand of a ]iro]K'r size 1o accoinnuxlate tlie tip of tlie toi'. ;!. Itiini;- hand and loc together approximating the ti]i of toe to tile ineision and snture well on all sides of the skin. 4. Place a retaining' device either of plaster of Paris or leather to keej) the parts immobile. Tiro TFrrA-.s- Later. 5. Sever the toe at the metatarso]ilialangeal .joint, leaving it at- tached to the hand. (Fig. 305.) Close defect in the foot. Tuo Ddifs Later. 6. Freshen n]i the hony surface at the floor of the nose and the skin on the side of the nasal defect. 7. Bring hand in proximity to nose and suture the free end of the transplanted toe, which has also been freshened on, into the bone exposed at the prepared nasal defect. (Fig. 306.) 8. Retain by plaster of Paris bandage as in the Italian method. Tn-o Weel-.'^ Later. 9. Sever the attachment of the toe to the palm of tlie hand and close this temporary defect. 10. Eemove the skin from transplanted toe from the jiart that is to come in contact with the subcutaneous tissue of the ridge of the nose. If the mass of bone is too large one may bite out a portion and also sha])e it in the form of a cohnnella and ridge, giving the nose a proper shaped jjoint. Suture the distal end towards the root of the nose. 11. Subsequent smaller corrections of making jirojier shaped nostrils, etc., should be done not before two weeks, wlu'u the circula- tion is well established. V. Finger Method. In cases where a gi^eater part of the bony portion of the external nose is absent and most of the soft parts, the employment of the finger, sacrificing this member for the formation of a nose, has been followed by good results. The cases especially suitable for this operation are those in which the greater part of the alae and in'obably the skin por- tion of the tip of the nose are still present, even though this latter por- tion be markedly draAvn in and adherent. Watt's Operation for Subtotal Loss of Nose. 1. Sever the columella at its attachment to the upper lip. PLASTIC SlUCKUY OK THK NOSE ANH EAR. 331 2. T;iki' llu' Ift't little iiiip'r ainl rciiinvc its n.iil .•mil matrix, also tile skill t'roiii its tip aiiti'riorly. '■'•. I';i>s this linger tlirou^^l I rriiiii;iiii nf tip nf nusc ami li\ at tin' root of tlu' iioso eloso to tlic frontal hour liy misuis of sil\i'i- uii-c, an aiva lia\iiig been pri'iiafi'il in tins ii'uion. ( l''i,Lr. -inT.) 4. Appily a iilastci- (•a>t to Imld paft> IminoliiliziMl in place. Tuu Wcks L,:l, r. 5. Amputate tiii^'ef at iiietacai-jiophalaniceal joiiil ami close de- fect in luuul. A Few Dai/s Later. (i. Trim down the free end of the liuii-er so as to make it narrow- enough to obtain two separate nostrils. Fi^,^ 307. Watt's nppr;itin!i for siiMotiil loss (>f nc 7. I'lish tliis end of the lingiT into the nasal caxity and fix liy anothel- MltUfe. 8. Suture l)ack the pri'viously se\ei-ed columella to the liji by refreshing their surface. fhn Week Later. 'J. Remove skin I'lom doisum of the now healed in linger at the nasal defect. 10. A flap from the forearm is made and >ntiiied in above the defect, fixed a,gain by plaster jacket and tieaied a- in any Italian method. 33l2 OPKr.ATIVK .Sl'KCEKY OF THE XOSli, THROAT, AND EAR. Fig. 309. I'lg. 310. Fig. 311. Wolkowitseh 's operation for total loss of nose. (Finger mt'tliod.) ri.ASTIC SlR(iKI5Y dl' TIIK NdSK AXU KAl!. ■ •'•' Wolkowitscli's Operation for Total Loss of Nose (Finger Method). I. Take till' roiirtli liii-rr nl' tlir li'l't 1:;umI. Ll. Make a iiiriliaii incisidn ii\ri- llif iliii->al Miil'a iT tlii' >aiiic I'roiii tho iiU'tacariKiiilialaiiural jninl \i> llic nail, lliidimli llic skin ainl siilx'utaiu'ous tissiu'. ."!. Disswt loosi' to I'itliri- side ricfly. 4. lu'inovc tlu> nail ami lie sine n[' the rcinnxal nl' ail <>[' its matrix. TiMulon must not he tlisturl)0(l. ( Fiji'- •J*'''^.) ."). l\onu)\i' the skin from tlu' tip of tlic rniiiff in iVnnt I'nr its attaclinicnl al tiir i-.Hit df the nose. (1. Split tin' skin and nndcrlyhi.n' tissuos tlirouuli to tiic liuui' in the median line at the rout of tlie nose, and separate iTPoly to either side, includin:^ tlu' margins of tlu' icnnaininu' apcrlnra iiyriformis. 7. In the hoiiy strnclnrcs at tin' rout of tin' no-i' make a kin llaps of tlie finger, w hieh are tm-ked nnder the dissected skin of tlie nose defect, witli two mattnss sutnics on eacli side. 10. Close the median ineisioii at the root of the nose as far down oxer the (inner as ]iossihle. II. Place a ipiantity of marly (Seoteh izaii/e) helow the linger li> liold it ii|i in the siiape nf a imse and pi; a di'essin-' oxer the surface. Then apply a lixation iiandage as in aii\ Italian operation. Nine Ddifs Liitir. \'l. K'enioNc the stitches and I'Xleiid the ineision over the dorsum of tiie hand so as to expose the entire nietaeaipophalani^cal joint f«n- excision. l.'i. Dissect tlie skin laterallv and inci>e it on eithi'i' side of the linger, hut do not sever in t'ldiit at this time. 14. During the next live days in twn separate sittings the skin l)edicle is severed and the metacarpophalangeal joint disarticulateil. 1.1. ('over the defect on the hand as in a regular disarticulation operation li\- the remaining skin anteriorly. K;. I!end and shape the now altached liuLier iu the rorm o|' a nose, place some mme niarl\ hehiw it and allow it tn remain fnr thi-ee more days for lirmer attachment, (fig. .'111.! 17. I'end sliai-pl\ lietweeii the lir>t and secnnd phalangeal joints 334 OPERATIVE SURGERY OF THE XOSE, THROAT, AM) EAR. Fig. 312. Von Esmareh 's operation for collapsed nose or absence of the pre- maxilla or an anterior perforation of hard palate. Fig. 313. Fig. 314. Clavicle method. (Gustav Mandry.) n.AsTic sriKiKin' III- Tin: xosk ank k.ai; 3:}") to siu-li a di'iii-cc thai \hr lii-st phalanx may he |ni>hi'il iiiln the nasal cavity. IS. I'n'parc tlic Ihnir ol' the im-c aihl if thi-ir i- a iinilion nf >f\i turn romainiim', rriiinxr all tin' inucnus iin'iiilu-aih' ami I'Sposc ils Imhi.v surface. lit. Ju'inovc all the skin and uraniilatidiis rrmii that iml of the liiiii'i'i- that has licmi ili-articiilalcd ami inisji ii intn the imsf auaiust the raw surface- i]rc|iari'i| at the thmr. I'll. Ihsscrt miw the lateral niari^ins of tin' a|iert\ii'a |iyrifiii-iiiis hiw nf the skin tlap nf the linL;-er. wliieli are again attaidu'd hy dUe mattress suture on each side. ill. (nver the entire denuded surface of this huny reeduslrueted framework with a K'rause llap iw with any tlaj) either from the i"ore- liead or arm. further >liL;ht enrreetions, as foi'matiou o( nostrils and ('0\-er for ediunu'lla, are >uliseipieutly pei-fuiMued. Von Esmarch's Operation for Collapsed Nose and When There Is Also Absence of the Premaxilla or an Anterior Perforation of Hard Palate. 1. K'eimive the nail of tln' little fumer (if the h'ft hand and freshen up the tip autei'iiirlv . 2. Freshen u|i the surface on the inner side of the tiji of the nose and what is still existiuL;- on the floor of the nose anteriorl}. If nose is ri'ti'aeted. it slioidd 111- freely dis>ei-ted and made mn\ali|e. .'). Fasten the liu.u'er with wire to the hone of the superior ma.Kiila about the hen up the mari:ins of the )iei-foration or defect at the I'oof of the month and sutni'e in the properly prepare(| stump of the linger. VI. Clavicle Method (Gustav Mandry). I. form a lla|i o\-er the region of thi' (da\i(de, consisting of skin and snhcutanecnr'- connective li>~ne and of the |ieriostenm ami hom- of the (davicle. Thi' hroad pe.jicle is sitnat.'.l o\cr the shoulder and the IVi'c iMid at the -t e rnoc la \ i c n la i' ai1 icniat ion. (FiLi'. '■'>]'■'>.) 336 OPERATIVE ST'RGERY OF TlfR NOSE, T7IR0AT, AND EAR. 2. Dissect this skin flap iip to the upi)or ami lower luariiins of the <'laviolo, loaviiis' it lioi'c attachod to the bono. 3. Cliiscl (ir saw out a slixci' of tlic t'laxidt' measuring 4..") cm. loim' l)y ()..") cm. -wiili' (iii(licat('(| liy r/-r/'-/>-//' — Fin'. .'!1.'!) near the stcnio- claxiciilar ai'ticiilatioii without ilctacliiiii;- tlic skin and ]i('i'iosti'un]. 4. In tlie free end of tliis sliver two small holes are ))ore(l for subsequent anchorage to the nose. 5. In the middle of this large flaii, right over the clavicK', a flap of skin and subcutaneous tissue is made in the form of a window, directing the pedicle towards the sternocla\icular articulation, in order to turn it on the under surface of the bone sliver, in that way assuring its nourishment from both sides, besides subsequently forming a dei'mal lining for the interior of the nose. This central flap is turned 180 degrees and made to come beyond the tenninal end of the bone sliver, where it is fastened with the skin above, thus suri'ounding this bone. 6. Close this newly-formed central l)uttonhole in the large flap by a few interrupted sutures. (Fig. ;'>14.) 7. Allow this whole flap to rest over its dissected area where it Avill attach itself temporarily, getting additional nourishment for its sustenance. Four Dai/s Later. S. Separate this whole ])edicle, including tlie doui)le skin covered bone sli\er, and liberate it more freely by commencing the outside incision over the shoulder and back, thus giving a greater motion to the flap f(n- its adaptation to the nose region. 0. Freshen up the nasal area, making a pocket at the root of the nose in which the clavicular bone sliver will be slipped. 10. F\])ose this bone sliver and place two strong sutures through tlu' lioles which have been previously drilled. 11. Turn the head towards the shoulder where the fla]i is formed, and bend it slightly downward so that the flap can be lu'onglit in close appro.Kimation with the nose without any tension. 12. Bring the tAVO strong sutures through periosteum and skin at the root of the nose and tie over a pad of gauze, fixing the bone sliver in the newly-formed pocket. K!. Aii]ily a few adisso<'t off the oi)iclorniis laterally IVdiii tlu' Hap ami I'l-cslicii up the margins nf llic api'rtura ]>> rirmini- sn as tn nlitaiu ]iriipcr uiiinii. 17. |-;\poso till' ru>] III' till' tiaiisplantril Imni' sliver and eventu- ally iVaetiire it so as tu make a lip nf llie imsi'. 1^. FreshiMi up an area nl' lln' Imur at iIh' llnnr nl' the nose just in iVnni and suturi' in this free end n\' thi' Imhh' •~li\ri-. 1!t. ('o\'er this liy the ui'\\l>' I'lH'ini'd cnl unii'lla. 111). Turn in the redunaut skin llap at tlir alar rei;iou to line the uewlyd'oi'nu'd nostrils and put in two small ruhhei- tultes. ill. K'ead.just the shnuhler flap and eii\er the newly-fonned bono det'eet with it as nearly as pnssilile: what rnnaius may ho covorod with skin lirat't or allowed to Lirannlate. '2'2. Snl)so tilna was successful in one case of the author's; in aiinthrr it lieranii' iicemtie and rrninxal \\a- iiMpii red. Snin nn- ])lo\ed deealcilieil bone chips in >onie casi'S of saddlehack luisv. lie- cently tlie author removed a sejitum by submucous resection, allowinj>: one layer of ])oricliondriuni to he attached and placed it in a dissected pocket of a saddh'liack imse nf ; ther |ialien1. This healed in very lieautifnily and resulted in success. In aiH)ther case three different im|ihintaliiin> were made into col- lapsed ahe whii-li liealrd in. Init appearrd In lia\e iu'mnie •disiirlnd. .\nnlhrr iih'tlind aihnrali'd iverntly is tn implant a nia>- nf fat frnm a patient iipnn w Imni a lapaintnmy is peil'nrmi'd. intn a dis- sected jiockct nf a saddleliack nnse. The authnr ha- tried this methnd in one case and it ap|)ears that the fat tissue remains alive. The niii' dilTiciilty is that the nose looks very larne foi- a time as a ureal amount of fat is used to fill up the defect, in oiiler to antieipali' the ali-nrptinu or shrinkaue of the mass. 338 Ol'EIiATIVK SUIUiKItY OF THE KOSE, THIIOAT, AND EAK. 'I'lie cniviloyment nf a sliver nt' hniic tVoiii tlic aiitcrioi' Ixirdcf of tile libia or a part of a I'il) is a mctliod that lias many advocatos. Israel's Operation for Saddle-back Nose. 1. Make an external incision 2 cm. lorn;- over tlie saddle and dissect to all sides subcutaneously, until by pulling on the tip of nose the appearance is normal. Close this external incision. 2. A piece of bone 3 em. long from anterior border of tibia is chiseled off and formed into sharp points on either end. 3. From the interior of the nose the previously dissected tunnel is found by means of a dissection and the sliver of bone is introduced in this direction, the upper end of the bone fragment coming in contact Fig. :il5. Israel 's operation for saddle-back nose. with the nasal bones, the lower at the tij^ between the external skin and tlie lining of the vestibule. (Fig. 315.) Goodale's Operation for Depressed Nose. (Fig. 316.) Modified by Watson-Williams. 1. The mucoperichondrium is dissected over the entire cartilag- inous area on both sides and ]iushed up and back. 2. Loosen up the tissue below the depression intranasally. 3. Cut out a flap of cartilage with its loosely adherent pedicle towards the depression. (Fig. 317.) 4. Slide this cartilage flap below the depression and bring down the mucoperichondrium into its original position. (Fig. 318.) PLASTIC SmOERY OF THE XOSE nXD EAR. 339 Fig. 310. i''g- ^is- Fig. ;ii;i. Goodale's operation for depressed nose. 340 OPKRATIVE srtUiERY OF THE XOSE, THROAT. AND EAR. 5. Hold hy transfixing gold-i)lated pins for tliicc weeks. Tile writer suggests silk worm gnt suture tied o\er rubber tubing- or gauze. (Fig. 319.) Ouston's Operation for Depressed Nose Below the Bridge. 1. Separate the eartihigiuous |)ortiilk. one i<\' llie liai'd niMiei- siilints is ;inelinred. ( l-'i--. ;:•_'•_•.) ■_'. i';i>^ the needle tViun witliin untwnrd al tlie Jnnelinn cif (he cartilaj^o and nasal iione, jnst at tiie middle of llu' dorsum. (Fi.y;. '■'>'2'.'>.) ."). Kepeat tlie first step on tlie other side of the nose. ( Fiu'. '.V2'.'i.} \. AppJN the metal ( ( 'aitei'- 1 hiid^e and set it liy means cre\\ >o llial it lits lirndy at the ha.se of the nn-,.. i l-'in-. :':2-i.) X^^ Fig. 32:i. Fig. .124. «M<1.tl.- l.nr-k nn 342 OrERATIVE SURGERY OF THE NOSE, THROAT, AXD EAR. .'). Draw fii'mly upward on the two threads so as to raise the Hat or (h>pressed nose and tie thoni over the hinge of the bridge. (Fig. 324.) If the tissues are fixed or if it is impossible to lift the nose by the threads, it may be necessary to loosen the nasal bones from the nasal process of the superior maxilla by means of chisels and forceps and then by fracturing. The septum of the nose may at times be so short as to necessitate incision. This treatment is best carried out with the patient in the recumbent position, but by employing adhesive Fig. 326. Carter's operation fur smltlle-back nose. plaster the bridge may be fastened to the forehead and then the patient may be allowed to walk or sit up. This bridge is allowed to remain in position from ten days to two weeks. Cleansing the interior of the nose witli Dobell spray is advised. Carter's Operation for Saddle-back Nose (No. 2). 1. Make a curvilinear incision to the periostemn from one eye- brow to the other, with convexity of the incision downward. (Fig. 325.) 2. Lift the skin flap and make transverse incision through the periosteum into the bone. 3. Elevate the periosteum uiiwards for three-eighths of an inch. PLASTIC SrUCEUY OK TIIK XOSK AND EAR. 34.'i 4. Kli'vntc till' skill jiinl sulK'ntaiit'iuis lissnc (ivcr tin' ilorsuiii of the nose and sidr of ihc fhccks as far as tln' clrlnnuily I'xists. '). Ki'iiiiivc ;i <\\\\i 111' ill!' iiliitli rill, with )ii'i-inst('iiin, aliout t\vi> iiU'lu'S \ouiX and split it ti aiisxtTsidy sn as to sliapo it to correct the deformity. 6. ScTa|ic till' caiUTlliius tissiir nlT tlu' lnuii'. 7. W'itliiiiit i-riiiii\iiii;- till' liliiiid riiiiii till' |iii'|.ari'il |Hifki't, insrrt the lK)ni' .ural't as far dnw ii tlir tip of the iiosl' as nrcosarx' and plai-r the upper end well undrr tlii' ju'riosteal flap. (Fig. 326.) 8. Oiisr till' skill llap with lini-sc liair sutures. 9. Apply cnlliidiiiii dri'ssiiii;'. Beck's Method for Saddle-back Nose. 1. Lift up tip III' till' iiiisi' and niakr a small srmicircuhir incision In the anterolateral pnitinii nl' the \ est ilmle at the niucoontaneons june- tiiin of the cartila.t;'' and Imne. L'. With ^layo's seissors dissert ii\er the hniiip as in l-'it;'. 'A2C}. A\'ith the same scissors eniia,uc and sexer the linnip which is usually made up of cartilaije. 3. Employ a i)ortion nf the rili, the anterini- surface of tiie tiliia, or a iiortiou of the se|»tal ridize. rrniii the patient himself or from an- iitiier patient w im has Jii>1 lieen ii]ii'rated mi I'm- snliiiiueous resection. The size of the Imne splinter slimild (■m-respond lu the si/e and shape of the deformity to he eoireeted. 4. The Mood ex]ii-essed fi'oni the ea\ily is mopped awav and an adliesi\-e plaster is drawn ti.yhtly o\ei- the hrid-e of the nose with no dressing between it and the skin. 5. One silk stitch closes the wound. ■Walshaus' Operation for Collapsed Alae. 1. }ilake a llaji of the iiiiieniis meiiihraiie of the most anlei'ior poi'lioii of septniii, one-i'iiiht h of an iin-li wide and luie-lialt' of an inch liinu', leaxdiii:- the liediele al the ilorMim of tile liosi'. (Fig. ol27.) ■J. U'oll np this miieiiu> inemlirane llap and fasten in the upper aiii^le ol' the nostril. (Fig. 327.) .'1. lii'|)eaf the same on the opposite no-tril. Lambert Lack's Operation for Collapsed Alae. 1. l\i'mo\e a strip of miieoii^ nieiiiln-ane from the right side of the most anterior poitimi nf the >epliiiii. measuring alxiut one-eighth inch w ide and mie half ineli hum. '2. ( ut thi-oii,uli the cartilage and miienns inemlirane into the left nostril corresiionding to the defect, lea\inL;, hiiwe\er, the llap intact at its liiiiiie ])edicle at the dorsnin of nose. 344 OFKRATIVE SrilGEKY OK THK XOSE, THROAT, AXD EAR. :!. Dcmulc the surface of its mucous nieuiln'auc where the septum and lateral cartilage of ahi come too-ether; also of the denual layer of the iiiuci- side (if the ala. 4. Turn the cartilage niucuus membrane Hap u\) in the right nos- tril plaeiui;- the two denuded surfaces together. ."). Make a similar flap back of this one, only reversing the denu- dation on the septum. (). Tuni this flap into the left side and tix to a similarlx dcnndcd surface of the ala, only further back. (Fig. 328.) Kg. 327. Fig. 32S. AValsliiius' opoiation for collapsed alse. Paraffin Injections in Nose and Ear Deformities. The history of this means of correcting nose and ear deformities •dates back to 1900, when Gersuny corrected a saddle-back nose by the use of melted vaselin, injecting it below the skin. Eckstein in 1901 employed hard paraffin which has a melting point of 140° F. for similar defects, and claimed for it superiority in that there was less chance for pulmonary embolism. This method was very warmly received and employed by Broeckaert, Brindel, Karenski, Lake, and others abroad and by Harmon Smith, Kolle, Quinlin and otliers in the United States. The principal indication for paraffin injection is deficiency of tis- sue about the nose or ears, since excessive growth or absence of tissues of the external nose and ears are not within the limits of this method of treatment. Frequently there are ])ost-traumatic or inflammatoiy con- ditions about the nose which leave scars and adhesions that will pro- \cnt proper injection of paraffin. In such cases, pr-eliminary dissec- tion or loosening of these scars may be necessary. The introduction of a small quantity of paraffin after such dissection to keep the skin from readhering is good practice. Subsequently one may complete the n.Asiic sri;»;i;m m riii. nosi. anh i;.\i:. .">)"i in.ji'ctioii in niic nr iihui' sittiiii;>- N<> niii'stliftic is I'ctiuircd cxcriil in yoiiiiu: iiuliviiliiJils who wdulil imt iciiuiiii quii't diiriiii; tlic iiijcc'tiini. Miiiiy uiitowanl ivsults liavi- liccii rt'iiorti'il t'linn the use of paralliii iii.jci'lioii ami affonliiii;- to ("oiiiU'U, who lias uathcrcil Ihi'in iVoiii the litciaturo, they may Itc irroupod as I'ollows: 1. Td.ric (ihsorpiinii ny iuloxudlinu. — 'i"hi> ciiiiililiiiii is most ]piolialily ihic to the impurities in the paralliii and not to the chcinica! alisorplion aini rcaotioii of the paralliii itscll'. Too iaru'c a quantity, alioiit 1 111 ot' thf liody wcij^ht, would iia\c to lu- iiijcctfd iirfoic an> l(i\ic symptoms would ho ohsorvcd. arcordinu to .TuJcnlT. '1. I iilliimiiKifiiri/ reaction when Ihr propci- tcchnic has not iircn carried out, in iii.jectius;' too lariie a (piantity of paralliii at one linic or if the material contains any impurities. '.]. Loss of tissHi dur to inri'ction and secoinlary aiisccss forma- tion has been observed to rration hav(> not hiM'ii ohserxed. Instninienls, the lield of operation, aiiil the material itself inu>t all he sterile. The -kin oITits the irreal est dil'lieulty, since ther<' are constantly n:any \arieties of microiirt^'an- isms about the nose, ahe and vestihule. which are loi'uted in and incor porated with the sehum in the jilands. and are \ i-iy hard lo eiadi<'a1e. However, since linctnre of iodiii has heeii eniploye(| hcfore operation for paintiiii; the area even withmit pi-e\ iously uhui;- any soap or water, there i> less cluuice fur infection after these injections. 4. Pressure necrosis will invaiiahly follow when tlie paraffin is injected into the skin pirojier latlier than suhcutaneously. It will also follow w hell too i.;reat a i|iiaiitity is iiijerlrd at one time hy shnttin.;;' olT the hlood supply, with a uicater ehaiiee for secondary infection. A.yain,' it is essential to he nio-1 ean^fnl if there exists some constitutional dis- tiiriiance m- local (le\itali/.at ion of the tissues, such as re-iilt- from scar tissue, firmly lioimd down skin must always be lirst liln'iated before tile inject ion of paraffin. ."). Shiidiliiiifi has been reporteil. especially when the paraflin w;is injected while \-ery hot. 'file author a.iii'ees with many operators thai this is very unlikely, because by tin' time the paraflin is injected into the tissue it has cooled olT to a deuiee approximatinn- the body tempera- ture. Since the hard parallins ( lOckstein 14(f) are now employed, complication from this cause seldom occurs. Sloii.i,diiu.si:, however, does occur when the injection is made into the w roiii; pla<-e. as into the skin especially where it is lirmly hound down nalnrally or by scars. This complication may be a\diiled hy fust makiii!,'- a siihciitaiieous in- jection of -terile oi- iiormai salt solution or h\- the subcutaneous dissec- 34() OPEr>ATIVE SURGEKY OF THE XOSE, THROAT, AXD EAR. tion and an injection of three-fourths vaselin and one-fourth ]iaraffin so as to ])revent roadherenee of the dissected surface. An incision sliould be made and plates of ])aratifin or Cargile membrane introduced. Then injections are made small in quantity until the deformity is cor- rected. It is well to observe the general condition of the ]iatient and in syphilitic cases a Wassermann reaction should always precede the injections to be sure that the blood is in good condition, even when the l)atient shows no active symptoms. 6. Suhinjection or the injection of an insuflicient (piantity can scarcely be classed as an untoward result; it is only necessary to inject again. If subinjections Avere common, less disagreeable results would be reported. 7. Hyperhijecfiou or the injection of too great an amount occa- sions the most disagreeable results met with in this procedure. This is especially true when this mass undei'goes early organization. Under these circumstances its removal by surgical measures is required, since the various solvents, as ether, xylol, benzine, chloroform and heat have very little efifect. Electrolysis, the negative pole being introduced into the mass, has been suggested as beneficial, but the author has found it of no value in a case of paraffinoma so-called, in which he employed this method. Instead of making external incisions the vestibule may be opened. It is well to remove the excess of paraffin just as soon as possible before organization has taken place. 8. Air emholisin may occur, especially wlien cold ])araffin is em- IDloyed. In filling the syringe, the needle is as a rule obstructed and an air chamber remains between it and the paraffin taken from the glass tube. This should be avoided by completely emjjtying the syringe and needle before refilling and then forcing out fresh paraffin through the end of the syringe. If a small air bubl)le gets in lielow the skin it will do very little harm. 9. Paraffin eiiiholisin is of a more serious nature. In fact, it nmst be named as the most dangerous accident in connection with paraffin injections. There are several reports of death from this cause and many grave symptoms, as blindness, pneumonia and cerebral embol- ism, have been recorded. If the needle is introduced below the skin separately from the syringe and no blood allowed to escape then the immediate danger of embolism following the fragmentation of the paraffin is obviated. It is thought that these small particles getting into the circulation caiase the trouble, but the explanation is more the- oretic than real. After eight years of personal experience with paraffin in various methods and locations in a goodlv iiundier of cases, the PLASTIC SIUC.KKY OK TIIK NIISK AND KAlt. ;J4 ( author cannot report a sinii^lc iiislam-c or even a s\iii|iloiii ri'lVralilr lo parallin ('inl)olisni. Ill, I'liiiiiiiii ililfiisinii or I'.ih-ttsinti nt paiiiHin will occur cspc- ,-i;ill\ nlti-r iiiJiM-tiiin- I'or the coi-rci'I'hin of a -addle iiaek nose, when th,. 11,.,'ilii' piiilll i> allowed to -o lieMUld the liiiiil- ..r after illjeelillU- a laiiier aiiiMUiit than one shnidd. ainl e>pi'ciall\ w lirn nsinu li'iiiid i hot ) ]iai-ariin or \a>elin. The liio>c areolar ti->iie> of the IoWit lid, eherk- and oychrows arc the pi-iiieipai location for dil'fn>ion of the parallin. By having- the assistant liold his tinu-ci-s liniil> down on the hony struc- ture over tile root of the nose, as well a- ;it il> siures abso- lutely the retention of the paral'lin within the limit- of this mold, which when it cools becomes \cry hard. 1 1. hiferfcri'iirc irilli lltr drlnoi -W Ihr nmsdc -// ///, nl,, n, iint(i.< low deformity of the nose is to he eoi-|-crti'd. The aiithm- ha> loiind that iheopposim;- mnsclos of the constrietor> of the ahe eaninM a.-t and th.' patient then comiilains of nasal obstru<-tion like that due to paial\sis of the dilating- or lifting- muscle of the winus of the no-e. In oidei- lo prevent the paraffin from coming down too t'ar a hnger should he inserted into the nostril during the injection and the tiji of the nose raised upward and outward, if a latei-al in.jeclicm is madi'. 12. Escape of iimolfni after injection can he axdided by thor- oughly mokling the mass into ihe desired shaiie. although this should be done even while the nee.lle is still within Ihe tissues so as not to get the mass into one place. The n lie >h.>iil.l he moved ahonl. almost withdrawn, and ivint rodnceck >iiice the paiaflin oflen >ticks to the needle. The neiMlh^ siiould he witlidrawn only after no more jiarallin whatever is escaping fi-om il. It escapes usually for a few moments even after the turning of the piston ceases on aceomit of tiie pressure within the syringe. A fine blunt ]ioiiited probe shouhl he jiassed through the o]K'ning of the skin so as to l)e sure that no paraflin is left in the skin puncture. A .Irop of collodion will further close the punc- ture and pri'Venl the escajie of any paiaflin. .\a>al moliou or manipu- lation should be prevented. If lii|uid paralVm is employed un' wlicii iijirjil'liii nf liii;li niclliiiii- pdini is used. The injection iiiiist l)c nccoinplislicil (|uickiy, ri-c(|uciitly iifccssitaliii^' llii' licatiii.n' of the needle o\'er a IhiiiH' .just liel'oi-e itit roihietioii — a in'ocess which may lie injurious to the skiu. Ai^'ain the sudden exjiulBion of the lii|uid pai'affin into the tissues may cause it to ])ass into undesirable locations sterile) 3ii Vaselin (xvliitc sterile) 3ii I'l.ASTIC SriKiKltV or TIIK XOSK ANII KAK. ''iV.) is tlic Iti'st to I'liiploy. (Mass lulics iiiay l>i' prcpart'd stfrili- in ail\aiici' and ill llii'st' tlic i»aial1iii may he it'stfriiizcd, tube and all, just licfori' the in.jt'c'tiiui. li\ wasliin.u; witli hicldoricl and alcohol. Tin- injections slionltl Ite made with this semi-solid itaiallin in a cold stale ln-eause the eomiilications anil nnplcasant resnlls may thus hr avuidnl. 1(1. Uifiicrsiiisilirriu'ss of tiie skin jilays a \ery small roh- in the objections or diniculties met witii in tiic use of iiaraHin injections. Usually for a short time oidy, twenty four to forty eii;lil hours after the injection is maile, is tiiere any complaint of pain. More often patients c used in small amounts at a time and if >ciiMe liitle lime in1er\-eni'- ln'lweeii tile injeetiiins. Har- mon Smith reports a sense of numimess following;- tiie injection and otlier authors have reported sul)se(|iu'nt nenralyie ])aiiis from the sensory nerve filaments caught in the newly furmeil connective tissue mass after the ])aral1in has liecome ahsoi-bed. If infections of the skin or subcutaneous tissue sliniijd t;il' constant result of paraflin in jections. Tt \aries a ureat to lie dlH' |o 1 1 \ pi ■ I'i 11 Ject i oUS. opeciailv of hot material. Keilness is un(|ue^t ionalily due io pres>ni'e, on the \-ennle> such as one would olitain in l>iei's iiyperemia, and possibly to iin active hyjieremia. nature's part to assist in absorliiiii;- the t'oreig"!! body, liaraflin. .\uain, late ap|iearauce of the ie(liie>> i> \ery likely due to cicati-ieial >nlientaneoii> coiil i-ael ioii> from llie new substitute connec- tive tissue ma-.-. Wlieiher the chemical action of the hydrocarbons has anythin.y to do witii the redness of the skin has not yet l)een determined. The early evidence of redness nia> be nliivcd by ice cold aiijilications, moist dressings of acetate of ahiminnm. idithyol salve, (en ]»er cent extract of eiuotol. bi'lljidonna. and adicnalin inteniall\ . In later stages the same treatment pln> the excntiial >e\ciance of newly I'ornieil blood vessels, pimcturim,' of the skin \ery superliciall> , .•ind electrolysis have all been suggested. Math' cases when \ci'\- stormv and I'cd. max' call 350 OPEIIATIVE SriUlEKY OF THE NOSE, THKOAT, AXD EAH. fur iiMiKivjil of some of the injected mass and older cases after all has been ne, may require the dissection of some of the newly snl)stituted mass of connective tissue. The author has found that a certain amount of redness follows these injections, bnt that it never lasts very long and eventually disappears. 18. Secondary diffusion of tlie injected paraffin has occurred a number of times, especially into the loose tissues of the eyelids. The difificulty lies in the fact that the paraffin is injected in areas tightly bound down, as the root of the nose, and finding a lack of resistance at this place it migrates into the looser areas. In all such cases tlie use of cold paraffin in small quantities will avoid this difficulty; when once diffusion or migration has taken place, excision is aixiut all that can be done. 19. lliijHipUtsid of the connective tissue following the organiza- tion of the injected matter has been observed a number of times, and the author had a very pronounced case come under his observation, which is here illustrated (see Fig. 329). The specific cause of such new formation of connective tissue in this extensive form is not known, and most authors believe it to be due to a special predisposition on the part of the individual, such as is found in the tendency to develop keloids. When such a disfiguring condition develops there is only one procedure admissible — the complete excision of the fibrous mass. If there should be a recurrence, a second operation must be performed. 20. Yellow appearance and thickening of the skin after these in- jections are observed in rare instances, and they are among the most difficult conditions to deal with satisfactorily. The cause is supposed to be the use of hard paraffin injected too close to the dermal layer in regions where there is not enough loose underlying tissue. The elec- trolytic treatment, by making a nnmber of punctures at repeated sit- tings, is advised. This Avill bleach the area by secondary scar forma- tion and contraction. In case the result from such treatment is not satisfactory, it may be necessary to excise the pigmented portions. 21. Breaking down of tissue and resultant abscesses due to the pressure of the injected mass upon the adjacent tissue after the injec- tion has become organized have been observed generally in cases fol- lowing trauma. Abscess formation has been observed without this cause, and may be due to the increased pressure on the blood vessels, causing their obliteration and the breaking down of the tissues. The treatment consists in making a small incision and draining the accumu- lated purulent material. When all reaction sjmiptoms disappear the parts are again injected. ri.Asric sri;i;i;i;v di' iiii', Nnsi-: anh i;ai:. :;:)i Technic of Paraffin Injections. I iisliKiiiints. — .\li"ui all tli.it i- r('(|uin'il is a syriiiu'c which is strmi:^- ami not Icui lioavy, with a siTrw m ratclii't anaiiiii'iiu'iit I'tii' cxiiri'ssiiij;' the |)aral1iii slowly. Imt wliicli can also lie made to cxiicl its coiili'iits in hcalcil liipiiil t'onii in a <'ontinnous lliiw. There arc iiian\ wiridirs dii the m.-nkei. ;iihl tlmse nf llannnu Smith. IJrceckaert. I'lck'^lein. KdHe, nn.Mli. \\;iIIl ril. \'arious shaped needles will sm^uevt theni-el\e^ f(ir u-e in difl'er- eid special localities. In injectinns ahniit the nose a needle with too lai^e a calihi'r shonld he axdidi^d. since thi' opi'nin.i^ will prevent hcal- ini;-: in fact, there is -leater liability to infection. Ai^ain. the lileediiii; is li'i'caler from the -kin. althouuh it i- ni\ei- df anv ureat conseiinence. Miilrriiil. I'araflin which has a meltiiii; point of 110° F., with the follow inir fdrmnia: sterile plate ])araflin, 15, .sterile white vaselin, ]2(), is made up and lilleil ini lli;it df the tube in the syrin.tre (0.5 cm.). The ends arc coi-kci|, and the cdik >tdp)ier is ei.atcd with a layer 352 orF.nATivK srr.cEnv or tiik xosk. tiihoat, and kak. of paraffin. Tlicse tubes are always ready for retiUiiii;' the syrins-e, and all that is necessary is to wash tliem in bichlorid and alcohol before iisiiiii'. Fllliiu/ llic Sjiinifir (i.iliilr Ihc in I'dir is at lialicti ) . — 'I'ui'n the rin.c," bar so thai it can be slipjicd ddw n, thus reh^asin^' tiic jiiston screw. Pull out the liandh' of the syringe, so llint tlie ])ai'ariin chamber is opened. Then uncorkinii' both ends of a ]ii-cpni(Ml tube ami holdiiii^- one end rinbt over the paraffin chamber of the syring'e, the paraffin is jiusbcd into it by means of the metal roiL It should be noted that the end where the needle is to be attached is to be free from paraffin; other- wise the air thus included will prevent the paraffin from filling- tlie en- tire chanil)er of the syringe, and on injecting, some air will enter the tissues. This may not do any liarm, Itut may elevate the tissues and deceive the operator as to the amount of paraffin injected. If hot liquid paraffin is to be em])loye will Taeilitate its solidilication and the retention of it> shape. The -nvilot r.ire mn>t he exercised, as already pointeniiiew hat. Supports or splints made by takin.u' two im]nrssions o;' the cither ear with denial compound (front and hack) aii' employed. Then the ear is ronjAlily sliaped and the exces.- . straji witii adhe-i\e pl,-i-ter. and haiida;;e to the siile of tlie head. Tin.- i> left uiidi.-tiiihe I \'ny one wcel< unless there -hmild be much pain nr fi'Ver. Siili.-ei|iieii1 1> a cottmi .-ujiport and baiida.u:e are worn foi- alinul three week-, iiiitil (ir,u,aiii/.al ion has taken ))lace. In the siili,-e(|neiit t re;i 1 1 1 lei 1 1 iif a iiewly made ear liv pla-lic. an injection of |iaiafliii hetweeii llie -kill layer- mav iiiidoiiiitedl> he lieiielicial to the coii>i>1eiicy and ap|iearaiice nf the I'.-ir. Paraffin Injections in Collapsed Alae. .l/r»:c/".s Mrthofl.— 1. Pack the nose (vestilmle) lirmly with cotton. 2. Pa.ss the needle under the -kill ovi'rl> ini;- the cartila.ue at tin- crease between the iio>e and cl k. forward and ii|)ward. :>. Distrilmte the iiijecteil mass (eipiai parts of iJaralliii and vas- eliii) over the ala mi a- to -I i lien il. bul not lo any .ureal minor deformities, as large alae or large nostrils or a very PLASTIC SnUIKUV OK TIIK XOSK ANMi KAH. 3-)') Fig. 334. Vig. 335. KoUc 's operation for luiiiip nose. ,M1'/^^ Fi;;. Beek 's operation for liunip no 35() OPKRATIVE SflUiEKY OF THE XOSE, TIIKOAT. AND EAR. loii^' li;ni,i;iii,i; ti)) of tlic nose, are as a I'ulc licsl corrci'ti'il liy cxlcnial iiietliods. Joseph's Operation for Reducing Hump, Length, Width of Nose and Large Nostrils. 1. An A-shaped incision is made over the anlerolateial jjortion of tlie nose, jnst above the tij). A corresponding incision is iiiaile aliovo tills, the distance depending on the amount of tissue that is to l)e re- moved. The ends of these incisions should reach to the margins of the alee. (Fig. 331.) 2. A wedge-shaped portion of the nose is now tfiken out, in- cluding the skin between the two incisions, the underlying connective tissue and cartilage. The hump or crest of the nose, containing bones and cartilage, is shaved off by means of the cliisel and tlie knife. (Fig. 332.) 3. The nose is shortened by excising a wedge-shaped portion of the cartilaginous septum, with its base at the dorsum of the nose and the apex running backAvard as far as the bony portion of the septiam. (Fig. 333.) 4. Suturing the jiarts togetlier, one deep suture should ])ass be- tween the ui^per and lower margin of the excised septum at the crest, so as to liring the point well u]i. The other sutures are superficial ones. 5. The dressing slioiild be sucli as to hold the ti]) (if the nose up- ward. Kolle's Operation for Hump Nose. 1. Make a longitudinal incision over the prominence of the hump (Fig. 334) and dissect otf the skin and periosteum to either side of it until it is completely exposed. (Fig. 335.) 2. By the aid of a chisel the hump is taken off, cai'e Ijeing taken not to enter the interior of the nose or to tear away the mucous mem- ))rane. If there is a tear it should be sutured at once. 3. If a broad bone defect is obtained liy the removal of the hump, tlien by the aid of a heavy forceps tlie margin.s may be jiressed together to obtain a sharper ridge. 4. Close defect ])y Halsted 's subcuticnlar periosteal suture. Beck's Operation. 1. Instead of the longitudinal incision, a transverse one curved ujjward, subsequently to be hidden by spectacles, is made across the bridge of the nose. The ends of this incision may go to some distance on the side of the nose and thus create a flap which Avill easily expose the hump. (Fig. 336.) n.ASTir SI -HI ; Kit Y or tur nosk and kaii. Xu '2. By moans of a cliisi'l tako olT llic Imiiiii. ( Fiix. •">.!7.) .".. ("loso in tlio same inaiuuT as in llic in-fccijinic oin'rafioii. Ballenger's Operation for Hump Nose (Intranasal). 1. By nu'ans oT scalpel tci>l tin- lowrr linrdcr of ilic nasal hunt's and pass tlirou.uii niucous nii'uiluanr lidwccn tlic skin anil nasal bones. Fig. .■J.3S. Ballciiyer's oiioratioii for lu.iiip nose. li,'. :VM>. l!;illciij;rr 's ojicriitiiui I'cir Innj; iwae. 2. Klcvatc the skin from the underlying; anterior port ion of tin- nasal bones by the ai iiicniliraiii' and cartilage to the (i|i|)()sifi' iimcii|ii'ricliiiniliiniii :iImi\c ihr point of the nose close 358 OPERATIVE SURGEKY OF THE XOSE, THROAT, AXD EAR. Fig. 340. Fig. 341 Fig. 343. Fig. 344. Roe's operation for hump, twist aud broad alsi or large nostrils. (Illustrated by Beek.) Fig. 329. Paraffinoma with attempted removal. IM.ASTIC SIUCKIIV Ol' Tl I K NdSK ANU KAIt. ^'i^ to the (lorsiiin and carry ilowiiwaid ami liack\varkin snrface with tlie na.^al nuiei.us nienihrane, and pa-s hehiw the .•\ci- the eartilaije and na.-^al hone.s. (Fii;. iUO. ) 2. Elevate the skin and suhcntaneous edinieetive tis.-iie liy means of elevators (the author ]»refers Mayo scissors, as liy npenini;- the blades the tissues are sei)arated witii the least traumatism) until tlie entire hump is exposed. (Fijj:. .S41.) 3. By means of a small saw the liuni]i made np nl' cartilage and bone is sawed olT ( Fiii'. .'14'_') and reniuved. If. a> i> freipientlx the case, the humji nose is at the same time twisteil ami (lepres>ed, the hump is sawed ulT paitially. Imt is left attached aliove to the liliri)us tissue as a sort of a pedicle and slid nvei- into the (K-jiression. lli-re it is subsequently retained, i l'"ms. .14;! and :144.) This fibrous pedicle is not ab.solutely necessary, as the bone and cartila.ne chip will live any way. If the depression be ,a;reater than the l)one cartila,a;e chip can fill out, small subcutaneous tissue llajjs are turned back into the de- pression. These are as a rule taken fi-om the tip of lateral imrtions of the ahv, which also are lai^e in inaiix cases. 4. Either a soft nielal o|- adhesive retention diessini;' is applied over the nose and the inei>ioii within tiie ala is sutured. Roe's Operation for Broad Alae and Large Nostrils, i I";--. .'!4.').) 1. An incision is nnuk' within the nostrils cIumt to lln' exteiior than in the preceding o])eration. 2. The cartilage is liberated and part of it is excised to^^^ether with some of the subcutaneous lissin-. ( I-'ig. ■'A(\.) '■■>. Suture and insert two small rnlii)er tulns. Fig. .■J47 shows final results. Beck's Operation for Hump Nose. 1. Lift np tip of the no~e and make with a knife a small semi- circular incision in the anterolateral poitioii of the vestilnde at the n^l(•lM•^taneon^ jnnctinn of the cartilaire and hone. 360 OPKl'vATlVK STRCEltV OF THE XOSE, THROAT, AND EAR. Fig. 345. Fig. 346. Fig. cil,. Roc's oiseiation for brnail al:i' or lar^o nostrils. (Illustrated by Beck.) 2. Dissect over the liuiiip with Mayo's scissors as in Fig. 348. With the same scissors engage and sever the hump which is nsually made np of cartilage. -c^X ^^^^^^^^ 0{!W^ 1 1/1 .-, Fig. 34S. Beck's operation for hump nose. 3. Displace this fragment by external manipulation and by the aid of fine forceps or the scissors in the eventually existing depression (if none exist remove the piece). iM.ASTic sri;r,Ki;v (ie riiK Nosr. anh i.\it. :{(i 4. If tho base from wliidi llic liiiiii|i is rciiKtvcd. is vi'iy liidiid ami sliarp, the ediri's may In- HIcil niT witii a straiirlif rasp or sliavcd otT witli a chisel. 5. Till' liinml i'\|)l('.->ril I'nuil till' caxitv is lini|i|iril ;i\\;iy ail>l ail CL Fig. .349. Fig. 350. Fig. 351. Kiilli^'s ii|iorution for long lip iiodc. adliosive jilastcr is ilrawii tiiiflitly over the luiiliir i^'i \\\v imsc wilii im dressing between it and tlir skin. 6. One silk stitch is ii>cd in chisc the wcnind. Kolle's Operation for Long: Tip Nose. 1. .\!;iki' Jill incision on cither side thro\i«:ii the entire lliickness of the nose, indudiiii; the septum, as shown in Fiir. •!41». lii^innina: at c, downward. 302 (Vl'KltATIVK srUCERY OF THE XOSE, THROAT, AND EAR. l'. From !■ to //. in a natural curx'c linr, all the tissues of the alu' arc scN'crod. ."). A short u])\var(l cut is made tlircuiiii tiic entire tiiickncss (if the columella at r. fi'om which point the scjitum is cut as shown in the (lotted line d. towards e. 4. The tip h of the part (/ is now cnt ofl', leavini;- the nose as in Fig. 350. 5. The front part a is now sutured to the remaining portions of the columella at h, and the cartilages of the alfp where they are pro- truding are excised to such an extent as to permit union of the skin over them, as .shown in Fig. .351. IX. Prothetic or Artificial Noses. There are frecjuently anatomic, jiathologic and social conditions that require the correction of the nasal deformity to l)e made by the aid of artificial devices. It can be said without (juestion that so far as the appearance is concerned, at least if not too closely scrutinized, an artificial nose that is correctly made looks much better than one that results from the most of the best surgical procedures. (Figs. 352-355.) For instance, in cases of carcinoma which have been operated upon to the extent of removing the greater part of the nose, there will naturally l)e some hesitation about performing a plastic operation. In cases where the face is all scarred up it is much better to employ an artificial nose. There ai'e some people who have not the necessary time to have plastic woi'k done on their noses by reason of the necessity of making a living and i)roviding for their families. These artificial noses may be made to fit any kind of defect and are usually held in place by spectacles and adhesive (actors') paste. The making of these noses is left to a specialist in this line, but only under the direction of a physician, since the condition of the nose nnist be thoroughly examined before fitting an artificial nose. Artificial Supports. — In noses in which the bony framework- is destroyed or absent one may introduce -vvdre or lubbei- supports made especially for each individual case. In cases of lues, in which there exists a perforation in the hard palate, a sort of a horn may be vul- canized i;pon a dental plate that will ])ush the collapsed nose forward and thus sujipoit it. X. Orthopedic Method. By wearing certain forms of apparatus which usually must be specially made in each individual case, a deformity may be changed, especially in early life oi- when it follows a traumatism. It is also pos- ri.\>rir >^i;l,l.i;^ m rm: mi>i-. ami i;.\i;. :5(i:5 FIc. 355. 364 Ol'KKAriVE SnuiERY OK THE NOSE, THROAT, AM) EAR. siblo to correct collapsed or saddle-liack nose bv s])ecia! iiietliods. (Fi^'. 324.) XI. — Operations for Closing- Perforating Septum. Goldstein's Operation. 1. Freshen iij) the edges of the perforation and elevate the mneo- lierichondrium from the cartilage for al)out one-half inch. 2. Kemove a small rim of the cartilage all along the perforation by means of Ballenger's single-tined swivel knife. (Fig. 356.) 3. Outline a nmcoix'i-icliondi'ial flajt on the most convenient por- Fig. 356. P"ig. 357 Fig. 308. Goldstein 's operation for perforation of septum. tion of the septum, with the hinge pedicle at the margin of the per- foration. The author would suggest the use of the cautery in order to destroy the epithelium so that tlie flap may heal more easily. (Fig. 357.) 4. Dissect this flap and bring it between the two layers of the mucoperichondrium about the perforation. 5. Suture through and through by a quilted suture with the aid of Yankauer needle. (Fig. 358.) I'l.ASTIC Sl'Kl'.KItY OK Till'. NOSK AND KAIi. 365 Hazeltine's Operation for Perforation of Septum. 1. l''rc>ll('ll ll|> llir Ili.llLlills <■ I ( l-'ii;-. '.','>'.>) ;iMil i'l<'\;iti' tile Illin'ii- l)eriohonili"iiiiii (ii> in tlit- siil)imicmis n-scfliim ) wIutc the ;inti'ii()r tliip lii'.^;. 2. All iiicisiuii lhii)Ui;li llu' iiiiic(>|icrii-li(iniliiuni ■•iliout oiii- hall" Fiir. .35!l. Fig. ."CO. Fig. 361. niizollino'.s o|ii>riilion for p'-iforHtiiiii of scptniii. to Olio inch anteriorly to iicrforation (/;-/*, Kiii;. i!.")!!) is iiiaih', mikI flu' flaj), witli pcdich' altovc any ,i;ranulati(ni. Goldsmith's Operation for Closure of Septal Perforations. 1. Kxeise margin of perforation li\' the Italleu^er's siii,iide-tiiie swivel knife. 2. Separate the mueopei'icliondrial Hap on either si(h' all around the ]ierforation. ."!. Take a piece of cartilage eitiier from anotiier case just ojier- ated n])on for deviation hy the submucous method, or a jiioce of sheep's septal cartilage, wJiich must be larger than the perforation. 4. Slip this cartilage plate into the dissected fla]is and replaee earefuliy all around the ])ei'foration. ."). I'ut in anteriiu' nas^d splints to I'etain the cartilage and nuico- perichondrium in ])lace for forty-eight hours. 'i. Subsequent cauterization to assist in epithelialization ami a()- plieation of scarlet red ointment constitute the after-treatment. OTOPLASTY. ()to])lasty is a subject that hiis i-eeeived \ery little attention as (■omi)ared with rhinoijlasty, and most text books contain very meager information on the subject. However, nuich better cosmetic results are obtained than in nasal plastics, es]iecially in deformities or mal- ])ositions. in the absence of the eiitirt' or a greater portion of the ani'icle, the results exce]it witli ]irothesis are very unsatisfactory. There is one comfortim^' fact that in women deformities of the ear may be hidden by long bail'. Kai' plastics are performecl jiriuci^ially for cos- metic reasons, since the ]iliysiologic i'uuclion is but slightly influenced unless it be in cases of congenital atresia, with ))resence of a good middle ear and auditory nerve apparatus. Classifications According' to Kolle. T Tj • I 1 « • I l-'iiilateral. I. Freaurnnilar dehciency p-i. f . .. i I Tnilateral. II. Postaurieular deficiencv. ,,•, , „-i 1)1 lateral. iM.Asiic sii:(ii:i!\ (11 iiii-: nosi'. anh icau. 3G? General Classification. 1. Ma.lntiji (liiriiV ,.;ii-). II. As_\ iiiiiiclry ol' the two oirs. 111. I K't('niti)|i\ (f.-iLxc id.sitioM nf tlic .•uii-i<-|c). I\ . SyiR'chi.-i (if the ixislcrior siiit'iicc df tlic niiriclc. \ . Pru.ji'ctiiii:'. idll or doii' i-iiis. \ I. I'uinlcd car ( I 'arwiiiiaii tnlicrck"). \ll. Maca.-us car. \'lll. Wildcnmitli's car. 1 .\. .\l),l laruci- jiart. 'I'lie l»ase of tlu- \' is at tin- Fig. 362 Fig. 3(5.;. UmuuI oiHSrntion for inncrutiii. 368 OPEUATIVE SUlHiKItV OF THE NOSE, THROAT, AND EAR. external border of the ear. (Figs. .')til2 and 060.) The size of tlie wedge- shaped piece to be removed will depend on the size of the deformity to be corrected. '2. ?iXcise a narrow wedgc-sliapcd st'uniciit fi'om tlic Iowit lialf of the auricde, the base of this wedge being at the incision, the apex dii'ected towards the l()l)ule. (Fig. 'MU.) This is necessary to mak'c the upper and lower portions of the auricle lit for exact a])pr()ximatioa of the helix. 3. Sntnre the lower Avedge first and then the large transverse defect after exact ajiproximation. Fig. 365. Fig. 36G. Pnrkhill's npcratioii for maorotia. Parkhill's Operation for Macrotia. 1. Make an incision tiirough all the structures in line with the curve of the antilielix. 2. From each exti-emity of this incision make a curvilinear in- cision towards the enter margins. 3. A small tongue-shaped fla]i is further excised from this last ipcision towards the external border, in order to shorten the long- diameter of the ear, and the crescentic excision will make the width of the ear smaller. This will make a crescent-shaped defect with a little tongue. (Fig. 365.) Suture defect. (Fig. 3G6.) Cheyne and Burghard's Operation for Macrotia. 1. Excise a V-shaped piece of the auricle from the upper and outer part, the acute angle of the V being carried almost into the conclia. (Fig. 3fi7.) PI.AMK >l i;c;l".KV Ol" TIIK NOSK AXII KAIt. 36!> -. « oni'siuiiidiiii;' lo the upiiri- lnir.li'f nl' lli niclui .-i -cinliiiiiiir incision is niixlc tiironyli ;iil tlic -1 1 ik-i iiifs. ">. I'liuM liic latti'r's I'xtri'ini' I'uils two sliorl nirvctl incisions are niinlc III uu'ct the \'-sliai)i'(I incision, rcnioviny- llic two jiicccs tims formed. (Fiy. ;>(i7.) 4. Tile parts are lirouiiiil tunetlicr mnl ^ntnred on liotli i\' the anrielo. (Fig. 368.) Goldstein's Operation for Macrotia. 1. Make a curvilinear nicisitm down to tin' cartilage, witli its convoxity directed to tlie ontcr jnarnin of tiic car. on the jiosterior surface of tiie auricle. ( l''i.ii-. ."!()!>.) Fig. 367. Fig. 368. ClieyiU' mill Hiir^'liiiurs oprnitidii fur iiiiu-ri)ti;i. 2. Dissect off tliis llaji and lay o\ cr tiic mastoid ri'iiioii. ( Kiii'. 370.) 3. Cut througii tile cartiiai;e in the iierpeiidiciilar direction of tlie ear and curve the incision at each extremity for a short di.stance in order to make a sort of a cartilam' flap, (ircat care must be exer- cised not to cut tlironjiii the skin on tlic aiili lior surface of auricle, in other words, not to hnttonhole it. ( I'iii'. 37lide the llaji over with greater ease. 370 OI'KItATIVK sriHiEUY OF THE NOSE, THHOAT, AXD EAR. Fis. ?.m. 6- Fig. 371. Fig. 372. Goldstein's operation for macrotia. rr.ASTic smcKKV oi' tiik xosk axd kaii. .h I ."). Disscet also tlu' tli'i-iii(i|icri<-li(iiiilii\iiii .•inlcriurly rrmn tlic i-x- tonial iiDVtioii ol'llic i'XiuisimI fiii'tilaiic liccaiisc tlic miIis(m|iiciiI sutiuiii-i' will liavi' to lie doiic at that point. (i. Pass a siiiall siiar|i (Mirvcd needle anaed with line clironiieized catsut tlironu'li the nitper part ol" thi' internal eaitilaL:c Map (which will boconie the ovoiridinin" one). Then at the same place pass the needle tlironiih the external eartilaiife flap, which will liecmne the overridden one, and talsiny' in a small hit of cartilage ennie ont Ihi'on.uh lioth flajts, coniiiletiny oiu' mattress snlnre. Another snlnre of the same type is made in the lower portion of the im'ision. and tiie )>arts are re;id\ for sntnre. ( V'mx. •!71 .) 7. While the assistant hohls the parts touetliei- so as to iict an overridinit' ol' the internal flap, the sntni'es are tieil. S. The jiostorior dennoiierichondrimn tlap is In-oniilit liacl< a^ain ami sntnreil. (Viix. '.u'2.) Goldstein's Operation for Projecting Ear. 1. ^lake two cnrNilini'ar incisions iiaci< ol' tln' ;iuiicle, one n.-nmi: its convex border towards the onter border of the ear, the other towar.) 0. Excise an eUipti<'al jioition of the cartilaii'e of ;i -^i/c dependinL: upon the amonnt of projection pre>eiit. ( l*'iu. •"■74.) 4. Draw tlie cartila.u'e towai-ils the mastoid rcLiion ,inu snlnre to the ]ieriostenin at this point. ( Fi.u'. 'u'>.) .'}. Close the skin defect by a few interrupted sninres. ( Ki.u'. •'~i<.) Beck's Operation for Roll Ear or So-called Dog-ear. i Fii;. .177.) 1. -Make an incision tliron,::!' the skin on the jioslerior part of the auricle in line with the nsnal site of the antihelix. 2. Dis.sect the skin freely on either side of the incision, bnt not the ]ieiichondrium. .'!. Kxcise a very thin >liver of cartila:;c the whole length of the skin incision in a curvilinear slnipe. {V\ii. -'mS. ) 4. Demi back the helix and form an antihelix by donblini'- the eartilajfe upon itself. Hold the parts lou'ether on the anterior surface of the ear. 5. Pass two mattr<'ss sntur<'s of silkwoi-m unt tlnon.^h the skin, perichoudiinm, cartilaire. two layers of perichomirinm, cirtilaire, peri- chondrium and skin. These are tied over jiieces of rubb.T t to cut into the >kin. ( f'ii;. 'M'.K) 372 OPERATIVE SURGERY OF THE NOSE, THROAT, A::^D EAR. Fig. 375. Fig. 37(1. Goldstein's operation for projecting ear. Fig. 378. Fig. 379. Beck's oiieratiou for roll ear or so-called dog-ear. IM.ASTIC sriiCKItV (»K Tl I K. NOSK ANH K.AK. .)(.) (■>. l-'Acisc >m:ill imitiniis dI' cxcoss skin mi \\\v |iu>!ciin|- siii-r;ii'(< i\\u\ iiiJiUc ;i sulpi'uti«'ul;ii- sutmc. This siiiiic oinTiitioii cjiii Kc ;i(liipt«' car ur external auditory iMeatn>. ahont the -ize of tlie pinna on tile u]»i)i)site si(h'. taUiuii' in tlie sUin and all sui)eutaneous tissue ]iossible. •_\ Disseet tlie ahove oiitliiie.l (la|. and fold a1 the eouslridi'd iiiiddh' part so as to hriu.ir tlie raw surfaces in appositimi. .■). Suture alouii: the uiar.yins aliove and below. 4. Cover the denuded ari'a of defect by skin urafts or slide a liap from the occipital reniou and snjiport posteriorly by liau/.e pads. Siihsequeuf Correction. 5. Incise al)nve and below as sliow n in |-"i,i;. ilSj. |)iaciiif;' small trianijular llajis, back of the nniicle ami liiiiminu the latter forward into u more i)rojpctiii<;- shajie. .\l.-o excise a small portion of the newly-fonned auricle from the lower inari:in. to shape a lobnle. Beck's Operation for Synechia of Auricle to the Mastoid Squama. 1. Sever the adherent ear from the ma.stoid surface and ])lace between the surfaces irauze or rulilier tissue to prevent reunion ami wait for iiranulation fonnation. '2. Make a correctly outlined tlap to cover the mastoid region as well as posterior surface of auricle, on the forearm, on the side opjio- site to the synechia, since the subseipu^it immobilization is more com fortable in that way. Place rubber tissue 1m low this f^ap to ju'event its reunitini"- ami allow it to lu-come thicker. 0)if WeeJc Latrr. '.'). Fresiien up the surfaces on the nia>toi(l ri'uion, tnrii the anncle forward and suture into the forearm llap on the greater portion of the defect. (Fi.ir. '^X-2.) 4. Ajuily re.irular iilasti'r retention ca^i a^ in tli- Italian jilastic operation for th»» nose. Teu Dni/s Latrr. 5. Sever ]iedicle from forearm and snture on all sides, special care beinj; taken to make a natm-al lold at the insertion of the auricle. This is best aecomiilislied by a sjirinu wire like a spectacle frame over 374 OPERATIVE srHCEKY 01' THE XOSE, THROAT, AXI) EAI! Fig. 381. Szymauowski's operation for recoiistruetiu!; an auricle. ri.ASTU' SfKliKKV HT TIIK NOSK AM' KAK. ■>! ■! soiiit' liulil >lir>siiii;. to l»f lit'ld l>\ the wc.-iriim nl' s|)cct;i<-li's fcir the tiiiif lifiim. ti. S\itiirf ilrl'cct ill forciinii. liisti-iid III' usiiin- tlif tliij) troiii llic fon'Mriii one or two Wull'c iir;ifts. or Tliiorscli ur.-it'tiiii;-. iii;iy lie ciiiiiloycd In cover llif ildicl. AiiJiiii, the sli.liii:;- ov.t of ;i tlap iVoiii the l;itfi;il |iortioii ol' \\\<- occi|ml. cvcii Kig. 382. lifck's iipiMHtiiiii for sjTiechia of miriclo to nin.stoiil. llioiiiili it coiitiiiii liiiir, to cover the iii;i>toi«l I'ciiioii. will iiid n i^rejit dcnl and prevent the further i'oniiiilioii of a .synechia on tlie )iosteri"'r -m- face of the aurieh'. Tlie latter may he envorcd liy -kin L!raft>. Roberts' Operation for Absence of Ear. Thi.s anlhor'.s |iidceihire i> \eiy iniieh liiplif(l so as to piicUcr llic tlfl ouulily, and pcrrcct a|iproxiiiiatioii i> iiiipfialiv f. •|M'ii(liii:j r.-t llior Via. :!87. Fig. ass. Simple operation for eololioniata. ViK. 300. Onoii's operation f.ir eololiomnfa. Kolle's Operation for Projecting Ear. 1. Maki' an incision on tlic liack of the aurii-ic tlncc-(|iiartcis of an imh fnini it> mitci- niaririii. lic.iiiiinirin- aliovc at tin- sulcus and cnrvinL; n|i\vaid and outward ami tMcii gradually downward nntil the lowiT iiait (if llic sulcus is reached. The >ls with latiiut. (Ki- :!:»•').) .■>. nissect freely the skin and iieiiciiondrinni over the ]iinna and also the skin and periosteuin over mastoid i-eiiion. ( Ki";. 89t5.) 4. I'nite the>e hy inten-npti'd >utnres oV( i- the two lower flaps. (Fisr. :W7.) Von Mosetig-Moorhoff Operation. 1. .Make a tonune-shaped tlap lielow tlu' li.-tiiioiis opening, leaving tlie hiuiiod ])ediflo at the lower niar.iiin. (Fig. 398.) 12. Dissect loose, Init not too dose to the niai'.siin of tho ojieninij; or else too little hlood supply will remain to nourish the Hap. (Fig. 0. I'^reshen up tiie margin of the listnla and loosen the margin thoroughly for suture. 4. Turn the flap with its dermal layer towards tlie inside (to- wards the audittu-y canal) and suture to margin of listnla. ( Kig. 41)1 1. ) 5. Close newly-rornietl defect liy iirst loosening its margin (Fig. 401). snlise(piently either cover the turned-in llap with skin graft or allow it to gi;undate and cii-atrize. It hecomes necessary at times to make .secondary corrections at the pediide jiortion. Goldstein's Operation. 1. l.dOMii liic !ii,iiL;in> aliout the listnla freely on the cartilage as well as on the mastoid side, and freshen up the margins. '2. Make lateral incisions to allow free coaptation of the margins of the listnla. (Fig. 4l)-J.) :;. Clr.se hy means of .Mi.hel'> . ( Fi- 4(i;!.) 4. .\llow the defects created li\ I'ounler in<-isions for relaxation to yranulati'. Ear Prothesis. As in nasal defoi inities, there are times when the local as well as tho general loiidition does not warrant an operation of magnitude; under stilaiitiiin' tliis ilistal I'lul into aiioliicr motor iiir\c or ajiprox- iiiiatiiii;- it diri-i'tly to tin* I'l'iitral or proximal portion of sii«li a ncrvi". All liraiK'lii's of tlii' facial iirrvi' jfivni olT witiiiii tin- tciii|iiii;il Ixmi' arr not iiitliii'in'cd hy anastomosiiiu- prot'i'duri's. Tlii' dinci upair nf the sovi'i-i'il farial iii-rvi' is not fonsiili'ri'il in this discussion of iiiMiroplast\ . Till' mi'thods I'lnployi'd Iii-ri'tofori' an-: 1. facial s|iiiial accessory end to end anastomosis. '2. Facial hypoglossal, end (facial iici\c) to side (of hvperulos- sal). 'A. Faoial-hyi)o.a:liissal. end to I'lid. 4. Facial-spinal accessory and dcsci'iidcns hypoiilossi spinal ac- cessory anastomosis. • ). Facial-.iilossopliaryiiifcal anastomosis. The jiriuciples iinderlyinir neiiroiilastic surucry arc: 1. The approximatini;' iierx'es innst lie under alisoliilely no ten- sion. ■J. The neural >tructiire> of oih' iier\c >li()uld lie in cdutaci with the neural structures of the opjiosite nerve. (This is parliciilarly necessary in the end to side methods.) 3. Sutiirinn- must lie done with the linest of iiiatciial and under li'reat care (not so iiian\ sutiii-es liein^' used as in ciKJanuci- -IraiiLiula tioii I. 4. The anastomosed nerves sliould lie >urroiinded with muscle tissue or Cardfile memhrane, to pre\ciil Inn -teat a cicatricial forma- tion alioiit them. '). Alisolute asepsis is necessary to ohtaiii a i::ood result. (i. Adjunct treatment such as electricity, massaiic. tonics, etc., followinif the operation hastens reco\cr\. tln^ liiiie clcpcndiim on the deirree of muscular atrojihy which preceded the niiciatioii. 7. ( 'orrect diairnosis liefore the oiieralinn a> to the reaction to defeneration is very important, so as to he sure that if a jierfect anastomosis operation is performed and union is ahsoliilely )ierfect, a :;ood result is |iossilile; otherwise this excellent therapeutic pro cedure would lie discredited, as the luuscle wouhl not he susceplilih' of motion in >pite of the nnimpedi'd iiei\c slimulus. 384 ()I'KI;aTIVK sriKiKIIV ok TIIK XOSK, Tili;i)AT. AXD EAK. Spino-Facial and Periphero-Spinal to Descendens Hypoglossi Anastomosis.* 1. Make a V-slia})ed incision, one liraiicli of tlic ^' ciitrnii;- in front o[' the ti-a,u'ns, the other back of the eai- on the line witli the ti-a,niis. The stalk of tlie Y is directed forward and (hiwnward, in front of the stenioniastoid, for al)ont tliree inches in lenntii. Tliis incision goes thron,i;ii skin and suiierfieial fascia, (l^'ig. 4(15.) 1^. Dissect bluntly down to the muscles and expose the i^osterior border of the ])arotid yiand. o. l^levate the lobule of the ear, draw forward tlie parotid gland and dissect down into the narrow sjiace between the anterior borch'r Fig. 405. Incision for .s|iino-f;icial ana.stoniosis of the mastoid and the ]>osterior boi-uei- of the ranuis of the lower jaw. Here locate the facial nerve in its course from the stylomastoid foramen towards the posterior Ixirder and the under surface of the parotid gland. 4. l^lace a ligature (but not Wvd) ai-onnd it for subsequent identi- hcation and leave tliis field of operation f 7. K\|i(i>c till' li\ |i(ii:ltiss;il whii-li lies in lliis iciiioii. Jii-t win ic- tlic ofci]iitiil artiTv is nivi'ii oil" troiii the cxIitii.iI cnrdtid, .■ilmiit the tH'iitiiil tt'iiilitii ol' till' (ii.yfiistric imisc'ii'. S. Cut till' iliuastrif iiniscli« posti-rior to its cciilral tcinl(iii aiiil rollec't tins posti-rior liclly liackwavl. Vis. «<••!. Spino-fn<-iaI luul poriiilipro.xpiiinl to dosrcndcns liypuRloosi niinMoniosis. II. I.oratc till' (It'sci'iKlcus iiypnyflossi at this point as it leaves till' liypdiilnssiil and i)assi's (Inwnwanl on tlic sjicatli of tlii' common carotid artery. I'lace a tlircai! aliont tliis ncrvc also. {V\i\rotitl liiand (jiDstcrior Itordcr). 4. LtH-atf till' facial iutv i' as it ciitiTs this ^laiid. .'). Follow it Itclow tln" i-artilayiiioiis imrtioii of tlu> oxtonial :\n ditory canal down hcfwi'cii tlu" ixistcrior liordcr of the i-ainus of the lower jaw ami tlu- aiiterior lioriler of the mastoid [iroci'ss. (i. It may lu' ncci'ssaiy to divide the posti'iior lielly of the diuastiie imisele. Ketraet the styloliyoid iinisclo and i»ass about the nerve the author's nerve tracinf? forcejis. (Fi.a;. 407.) Follow the nerve to the stylomastoid foramen, which is hehiiKl the styloid jiroci'>>. and c-h>M- on the nerve. 7. Steadily jiull the ihtvc out of ilir ma^Inid canal ( >tylomastoid foramen) ami keep the forceps attached to the nerve. 5. AVithdraw iis much of the spinal accessory nerve as is neces- sary to make an easy approximation w itli tin' di>M(ti'd lacial nerve. 9. Trim the facial nerve end sijuarely to lit tlic >pinal ac<'essury and suture the two end to end. 10. Three sutures are placed, i-oin.i;' throni^li the neurilennna and lakinu in a few of the axis cylinders. An additional sui)])ortin;i snturc (continnous) takes in oidy the sheath of both the nerves. 11. ^lake a slit or pocket into the postei-ior Itelly of the iliiiastric uni-sele (if it is divided it should first lie nnitidi, or place a la>ir of C'ar.iiile membrane about the anastomosis. IL'. Cl.^e wonml. Facial-Hypoglossal End to Side Anastomosis. 1. Imi-r the skin, fascia and plaly>rna. beuinnin^' behind the ear and carrying' the .'nl downuarcl an.! then forward towards the tliyi-oid oartilaire. 2. Ketracing the tissues, the hypo-rlossal nerve is located by drawing: up the digastric muscles i)osterior to the sternomastoid where the sheaths of the great vessels lie. On the level of the thyroid car tilage, where the carotid ai-tery divides into the external and internal branches, the hypoglossal ner\c will b.' seen at the )ioint of crossing of the occiiiital and the inteinal carotid arteries. Here it turns for- ward and lies on the mylohyoid muscle. .".. Fxiio.se the hypoglossal nerve at the point closest to tile facial nerve. 4. Locate the facial nerve as in the facial-spinal accessory anas- tomosis, and draw it out in the manner described above from the stylo- mastoid foramen. 388 ii'K.i;ATiVK srr.cKnv ok tiik xosk, tiiiioat, axd kar. "). Trim the facial stiiin)i in such a nianiici- as to strip tlio iiiajoi'- ity of the axis cyliiiders of tlieir sheaths for ahoiit three lines. 6. Place three sutures tliroiiuli the stiiiiiii, thus gettin.n- it ready to join ^vitll tlie hypoglossal nerve. 7. Make a small buttonhole in tlu' exposed liyjiou'lossal nerve at tlu' point mentioned in division .'1, paraUel to the course of the nerve and on its upper border, to admit the prepai'ed facial stum]). Tt is Pcrotid F<5,cia1 nerve im ,,- planted end to Side in Irypo- Posterior belly of did,.nd reflected well to enter this buttonhole slit witli a tine pair of scissors and cut a few axis cylinders transversely within the sheath in order to get direct contact with the facial axis cylinders and thus obtain a more rapid regeneration. 8. Pass the already prepared sutures of the facial stumj) through tlie slit in the hypoglossal nerve from Avithin, outward, one on each side and the third at one end. The tving should be done by the oper- PLASTK' Sl"l!(ii:i;V Ol' TIIK XOSK AND EAU. 389 ator while the as.sist.-int l\' rdircps (spriii.ir) Jiiid liolds the I'iiciiil slump stciuly in the slit. Aiiotlicr sup IHirtinjr suture surrounds tliis anastonidsis in the sanir luanuer as in the spinal aecessory pmcethire. (Fig. 4(IS. ) 9. The same pr<)ee(hire as in the t'aeial spinal aeeessorv is i\>\ lowed in the jirevention of eicatricial forniatidii alumt the iniicm, as is also in the closure of the i'\tcrna] wound. Facial-Hypoglossal End to End Anastomosis. 1. The same proeeilurc as in ihc end In >ii|c n|irr;itiiin up tn the Parotid a,le>nd Fo>cie>l nerve An- astomosed end to end with bypo- Desccndens hypo^lossi Postet-ior dift- i /' ^O'Stric cut cind /// reflected I Fif,'. l(1!i. I'ai-iiilliypoglo.ssjil cml tn mil !Ui!LHfoniosi.s. l)oiut of union, except that the hy|iofrlossal is not pnp.ncd m. cIcm- to the facial nerve. (Fig. 4(l!>. ) 2. Follow the hyj^oglossai nerve nearer to the front as it enters the flooi- of the mouth. 3. Sever the hypoglossal and tuni it l)aek to join it with t!ie faeial nen-e, which has also lieen prejiared as in the other two pievions jiroeedures. 390 OPEKATIVE STIUiEIlY OF THE XOSE, THROAT, AXD EAR. 4. The union and iiiauageuieut of the anastomosis and tlie wound arc siil)ject to the same i)rocedure as in the facial-spinal accessory operation. Myeloplasty for Facial Paralysis. In eases of congenital I'aeial i)aralysis, or in jx'rmaneiit i>aralysis in wluch the peripheral branches of the facial nerve arc imbedded iu cicatricial connective tissue, or Avhen the paralyzed muscles of the face supplied by the seventh cranial nerve are completely atropliied and do not react to the electric currents, or finally if for any reason tlie hypo- glossal or accessory nerves are not accessible and the neuroplastie operation cannot be performed for any other reason, the masseter muscles may be used to obtain a straighter face. The associated move- ments following this operation arc oljjcctional. These, however, do not persist, for the patients re-educate that particular part of the uiasseter muscle which causes facial expressions. Teclinic. — Tender local or general anesthesia make an incision along the posterior border of the ramus of the lower jaw. The tissues are dissected forw^ard until part of the masseter muscles is reached. These are now separated from their attachment to the ramus of tlio jaw and the lower boi'der. A sort of a tunnel is now made ^vitli a ])air of Mayo's scissors, spreading the tissues rather tlian cutting thorn, until one reaches the external angle of the month. It is important not to go too high in order not to Avound the duct of the parotid gian