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Operations Upon The Air-Passages

By JOHN 0. ROE, M. D.,

NASAL deformities are generally divided into idiopathic or congenital and traumatic or acquired. The former are usually regarded as mere accentnations of certain racial types; but no special deformity can be said to be governed merely by racial influences. Congenitally deformed noses may, however, vary from a mere rudimentary knob to a very large and greatly distorted organ. Traumatic or acquired deformities sustain little or no relation to the natural conformation of the nose, and therefore may assume any form in which accident or disease happens to leave them.

From a surgical point of view, nasal deformities are to be divided into those in which the normal parts are present, but distorted from their natural position, and those in which there is a partial or complete absence of these parts. The first comprise those which affect the bony portion of the nose and those which affect the cartilaginous and soft parts.

Deformities of the bony portion may be subdivided into the vertical, in which the dorsal profile is distorted, being too convex or too concave, and the lateral, which, when viewed from the front, present abnormal contour, whereby the bony portion may be either spatulated or deflected; Deformities of the cartilaginous portion include excess or deficiency in the tissue of the tip of the nose, or its distortion from normal direction, and collapse or abnormal expansion of the wings of the nose.


The treatment of nasal deformities differs in those in which the normal parts are present, but distorted from their natural position, and those in which there is a partial or complete absence of these parts.

In the former, treatment consists merely in restoring the parts to their normal position; whereas in the second class the deficiency must be supplied by tissues taken from some other part of the body, or by artificial or mechanical supports. In all cases, however, after securing or maintaining full respiratory patulency, the main cosmetic indication is to restore the symmetry of the nose. A nose which was originally proportionate to the face will, if deformed, appear very unsightly; while the same nose, although made one or two sizes smaller, will have a more or less handsome appearance if its different parts are perfectly symmetrical. So symmetry, and not size, is to be considered. In the correction of deformities of mere displacement all operations should be done subcutaneously and without wounding the skin, in order to avoid scars which might be as unsightly as the original deformity. In some instances fracturing of the nasal bones and of the septum also may be necessary in order to restore the parts to their normal position.

In all intranasal operations full asepsis of the instruments and hands is essential, and of the nasal vestibules, where the vibrissae form a natural sieve to strain out all foreign matter from the inspired air. Mild antiseptic spraying and mopping Of the accessible portions of the nasal chambers and nasopharynx should follow, and may be repeated after operation if clearly demanded ; but rather better nasal results, with far less danger to the ear, have followed the abandonment of too much after spraying and syringing.

The Convex Vertical Deformity of the Bony Portion of the Nose. In correcting this deformity the skin is first raised from the deformed or projecting portion by incising within the nostril through to the under side of the skin. The opening is then enlarged sufficiently to admit the instrument required for the removing of the redundant tissue, which may be bone scissors, rongeur forceps, a slender saw, or a chisel, according to the nature of the tissue to be removed. Care must be exercised not to remove too much of the redundant tissue, lest a depression more unsightly than the original deformity be left in the top of the Dose. This accident more readily happens when the vault of the nasal passage extends all the way up into the projection, for the nasal chamber is very easily opened into on removing the projecting angular portion. After this redundant tissue has been removed, a gentle compress should be placed over the dorsum so as to maintain the integument coaptated against the Dose, and worn from four to six days or until the skin has united to the tissue beneath.

Concave Vertical and Spatulated Deformity. The operation consists in filling in the depressed and lowering the unduly prominent portions. As the depressed or saddle back deformity, as it is termed, is usually the result of injury causing displacement of the tissues, it is not often that the nose can be made as large as it originally was; but it can be made symmetrical by filling in the low places with tissues taken from the elevated portions. This is done by raising the skin from the dorsum by incising from the inside of the nostril, as before, and if the nose is flattened out, removing to the top of the nose the displaced tissue found at the sides, by making flaps and turning them upward. Bony ridges or projections are in this manner to be used by carefully sawing them off with a sharp slender saw. If the displacement of the tissue is into the nares, it can be utilized in the same manner by turning the flaps made from it up under the skin upon the dorsum of the nose.

When it is necessary to refractors and raise the depressed nasal bones, this is done according to a method which I have devised by an incision, as before, sufficiently large to admit one blade of a pair of stout forceps, which is slipped under the skin raised from the nasal bone; while the other blade, covered with a rubber hood or adhesive plaster to avoid lacerating the mucous membrane, remains in the nasal passage. Sufficient force is then exercised to fracture the bone, assisted by slightly rotating or twisting the blades, when it can be raised to the desired position. The bone on the opposite side is then, if necessary, fractured in the same manner, and they are held in the desired position by an internal support, as described in the Treatment of Fractures of the Nose (page 1122). If the end of the nose still projects above the line of the central portion, it can be lowered, as later described.

Many plans for the making of a new nose, as will be presently described, have been used for correcting these minor defects. There is no advantage in or necessity for performing external operations when we can work subcutaneously to avoid wounding the skin and also utilize the normal tissues instead of resorting to mechanical supports for the correction of these deformities.

Deflection of the Bones of the Nose. In correcting this deformity it is usually necessary to fracture. the nasal bones, and on one side force the bone outward, on the other side inward. It may be also necessary to fracture the nasal septum, more or less, and to overcome the distortion of the cartilaginous portion. After fracturing the bones they should be held in the desired position, as in the treatment of fracture of the nasal bones. Great care must be exercised in the performance of these operations, and they are only to be undertaken under the most favorable conditions (see page 1119).

Excessive or Deficient Development of the End of the Nose. The operation for excess (commonly termed pug nose) consists in turning back the mucous membrane and, from the interior of the nostril, removing enough of the redundant tissue at the end to make the nose symmetrical and to bring the end down on a line with the dorsum. The mucous membrane is then replaced and supported by a light antiseptic compress in the interior of the nostril. Any associated expanded condition of the wings should be dealt with as will presently be described. After the operation the nose is to be held in the desired shape by the metallic form (Fig. 641), applied to the outside of the nose for several days, until healing in the exact position has taken place.

Deficiency of the tip is corrected by raising the skin and filling in the defect by means of plastic operation according to the conditions found. Where the frenum is short or defective, this can be rectified by taking flaps from the floor of the nose or upper lip. The upper portion of the tip can be filled in with tissue taken subcutaneously in the form of flaps, from the sides of the nose and cheeks (see also Fig. 671).

Often a flattened condition of the end of the nose is associated with a lateral expansion of the aloe, and is relieved by correcting the latter condition.

Deviation of the Tip of the Nose from the Median Line. As this deformity is almost always associated with deviation, distortion, or dislocation of the triangular cartilage of the septum, it is usually necessary to straighten the septum, and in some cases this will be found to be all that is required to correct the deviation of the end of the nose.

This operation is performed by loosening the cartilage, and sometimes the columna also, along its junction with the superior maxillae, and making a vertical incision through the cartilage at the bend or point of deflection. The cartilage is then placed in position and held there with transfixion pins or splints or hollow plugs placed in one or both nostrils. Sometimes incisions are necessary to overcome the elasticity of the cartilage at other points. In most cases this is best done with a bistoury. With a finger in one nasal chamber we can determine when the cartilage has been completely incised from the other side without cutting through the mucous membrane beyond. By leaving the membrane intact on one side, it serves as an excellent splint to maintain the edges coaptated while healing. In some cases the end of the nose may appear to be deviated by reason of an excessive development or expansion of the shield cartilage on One side alone, the other side being straight and normal Sometimes, when the lateral shield cartilages are deformed or distorted to one side, it is also necessary to freely incise them from the inside or loosen their attachment in order to overcome such elasticity as may tend to reproduce the deformity. The nose should then be held in place with a splint on the inside (Fig. 644) or a form on the outside, or sometimes by both, until it becomes fully fixed in the desired shape and position.

It is not infrequently the case that distortion of the end of the Dose is associated with a deviation of the whole Dose, in which cases it is necessary to combine the operations for correcting the deviation of both the osseous and cartilaginous portions of the nose.

Collapse or Expansion of the Alm. Correction of the deformities of the wings, whether collapsed or expanded, consists in carefully incising in .several places from the inside the lower lateral and sometimes also the upper lateral or shield cartilages (see Fig. 645). It may be necessary in some cases .of greatly expanded or inflated alae to excise a V shaped portion of the cartilage to permit of its being moulded to the desired shape. The parts are then to be placed in position by first inserting into the nostrils an internal support of the desired size and shape, consisting of a short tube of suitable material, and should be held there by an external shield until firmly fixed.

In case of expanded nostrils it will generally be necessary after the operation to apply only the external support or compress to maintain the parts in the desired position until the tissues become more fixed ; whereas in the collapsed condition of the wings the external support is rarely necessary, the nostrils requiring simply to be expanded to their normal size and shape, and maintained in this position until the tendency to collapse is overcome.

Should the expansion of the alae however, be due to distention from an intranasal growth or foreign substance, the necessity for the removal of' the growth or body is self evident before the deformity of the nostrils can be overcome, and further intervention may be unnecessary (see also Fig. 672).

Stenosis of the Nostril. The nostril or the vestibule of the nose may be so small upon one or both sides as greatly to impede proper respiration. This may be a congenital smallness or deficient development or an acquired lesion due to cicatrization after burns, lupus, or syphilitic ulceration. Acute inflammation of furuncular or other nature may temporarily close the nostril but this would call only for evacuation of pus or similar obvious intervention. For the simple stenosis, dilatation by frequently forcing in the lubricated finger may be sufficient, or the wearing of a tube for a time may be required. When the constriction cannot be thus easily overcome, divulsion may be necessary, care being taken to maintain the passage well dilated until after the parts have healed. Where loss of substance precludes success by these simple methods, plastic operation by flaps or skin grafts will supply the deficiency.

The cutting away of a stenosis where the mucous membrane is already too limited in extent should not be attempted, for the reason that the surface will invariably grow together throughout the extent of the incision. In these cases it is best to raise the skin or mucous membrane from the contracted portion and remove the cicatricial connective tissue from beneath, then replace the parts and dilate the nostril to its fullest extent until healed, when they will remain in place, leaving the opening of the vestibule free.


There are two principal methods by which defects and deficiencies of the nose may be supplied or corrected, according to the condition of the case : by rhinoplasty, using only living tissues, and by internal artificial supports.

Rhinoplasty may be complete or partial. It is termed complete when the whole or the greater portion of the nose is supplied by tissue from some near or distant part; and incomplete when a small portion only is supplied.

(1) The Indian method, which takes the tissue from the forehead, was originated in Hindustan. It is serviceable only in supplying nasal defects in which there is a moderate loss of tissue; for when there is destruction of the entire bony framework of the nose, sufficient material is not obtainable from the forehead to fill in the defect, and the transplanted tissue sooner or later drops through the large opening, and the nose sinks again to the level of the face.

In order to ascertain the size of the flap, a nose as desired is modeled of wax or plaster of Paris, and the portion that has been destroyed is outlined upon this model. Then by moulding a pattern of paper or thin leather over this model the exact size required is accurately determined, which should be made about onethird larger, in order to allow for the shrinkage of the tissues on healing. This pattern is then turned upward and spread out upon the forehead, the part corresponding to the lower portion of the nose uppermost, and outlined with ink or tincture of iodin to indicate the portion of the skin to be cut out. If the height of the forehead is not sufficient for the size of the flap, more room can be obtained by cutting it out obliquely (as shown in Fig. 673), care being exercised not to cut too near the eyebrow, lest the latter be drawn up by the retraction of the sear. The flap should be cut out by a single firm stroke of the knife, so as to afford an even, smooth edge. The flap is then raised and made to include the periosteum, or the anterior table of bone is included by chiselling it off, if desired, and the flap brought down and stitched into place by very fine gut, silk, or horsehair sutures.

In making this flap the pedicle should be sufficiently long to admit of being twisted upon itself, usually from left to right, so as not to compress the vessels, and wide enough to include plenty of nutrient vessels, especially the angular artery.

The low portion of the nose can be still further filled out by a flap taken from the root of the nose, made after the frontal flap has been cut out, so that all the skin of the bridge and root of' the nose between the flap and the defect can be utilized. The width of this flap should be the same as the neck of the frontal flap, and left attached along the upper border of the opening. This supplementary flap is first stitched into the opening, the integument looking inward, after which the frontal flap is brought down over it and stitched into place.

Before these flaps are made the nose should be prepared for their reception by freshening the edges of the gap. Any cicatricial tissue that should be removed from the borders can be turned into the center in the form of flap, to assist in elevating the dorsum

The twist in the pedicle usually forms an unsightly prominence, which can be obviated somewhat by cutting one side longer than the other, and afterward rectifying it by operation. The edges of the bole left in the skin of the forehead are then sutured together as closely as possible and any denuded space should receive a sprinkling of Thiersch grafts, so as to leave the least amount of disfigurement on healing. The coaptation of the edges is considerably facilitated by raising the skin for a considerable distance on either side so that it can be slid toward the center care being exercised not to constrict the frontal flap. The new columna of the nose may be formed at the same time from a tongue from the forehead included with the flap, or from the upper lip, as will be described further on

The after treatment consists in maintaining the parts aseptic by light boric acid and bichlorid dressing very carefully applied. The dressing should not be changed oftener than required ; and secondary hemorrhage should be guarded against by light, pressure when it seems imminent. The flap may remain dark and edematous for some time, and finally unite most successfully. The swelling can sometimes be relieved by leeches or slight scarification.

A number of variations of this method have been practised by different surgeons, and nearly every operator has some modification peculiar to himself.

Verneuil made one incision along the median line of the depressed portion of the nose and two transversely at the base and tip respectively, and dissected up the two lateral flaps. he then raised an oblong flap of the requisite size from the middle of the forehead, leaving it adherent between the eyebrows by a pedicle, turned it directly downward, and stitched the two lateral flaps together over it; the skin of the flap lying inward, so that the raw surface came against the under surface of the lateral flaps

(2) The German and French Method. This consists in the formation of the nose from tissues taken from the side of the face. It was first proposed by Dieffenbach, and later modified by Nelaton to avoid the frontal sear left after the Indian operation.

This operation consists in making a double flap, one from each side of the nose, including a sufficient portion of the cheek, joined together by a common pedicle at the root of the nose. These flaps are then united in the center and carefully stitched together. A pattern of the desired form is made, so that the flaps are accurately cut in such a shape as to form the column of the nose and also sufficiently long for turning in to form a double edge to the nostrils (Fig. 674), which are kept open by hollow vulcanite tubes until the healing is complete and all tendency to cicatricial contraction is overcome.

Nelaton modified this operation by making additional parallel flaps from the cheek just outside of the two primary lateral flaps; and these were brought to the center and stitched in place under the two primary flaps, which were then united along the median line of the nose.

When the tissue of the dorsum of the nose is gone and the septum is still in place, the latter can be utilized, as Mr. Bell and Nelaton suggest, and held in place by transfixing the septum and both the flaps at their outer lower edges with a straight needle. The wounds in the cheek may be partially closed by sutures, but are usually left to heal by granulation the resulting depression adding to the relative prominence of the new nose.

(3) The Italian or Tagliacotian Method. This was first practised by Branca of Sicily, by Bojani of Calabria, and Alexander Benedetti, professor of Anatomy at Padua, about the year 1495 ; but it was Tagliacozzi who, about the year 1587, so popularized the method by his skill and dexterity that it has since been known by his name. It consists in cutting from the biceps region of the arm a thick flap for the formation of the nose. Parallel incisions are made about four inches in length and of sufficient width to allow for the subsequent contraction on healing. This flap is raised except at the attached ends. A dressing is passed be neath to prevent reunion, and the wound, as practised by Tagliacozzi, was left open to granulate ; by modern methods, how ever, the parts are maintained aseptic and the edges of the wound stitched together beneath the flap. At the end of about a week, when the flap has become suf ficiently shrunken and hardened by ex posure and covered with granulations, it is liberated at the tipper portion, and then permitted to shrink still more for another week or two before it is attached to the face.

After the edges of the nasal tissues have been scarified and fitted for its reception, the arm is placed in position and the upper end of the flap carefully shaped and stitched in place. The arm is then firmly held in place by means of the cap and Jacket apparatus shown in Fig. 675 until the vascularization between the flap and the nose has taken place. This usually requires about ten days, when the pedicle is severed and the arm released. This severed end of the flap is then carefully cut, shaped, and stitched, so as to form a symmetrical end to the nose. Owing to the painful nature of this operation and the distressing position of the arm, it is not frequently resorted to.

Von Graefe made a flap with but one pedicle, and implanted it at once. This is inferior to the original plan, as it does not obviate the constrained position of the head and arm and lessens the chances of union, and is followed by much greater shrinkage of the nose after the operation. Warren of Boston took a flap from the anterior portion of the forearm, about two inches above the wrist, transplanting the flap at once, and in some cases succeeded in separating it on the fifth day.

Partial rhinoplasty consists in supplying minor defects of the different portions of the nose, usually of the alae, if the tip and the columna, which have been destroyed by lupus, syphilis, by injuries, or by mutilations. While less extensive, these operations are often' more important to the function of the nose than the complete rhinoplasty.

Each case requires a special study and ofttimes the greatest skill in order to adapt the operation to the conditions found.

The Restoration of the Aloe. The aloe when destroyed may be formed from the same side of the nose, from the opposite or sound side, from the cheek, from the upper lip, or by the jumping process. The lateral flap method of Denonvillier consists in dissecting a triangular flap from the sound tissues above the defect, which can be brought down on a line with the normal wing of the nose. The vertical incision is begun just above the end of the nose, leaving sufficient tissues to nourish a flap, and is carried up about half the length of the nose, as required, where a second incision is made obliquely downward to the upper and outer angle of the ala.

The flap may be taken from the bridge of the Dose (Fig. 676), from the opposite ala, from the cheek, or from the lip, as the circumstances of the case dictate, and slid into place or carried across untouched surfaces by the jumping process. The Restoration of the Tip of the Nose. Mere shortness of the tip is best corrected by sliding down a A shaped flap (Fig. 671). Keegan's operation consists in making a flap on each side of the bridge and base of the nose and extending the lateral incision downward to the upper border of the root of the nasal alae These flaps are dissected out from above downward, leaving the flaps attached at the lower border. These flaps are to be cut of the size necessary to fill the defect at the end of the nose when turned downward, sufficient allowance being made for contraction while healing.

A flap is then taken from the forehead in the usual manner, twisted and turned downward, and stitched into the place from which the other flaps have been removed. This is made sufficiently long to form the columna of the septum if lacking, the opening of the nostrils being maintained by hollow splints of the proper size and shape.

In Ollier's operation the incision is carried from a point near the center of the forehead to a point on a level with the lower border of the alae. The skin only is dissected up from one side; while on the opposite side is included the periosteum, which underlies the upper portion of the flap, and the left nasal bone, which is separated by means of a chisel. This entire flap then is carried downward sufficiently far to form the contour of the end of the nose and stitched there, the bony portions being secured with wire sutures. The space left by the removal is filled by a bony outgrowth developed from the periosteum, slid down from the forehead to cover the opening.

In some of these cases it is possible to supply the whole defect at one operation, but quite often secondary operations are necessary to form the columna, and improve the opening of the nostrils.

Restoration of the Columna of the Nose; Utilization of the Upper Lip. Many methods have been employed for the restoration of the columna. The Italian method, though not frequently employed, consists in taking a flap from the palmar surface of the band and suturing it in place so as to form the column of the nose, the band being held firmly in place until the flap has become united to the nose, which is similar to the Tagliacotian method of restoration of the nose. In Heuter's method the columna is formed from the skin covering the dorsum of the nose. The flap is cut out obliquely, to facilitate its rotation into position, and so cut that the rotation takes place at the tip of the nose, which renders it thicker at that point and thereby assists in elevating the tip of the nose. For the purpose of rendering the columna, more rigid he recommends that the upper portion of the flap should include the periosteum covering the nasal bones, so that the formation of osseous tissue will afford a more rigid support.

Wood's method consists in making a flap from the central portion of the upper lip, between the cutaneous and the mucous surfaces, extending downward to, but Dot through, the vermilion borders of the lip. This flap is turned upward and covered by flaps taken from the cheek on either side.

Dieffenbaeh's method consists in making two vertical incisions through the entire thickness of the upper lip, thus making a tongue about one fourth inch in width, which is entirely freed, except at its tipper attachment. This is turned upward and united to the remains of the old columna and to the alae by fine sutures. The mucous membrane of the lip, which looks outward in its new position, soon becomes skin on exposure to the air. The cut surfaces of the lip are then brought into apposition and united exactly as in the operation for harelip.

Utilization of a Finger. The first to make use of the finger to supply the loss of a nose was Hardie of Manchester, England, in 1875, at the suggestion of his house surgeon, Mr. Tyler, and it was next employed by Prof. Sabine of New York, in 1879.

In 1893 the writer performed a similar operation on a lad of sixteen years of age, whose nose had been destroyed by hereditary syphilis, leaving a considerable aperture, around which the skin was very much wrinkled, since it had not been destroyed, but bad lost its central support, which gave the lad a very repulsive appearance. The incision was made under the lower border of this wrinkled skin, which was dissected out for the insertion of the finger. The left ring finger was prepared by removing the last phalanx, so as to do away with the nail, was denuded of its cuticle as far up as it was to be inserted beneath the skin, and the remaining portion was split in the center on the palmar side down to the bone. The tissues forming a double flap were turned outward and stitched to the edges of the skin of the nose after the insertion of the finger in the place prepared for it. The arm was then firmly held in place by plaster of Paris bandages, similar to the Tagliacotian method, until the union between the finger and nose had taken place, when the finger was disarticulated. at the knuckle. When the finger had become solidly united to the nose a portion of the bone of the finger was cut out, so as to leave sufficient redundant skin out of which to form the columna and the nostrils, the latter being kept open by hollow plugs.

The result was at first exceedingly satisfactory ; but at the end of a year the nose had very materially diminished in size, due to a settling of the finger down through the aperture between the nasal bones, which was too wide to give it support.

This method would be exceedingly serviceable in some cases where the aperture was too small to permit the bone of the finger to drop through; but in cases where this aperture is too large, this method is far inferior to that of inserting mechanical supports beneath the collapsed tissues.

The Employment of Artificial or Mechanical Supports. The use of artificial supports is required in those cases only in which the central cartilaginous or bony supporting frame is wanting, as is often the result of the ravages of syphilis. This method was first suggested by Letievant, who in¬serted beneath the skin of the depressed nose a supporting framework of aluminum. C. Martin improved upon this by substituting platinum. The device as used by Martin, which is the one most commonly employed, consists of a trian¬gular piece of platinum, bent in the shape of the nose, the upper end of which rests on the nasal spine of the frontal bone, the lower wings being supported by two arms, one on either side, the ends of which are embedded in the superior maxillae (Fig. 677). The dimensions must, of course, correspond to the size of the Dose to be supported.

The form is introduced by first performing the Rouge operation, in which the upper lip and nose are cut loose and turned up over the face so as to avoid wounding the skin, and also to gain direct access to the superior maxillae for drilling the holes in which to securely anchor the artificial bridge. The holes should be made in the inner side of the canine eminences, about on a level with the floor of the nose, care being taken not to enter the antrum. The location of the holes should be determined by the most careful measurements, in order to bring the artificial bridge in the median line of the face.

This apparatus has also been used by some for elevating the center of the nose in those cases of depression in which the bony framework is present. In these eases it invariably ends in failure, for it must necessarily be inserted between the skin and the osseous structure, leaving a closed space between the metallic bridge and the bone. No drainage is afforded, and sooner or later irritation is excited, the contained discharges decompose, and ulceration results. In the most favorable of these cases the device has been retained from one to five years, but in every case, sooner or later, some accident happens to the nose; or, on account of some complication, the artificial support must necessarily be removed, leaving the nose in a worse condition than before. This method of support is only successful and only necessary in those cases in which the bony support is gone and where thorough drainage takes place into the nasal cavity, thereby reducing the irritation to a minimum.

In a case where the entire central support of the nose was gone, including the entire vomer, together with the nasal and lachrymal bones, the nose being completely flattened on the face, the writer inserted a support according to the method already described. The bridge was made of hard rubber, with arms made of a gold and platinum alloy. The arms constituted one piece, a band running over the form in a groove made for its reception and securely riveted to it. This made a much lighter bridge, quite as strong as and less irritating than platinum, and exceedingly satisfactory. But whatever form of bridge is used, it should be prepared as far as possible beforehand, leaving only the position and width of the arms to be adjusted to the situation of the holes made in the jaw at the time of the operation.

It is important in these cases that the most thorough aseptic precautions be observed on inserting the bridge, and that the bridge be so inserted, so moulded, and so smooth as to prevent any friction or unequal pressure upon any of the soft parts; and it is also important that the supporting arms should be buried deeply in the maxillae, so that they are not easily displaced. Martin employed a bridge with attached arms for insertion in the maxillae to hold the bridge in place; but the plan of cutting the bridge and the supporting arms from one piece of metal when platinum is used, as suggested by Hopkins, is far better.

Before undertaking any operation for the restoration of the whole or any portion of the nose, we should ascertain if the disfigurement is the result of an injury or disease. If the latter, we should be certain that the disease, be it syphilis, lupus, etc., is completely arrested or cured. Also before deciding on the operation to be adopted, we must thoroughly investigate the condition of the different parts of the nose and also of the face in order to determine which region, the forehead, the cheeks and face, or the arm, will best supply the requisite tissue free from scars or disease and leave the least disfigurement.

In performing these operations the greatest care and skill are required to insure the best results. Each case requires the most careful study, for as Prof. Gross has well said: “For repair of these various defects some of the nicest processes of the art and science of surgery are required," . . . and that " if the operation is entered upon heedlessly or without due preparation of the part and system, failure will be almost certain."


Of the internal structures of the nose, the septum is the part most frequently deformed, presenting deviations from the median line, spurs, ridges, hyperplastic thickenings, and exostoses.

Deviation of the septum (see page 917) may affect the whole septum or some part of either the osseous or the cartilaginous portion. It is most frequently found in the cartilaginous portion, and next in point of frequency at the junction of the cartilaginous and osseous portions, while deviation of the posterior portion of the vomer is exceedingly rare. The division of deviations into osseous, cartilaginous, and osseo cartilaginous, as suggested by Jarvis, is by far the most natural, and further attempts at classification are unnecessary. Thickening on one side of the septum is sometimes deceptive, giving the septum the appearance of being deviated to that side, when the plane of the other side may be perfect. Sometimes the septum is curved at different parts in such a way as to give it the shape of the letter S.

In some cases the deformity may consist in the septum being located to one side of the median line, although not deflected or curved, causing one meatus to be larger than the other.

Spurs, ridges, and hyperplastic thickenings may be found on any portion of the septum, although they are most frequently found located : First, along the line of junction of the vomer with the superior maxilla; secondly, along the line of junction of the anterior border of the vomer with the triangular cartilage and the lower posterior part of the perpendicular plate of the ethmoid ; and thirdly, along the line of junction of the anterior border of the ethinoid with the triangular cartilage. They may be either unilateral or bilateral. Those located along the junction of the vomer, triangular cartilage, and superior maxillae are more often bilateral than when elsewhere.

Deviations of the septum are very often associated with deformities of other portions of the nose, and also of the superior maxilla, and with a small high arched bard palate, approaching a scoliosis of the whole face.

The treatment of the different deformities of the septum consists in the restoration of the parts to their normal condition. The importance of correcting these deformities, which almost always produce more or less nasal obstruction and reflex disturbance, can scarcely be overestimated.

The treatment is palliative or radical, the palliative measures consisting in the removal of such conditions as may have influenced an abnormal growth of the septum, such as the removal of adenoid growths, enlarged tonsils, or of any conditions which may interfere with the proper development of the Dose during infancy and childhood, and the reduction of hyperplastic thickenings by medical measures.

The radical treatment may consist in forcing the septum into its proper position without the employment of cutting or fracturing instruments, by exerting pressure upon the convex side by the introduction into the nostril of plugs or tents, slowly forcing it over into place; these methods are, however, usually painful and unsatisfactory, and are not to be recommended.

The more surgical treatment consists in the forcible straightening of the septum. The methods employed, according to the conditions found are: removal of the prominent portion of the deflection with knife, chisel, saw, scissors, drills, needle and snare, or punch ; destruction of the prominence by caustics, electrolysis, or galvano cautery ; incising the septum with a knife or cutting forceps, and restoring it to position by finger pressure, by the employment of pins, or of forceps having flat parallel blades; fracturing the septum by means of comminuting forceps.

Deviation of the septum is almost always associated with spurs, ridges, exostoses, etc., which have resulted from the same cause as that which caused the deviation, and these should be removed before the septum is corrected. If the spur or ridge is cartilaginous it is most easily removed with a cartilage knife, although good authorities recommend its removal with the galvano cautery, and some by the use of electrolysis, inserting both poles into the outgrowth at the same time.

Osseous outgrowths are most easily removed with a nasal saw or drill, or the bone scissors or rongeur foreeps may be employed. H. Allen lifted the lip after Rouge's method and chiselled away exostoses of the floor. The drills may be burrs of various forms or the trephines devised by Curtis, and may be driven by the dentist's treadle engine or an electrometer. Good willie and others protect the soft parts with a shield which covers the outer side of the burr or trephine.

When the spur is associated with a marked thickening of the vomer on that side, the use of the trephine, as proposed by Wright, is to be recommended in some instances. A hole is made from the anterior to the posterior end of the deviation in such a manner that it goes as close to the mucous membrane on the other side as possible without perforating it. Into this resultant tunnel a slender saw is inserted, and the exostosis is removed by sawing upward and downward from this point (see Fig. 679).

The use of the snare and transfixion needle for the removal of cartilaginous spurs is sometimes to be commended. The portion to be removed is transfixed with the needle, and the wire loop of the ecraseur is then passed over the needle (see Fig. 680) and drawn up tightly, and the engaged portion cut through.

Caustics, electrolysis, and galvano cautery are employed in some cases if the cartilaginous spurs are not large and other operative measures are rejected by the patient. Electrolysis in these cases is very warmly advocated by Casselberry.

Forcible Correction by Forceps. The forceps most commonly used are those devised by Adams, illustrated in Fig. 572. The disadvantage of this instrument used alone is that it will simply force the septum to the median line without correcting the usual redundancy; it is mainly serviceable in the correction of osseous deformities, because in the cartilaginous portion it does not in any degree overcome the resiliency of the cartilage. In still ruder manner Hewetson's forceps press open the stenosed naris, crushing the weakest point. Browne claims that the crushing of the turbinated bodies and bones, and fracture of the outer wall of the nose, which must take place in some instances, appear to give rise to no troublesome symptoms."

A number of modifications of Adams's forceps have been devised. Juarasz made them with detachable handles, so that the blades could be left in situ, held by means of screws, after the correction was made. Garrigou Desarenes, to overcome the resiliency of the septum, had one blade convex and the other correspondingly concave, and tightened with a screw.

Hope of New York has devised a forceps to be used in connection with the Adams forceps in operating on the cartilaginous portion of the septum. One blade has a steel pin which is received into a corresponding opening in the other blade (see Fig. 678). The operation is then marked out with a line of punctures with this pin, which so weaken the cartilage that it is easily fractured. This instrument may be used in the thin portion of the bony septum.

For the purpose of incising the cartilage so as to overcome its resiliency Steele employed a stellate punch with radiating blades (see Fig. 678), and held the parts in place by means of plugs inserted into the previously obstructed nasal chamber. Asch accomplishes this with a pair of curved cartilage scissors, similar to buttonhole scissors (see page 918).

J. B. Roberts uses pins for holding the deflected portion in place after the resiliency of the septum is overcome with a knife. This same plan is also adopted by Watson, after having obliquely cut the septum along its greatest convexity and set it over in the center. The pin, which should be gold plated to avoid corrosion, is inserted either through the dorsum of the nose or from the nostril so as to hold the flaps together, and the point is embedded in the floor below or the septum behind sufficiently to hold the pin in place until the parts are united.

Gleason makes a horseshoe incision through the lower side of the deflected portion and pushes the flap through the opening thus made. A dressing is inserted on the convex side of the septum to control bleeding and to hold it in place until the parts are united.

For the correction of the osseo cartilaginous deviation, Fig. 678 represents a pair of fenestrated forceps devised by the author in 1891 for the purpose of fracturing the septum. One blade of the forceps is fenestrated, while the other is made sufficiently narrow to fit loosely into the fenestrum of the opposite blade. The distance which the second blade passes through the fenestrum is regulated by a screw in the handle.

The fenestrated blade is inserted on the concave side of the septum, which is fractured sufficiently to overcome the resiliency. The advantage of these forceps is that fracture of the septum can be accomplished without wounding or lacerating the soft parts. The parts are then forced into the median line by a small nasal spatula, and a dressing is inserted on the convex side of the ,septum sufficient to hold it in the median line until it has become permanently fixed. These blades are detachable, and may be replaced by Adams's plane blade or by Hope's pin or Steele's stellate punches the penetration of the latter being controlled by the screw so as to spare the farther mucous membrane, if desired.

The redundancy of tissues which is frequently associated with the deviation requires removal to complete the procedure. Stich projections may be removed in part before straightening, or at a subsequent operation ; but it is still better to determine the extent of needed excision and to have this form a part of the main operation. Older operators were much afraid of perforating the septum, lest a permanent bole result; but with neat, clean ,operating there is little reason to fear any failure of the mucous membrane to unite unless there has been too much excision of tissue.

In all these eases the parts should be rendered aseptic by thoroughly cleansing them with a solution of bichlorid, I : 5000, both before and after the .operation. The most aseptic and satisfactory form of dressing is a cotton plug, made by winding cotton over a small metal plate of sufficient size to fit the meatus Before insertion iodoform is blown into the nostril with a powder blower, and the plug dipped into a solution of bichlorid. If thorough aseptic precautions are taken it usually can be left for three or four days before removal. If further support is required the nostril should be re irrigated, cocainized, and a fresh plug inserted.

Hollow splints made of bard rubber (Fig. 573) are employed by Asch and others, but they cause much more irritation, are less aseptic, and I have not found them so satisfactory as the cotton plugs.

In nearly all cases if the operation is properly performed and all elasticity of the septum overcome, support to the septum is required for three to five days, until the provisional exudate is thrown out, which is ample to keep the fragments in situ and the septum in the median line Without any return of the deflection.


are of not infrequent occurrence. Normally the t urbinated bones project from the outer wall of the nasal chamber and turn downward and outward like a scroll, as shown in Fig. 679.

Instead of their normal bending downward and outward they are frequently twisted and distorted, projecting across the nares into contact with the septum.

Deformity of the inferior turbinated bone is frequently associated with hypertrophy of the turbinal body ; while that of the middle turbinated bone is associated with a marked thickening of the bone itself, which obstructs the passage and impinges firmly against the septum, or forces it over, as shown in Fig. 545, and is the cause of much irritation, frequent sneezing, and not infrequently persistent headaches.

In the case of the lower turbinated bones being distorted without hypertrophy of the soft parts, they call be fractured and bent backward, usually with a pair of nasal forceps. But the middle turbinated bone is best dealt with by sawing off the projecting portion and fracturing and forcing the remaining part backward against the outer wall of the nose with a small spatula, holding it in place by a light antiseptic cotton dressing until the bone becomes sufficiently fixed and the passage is permanently free.

Reduction of Hypertrophy of the Erectile Tissue. The inferior turbinal bodies are more frequently found hypertrophied than any other portion of the intranasal tissue, owing to the extreme vascularity of this tissue and its sensitiveness to atmospheric changes. The next in point of frequency is the middle turbinal, and third, the erectile tissue covering the posterior portion of the septum.

The principal methods, employed for the removal or reduction of these hypertrophied tissues are cauterization with chemical means or the galvanocautery, and removal with a snare or cutting instrument.

Where the hypertrophy is small, due mainly to thickening of the interstitial connective tissue, chromic acid fused oil the end of a small flattened probe gives very satisfactory results. The part should be anesthetized with cocain and then thoroughly dried to prevent the acid from liquefying and running down on parts below. After the acid is applied the part should be dried with cotton and sprayed with an alkaline wash.

Trichloracetic acid and strong lactic acid may be substituted, although less effective. The former is claimed to give a specially aseptic eschar.

In those cases in which the turbinal swelling is mainly of a vascular character, linear incisions with the galvano cautery through the tissue down to the bone, so as to obliterate the deeper vessels, is far preferable to chemical caustics (see pages 888 and 910). Delavan has suggested deep submucous incisions with a slender knife for severing and obliterating these vessels.

When there is a large amount of interstitial hypertrophy, as we find in chronic cases of nasal stenosis, the tissue is best removed with a Jarvis snare (Fig. 680), held in place, if necessary, by a transfixing pin.

When this tissue cannot be engaged by the snare it may be removed with nasal scissors. Care, however, should be exercised in every instance not to remove too much of the turbinal tissue, lest there result a dryness of the pharynx from lack of sufficient moisture imparted to the inspired air.

Hypertrophy of the vascular tissue on the septum is best destroyed with galvanocautery used very cautiously. Masses occur also on the upper portion of the septum, caused by the irritation from contact of the turbinal. These when small in amount may be removed with chromic acid, or if large they can be cut away with a nasal knife. In operations in the nose there is little or no danger of the mucous membrane failing to cover the denuded part, even after the removal with the knife of quite an extensive portion ; while if destroyed with the galvano cautery, the mucous membrane is replaced with connective or cicatricial tissue. This is particularly the case in operations on the septum.

Synechia of the nasal passages may be congenital, but is most frequently found after disease or operation in the nose when the two opposite surfaces have been denuded at the same time, granulation tissue shooting across and uniting the parts during the process of healing. Occasionally a spur grows across into contact and becomes attached to the turbinal, when a synchondrosis or synostosis may take place (Fig. 679). It has often proven a very obstinate condition to remove, for if the band is bodily cut away it will almost invariably reform. The best plan for preventing its return I have found to be in cauterizing one side only with the galvano cautery, after cutting the band away, for the reason that cut and cauterized surface,, ,, do not readily grow together. Previous treatment to shrink the tissues and separate the surfaces greatly facilitates operation and cure.

Any granulation tissue that may shoot out can be touched with chromic 'acid. Another excellent plan is to wear a small metallic plate covered with asepticized cotton until the parts on the two sides are healed. This method is more troublesome and disagreeable to the patient than the other.

Removal of Neoplasms. The operative methods of dealing with these formations vary as much as the structures themselves. Myxornata, or nasal polyps, are the most frequent (see page 1075). They may constitute simply small polypoid growths, very easily removed, or they may be multiplied like a bunch of grapes hanging from its parent stem, or they may constitute one huge growth, occupying the entire nasal chambers and extending into the accessory sinuses.

Various agents, as chlorid of zinc, iodin, carbolic acid, alcohol, have been recommended for local application or injection into the growth; but they are rarely effective and not advisable except when the polyps are exceedingly small.

Previous to the invention of Jarvis's snare these growths were usually removed by divulsion grasping the polyp with a stout pair of forceps and twisting it off. But with Jarvis's snare and the use of cocain these operations have been greatly improved. Fig. 681 represents the application of the snare to a polyp in the nose.

The snare, armed with a No. 5 piano wire, is carefully introduced over the growth, then by a gentle forward and backward movement it is worked up as near the base of the growth as possible before tightening. This is best done by holding firmly with thumb and index finger the outside tube to which the wire is attached while the cannula is forced forward by the middle finger pressed against the nut. Escape of the growth is thus avoided; and after it is secured, the cutting is done by screwing down the nut as fast or as slow as seems best.

The return of the growth can often be prevented by cutting the pedicle with a slender knife, taking a portion of the periosteum or a scale of the bone with it.

In case the polyp involves the whole of a turbinated bone, it may be necessary for the eradication of the growth to remove the entire bone.

If the growths are small, I have found the interstitial injection of a saturated solution of bichromate of potash into the neck of the growths exceedingly effective in not only destroying them but preventing their return.

When the ethmoid cells are involved they require curettement in order to reach the deep portions of the growth.

After removal of the growth the parts should be kept clean with an antiseptic wash and carefully inspected. Any recurrence or small portion that escaped removal should be removed or destroyed The patient, at frequent intervals, should return for an inspection, to insure against a return of' the growth.

Fibroma and Angioma. In the removal of myxomatous growths and nasal polypi very little hemorrhage is encountered; but in cases of the firmer and more vascular growths it is often profuse. This is best avoided by using the galvano cautery loop or the cold wire snare. In the use of the galvano cautery loop care should be taken not to have the wire too hot. If brought to a dull red beat only, it closes the vessels as it passes through the tissue; but if raised to white beat it cuts through quickly like a knife, and leaves the vessels open. In one case of angioma of the nose the writer removed a portion with the galvano cautery loop which was followed by profuse hemorrhage, requiring plugging of the Dose; whereas a very much larger portion of the same growth was removed very slowly with the cold wire snare, and all hemorrhage was avoided.

The chief difficulty of removing from the nose large growths with the snare is in engaging the growth in the loop. This is most easily accomplished with a small flexible copper wire having a shot attached to one end and a stout silk thread to the other. The head of the patient is thrown backward and the shotted end insinuated along the upper side of the growth. When the shot has reached the posterior wall the bead of the patient is erected and the shot is slowly pushed down into the pharynx.

A similar one is passed through the lower meatus below the growth, when both wires are grasped with a pair of forceps and pulled out through the mouth. The copper wire is then removed and the ends of the thread tied together, when, with the aid of the finger behind the soft palate, the thread can be drawn tip around the base of the growth. One end of the thread, preferably the upper end, is then attached to the steel or platinum wire with which we wish to encircle the growth and drawn round it and attached to the instrument for removal. In this manner some of the largest growths of the nasal passages may be removed with little risk of hemorrhage.

In some cases in which it is impossible to pass a loop around the growth, before recourse is bad to the knife, electrolysis, best applied by the bipolar method, will sometimes be successful in arresting if not obliterating the growth. The bipolar needle should be plunged directly into the base of the tumor, and the current employed should be as strong as the patient can comfortably endure, cocain, of course, being first applied.

Enchondroma of the nose, as well as the septal ecchondroses, can usually be removed with a knife. In some cases it may be removed with the snare or with the galvano cautery. Electrolysis has been commended, but seems to the writer a tedious and useless procedure when the outgrowth can be so quickly and creatively cut away.

Osteomata found in the nose are of two varieties, one being composed of consensus and the other of ivory structure. They are usually located in the upper part of the Dares, and may involve the accessory sinuses, often causing fetid discharges and pain from pressure. They are usually attacked with the saw or drill, the ivory variety being often removed only with the greatest difficulty, unless the point of attachment yields readily to the chisel or other instrument.

Malignant growths should, if possible, be totally extirpated, otherwise the partial removal tends to increase the rapidity of the air growth. Partial removal may, however, in some cases be expedient. In sarcomatous growths the galvano cautery loop will sometimes be successful in arresting the advance. A case of the kind was reported by Lincoln, in which the thorough removal of the growth with the galvanic snare caused the complete arrest of the growth for years.

In the case of carcinoma, it is only through complete extirpation of the growth that success is attained. The most radical and effective method of reaching the interior of the nasal chamber is that devised by Rouge of Lausanne, which consists in dissecting up the upper lip close to the superior maxilla, together with the whole soft structures of the nose, and turning them backward over the forehead, when the nasal chambers come plainly into view and become directly accessible for any operative procedure. Partial or total resection of the bony parts may be temporarily made, or the superior maxilla or other parts may have to be excised.

Coley reports many cases of sarcoma successfully treated with serum of streptococcus and bacillus prodigiosus. I have succeeded in destroying a sarcomatous growth with the injection of a saturated solution of bichromate of potash, already referred to in connection with polypoid growths,


Abscess of the septum may result from an injury or other causes (see pages 899 and 1117).

The treatment consists in the evacuation of the pus by a free incision with a small nasal bistoury. The cavity should then be washed out with a bicolored or hydrogen dioxid solution injected into it. When the abscess is bilateral an incision is required in one side only, for the reason that the two sides almost invariably communicate. The cavity is then kept collapsed by pressure on each side by means of a suitable dressing placed in each nostril. This should be removed and the parts cleansed and dressed daily until cured.

This condition must not be mistaken for a hyperplasia on the septum or an ecchondrosis of the cartilage. The question is quickly settled by exploration with a probe.

Abscess of the turbinal body sometimes occurs as the result of inflammation of the turbinated bone going on to necrosis. Sometimes these abscesses are chronic, and the discharge mistaken for that originating from an accessory sinus.

The operation consists in the free opening of the abscess and the removal of any necrotic bone that may be present, which is best done by a small burr run by an electric motor. , The dead bone can be eradicated in this manner without cutting away the turbinal, which should be removed only when entirely diseased.


Bony occlusion of the posterior nares is often congenital. In operating for its removal the size and extent should first be ascertained by the combined exploration of the anterior nares with a curved probe and with the finger in the posterior nares. When this is determined it should be removed with either a drill or bone cutting forceps. Great care must be exercised, for the position of the bony formation frequently renders the operation extremely hazardous. In the case of a child that recently came Under the care of the writer, the posterior nares were completely closed with a firm bony formation which had existed from birth. This was removed with a Curtis drill passed along the floor of the nose; when an opening had been made, one blade of a small right angular bone cutter was passed through and the bone chipped off until an opening of the requisite size had been made. Cicatricial tissue may close the opening secured, and must be removed as fast as it forms Trichloracetic acid has been praised as the cautery least apt to be followed by return of the occluding tissue.

Stenosis of the naso pharynx due to the adherence of the soft palate to the pharynx may be congenital or it may be due to ulceration resulting from acute inflammation, as in diphtheria, from struma or tuberculosis ; but is most commonly the result of syphilis, which in children may be hereditary, but in adults is usually acquired. The stenosis is rarely complete, there being nearly always a small opening between the two cavities. Complete stenosis in the case of a child recently came under my observation.

The readiness with which severed cicatricial adhesions reunite renders these operations extremely unsatisfactory ; accordingly a great many devices have been resorted to to prevent reunion of the parts after having been separated, such as the insertion of rubber tubes, plates of hard rubber, metal rings, air bags, and mechanical dilations. The most successful plan is that devised by Nichols, who with a curved needle passes a heavy silk thread through each side of the cicatricial tissue and ties it in the center. Tile knot is then slipped around back through one of the openings so as to be entirely out of the way, lying in the naso pharynx, and is allowed to remain there until complete cicatrization has taken place around the thread in a manner similar to the treatment of web fingers. The string is then removed, and by inserting an angular knife in one of the openings the adhesion between the two openings is cut away.

The best plan for keeping the cut surfaces apart until healed is by means of a small flat piece of hard rubber attached to and held in place by a string passed through each nostril and tied in front of the septum. In some cases daily dilatation of the parts is necessary to maintain the proper size of the opening, and in moderate stenosis only such dilatation may be necessary


Has been dealt with earlier (page 966), and but few points need be here added.

Maxillary Sinuses. The disease of the maxillary sinus most fre¬quently necessitating surgical interference is empyema. There are five methods for gaining access to this cavity :

(1) Through the natural opening;
(2) through a tooth socket or alveolus;
(3) through the canine fossa or the canine eminence or the malar ridge;
(4) through the inferior meatus;
(5) through the bard palate.

Acute or subacute inflammation of the antrum can frequently be treated successfully through the natural opening, which in most cases is easily found with Hartmann's, or preferably with Myles's, silver tubes (Fig. 593). The second method, however, is the one most frequently resorted to, because it is the easiest and, as a rule, causes the least disturbance to the patient. In many cases the floor of the antrum is divided into separate compartments by septa. It is therefore important that the internal orifice of the opening through the alveolus should be wide enough to include and cut away any septa that may be present in order to afford free drainage. In many cases it is advisable to make the opening long and narrow and wider on the inside by separate insertions of the drill; or the two outer holes can be made a short distance from each other and the intervening space sawed out. By making an oblong opening in thi's way the food does not so readily enter, and in nearly every case a tube can be dispensed with. When a tube is required, Myles's soft rubber tube (Fig. 590) is the best.

Some authors advise making a very small opening, which, in the experience of the writer, is unpractical, as it does not afford sufficient room for the exploration and free drainage of the cavity or the removal of growths, which are frequently found to be the exciting cause of the discharge. In case the premolar teeth are sound or a very large opening is necessary, it is best made through the canine Glossa. In cases of growth in the antrum, it is frequently necessary to make a very large opening to permit free inspection of the interior and thorough removal of the growth.

The writer's method of opening the antrum through the canine fossa is first to incise and turn back the soft parts where the opening is to be made, then to drill a small bole near the lower side, which permits a preliminary exploration of the interior of the cavity with a probe to determine its size and shape. A slender saw is then introduced through this hole, and a circular button of bone of the desired size is sawed out of the anterior wall. It is usually desirable to make the opening sufficiently large to freely introduce the finger, which is a valuable aid for exploration. This large bole also affords ample space for the removal of growths or other diseased conditions and a ready access for treatment. This method of removing the bone with a saw I have found to be far superior to the use of the chisel commonly resorted to.'

When the outer bony wall of the nasal chamber is thin, an opening through it is easily made with a small curved trocar and cannula; but when this wall is firm, it is best made with a curved spiral drill attached to an electric motor. This method has often been found serviceable in recent cases, but it is not a route generally to be recommended, for the reason that the floor of the antrum is frequently much below the plane of the floor of the nose, and discharges from the nose will find their way into the antrum. It is also impossible through this opening to remove growths or to explore or properly treat the antrum when extensively diseased.

Opening through the hard palate is sometimes resorted to, and conditions may arise where it is the most advisable method, although generally it is not to be recommended, on account of the readiness with which food and other substances may be forced through the opening from the mouth.

Disease of the Ethmoid Cells. Disease of the ethmoid cells is very often associated with nasal polyps and in these cases the anterior ethmoid cells are most frequently affected; but when there is necrotic condition of the turbinated bone, the posterior ethmoid cells and also tile sphenoid cavity are also very frequently involved. When unassociated with nasal polyps, the tissues covering the middle turbinated and ethmoid mass frequently have a boggy, doughy character and a pale color, resembling a polyp. In other instances the enlargement of the turbinal consists of a true connective tissue hypertrophy, causing pressure on the septum and much reflex disturbance. In some cases the bone is denuded, which is very readily detected with a probe, and has been termed by Woakes " necrosing ethmoiditis." This condition is usually attended with purulent discharge, headache, supra orbital and peri orbital neuralia, and sometimes the vision in the eye of that side is interfered with, or choked disk is found on ophthalmoscopic examination.

The only effective treatment is free opening of the cells and curettement of the diseased portion. In order to reach these cells, more or less of the turbinal body requires removal. A boggy hypertrophy of tile middle turbinal bodies is best removed with a Jarvis snare, which is frequently employed for removing the turbinated bone; but for this purpose Myles's cutting forceps is preferable, for the crushing of the bone by the snare is not desirable. Burrs and drills are employed by some. Bosworth employs a burr run by a band motor, and depends largely upon the sense of touch with the ink strument to locate the point for operation. This method, however, is hazardous, except for one thoroughly skilled in these operations. When the cells have been freely opened and sufficiently curetted to break down all the diseased cell walls, the cavity should be thoroughly washed out with an antiseptic solution and packed with iodoform or sublimate gauze. This should be renewed as often as required, usually daily, and the healing process stimulated by mopping with a silver nitrate solution, 30 grains to the ounce. If the purulent discharge continues, it indicates that all of the diseased cells have not been reached, or that the discharge comes from a neighboring sinus, which should be investigated.

Disease of the Sphenoid Cavity. As already stated, disease of tile sphenoid cavity is often associated with disease of the ethmoid cells and maxillary sinus, and is usually determined by tracing the source of the pus, aided by the use of the aspirating needle, or exploration with a probe. The opening in the cavity can sometimes be found by passing a probe directly backward along the lower border of the middle turbinal body, using that as a guide. Oftener it is higher and more lateral, so that the probe must curve outward and cross the posterior third of the turbinal (see Fig. 682). Empyema as in the maxillary sinus can also be determined by the effervescence on injecting into the cavity a small quantity of hydrogen dioxide This cavity sometimes becomes the seat of polypoid or other growths and degenerated tissue, requiring curettement. In simple empyema the cavity should be washed out and medicated with a syringe having a long, slender nozzle.

Other diseased conditions frequently require a free opening of this cavity, which can be made by drilling through the anterior wall. This can safely be done by first ascertaining the distance of the anterior sphenoid wall from the end of the nose and marking the distance on the drill; then by allowing sufficient for the penetration of the wall of the cavity, we know exactly the distance beyond which the drill should not be passed. Ordinarily the entering of the drill into the cavity is at once perceived by the operator. When a sufficient opening has been made by the drill or the rongeur (see page 984), the growths or other diseased tissues are removed by curettement, the cavity is cleansed with an antiseptic solution and packed with iodoform or sublimate gauze, as in the case of the ethmoid. Afterward the cavity requires frequent irrigation with a medicated solution until the parts are healed. After irrigation of the cavity the head should be held downward in such a position that the cavity will be entirely drained.

Disease of the Frontal Sinuses. Disease of the frontal sinus is almost invariably associated with disease of the nasal cavity most commonly polypoid growths or enlargement of the middle turbinal obstructing the infundibulum. Empyema of the frontal sinus is most frequent, although it may be the seat of growths and degenerations. The disease of this cavity is indicated by the flow of pus from the upper portion of the semilunar hiatus, and by pain and tenderness to pressure over and around the eye.

The treatment of frontal sinus disease is by drainage and injection's of medicated solutions into the cavity. This can be reached by two routes: through the infundibulum or natural opening, or by an external incision through the bony wall. Through the infundibulum a slender silver catheter may be passed and the sinus irrigated and medicated, and in recent cases a cure is affected in a short time; but in chronic cases it must be reached through an incision in the outer wall. The incision should be made along the eyebrow, and the tissues raised and turned backward a short distance to give room for opening the bone. The cavity is best entered just above the supra orbital ridge with a small drill run by electric motor, controlled by a foot switch. Through this opening the cavity can be explored and its size and the relations of its walls ascertained. A larger drill can then be employed, or a button of bone taken out with a trephine, or the portion of the wall sawed out with a slender saw, as in opening), the antrum. Luc adopts the plan of making a vertical incision from the root of the nose upward and so raising the soft parts that the opening through the bone is made under the flap just outside the median line, so that the two wounds will not come opposite each other. When the opening has been made, the cavity is curetted or dealt with according to the conditions found. A Bryan soft rubber drainage tube is then inserted through the natural opening into the nose, the flange on the head of the tube remaining in the cavity to keep the tube in place, and through this the cavity is irrigated and medicated from below. The external wound is then closed in the usual manner. It is important that the line of the incision, when horizontal, be made along the line of the eyebrow, so that the sear will be obscured by the hair.


The most frequent obstructions in the naso pharynx are adenoid growths or enlargements of the pharyngeal tonsil (see page 952), although nearly every known variety of growth is encountered in this region. A variety of methods is employed for the removal of these growths, as curettement, the use of cutting or divulsion forceps, scraping them out with the fingernail, or burning them away with galvano cautery. These methods are applicable to the different conditions of the growth. When it is one rounded mass it is best removed with Lowenberg's postnasal adenoid forceps, having a posterior scooped projection, as shown in Fig. 682. When composed of independent vegetations scattered about the pharynx (Fig. 583), the simple ring knife or Gottstein's curette may be chosen. When the mass is soft and spongy, it is very easily scraped away with the finger (Fig. 683) or with Darby's artificial fingernail attachment. When it is firm and more or less pedunculated, it is often best removed with a postnasal snare curved to pass up behind the soft palate. In children the use of a general anesthetic is always advisable unless there is some counter indication to its use. Chloroform or Schleich's mixture is the most satisfactory, and the operation as performed by the writer is as follows:

The child is anesthetized, a mouth gag introduced with its bead slightly dependent. The tongue is then depressed and the chosen instrument introduced behind the palate and the growth removed. The child is then placed on the side, preferably the right, if the operator is right handed, so as to allow the free escape of the blood without the danger of its being inspired into the larynx. The vault should then be digitally explored to determine if every part of the growth has been removed ' which should be done before the operation can be considered completed. After the operation the vault of the pharynx can be irrigated with a postnasal syringe, using a bicolored solution, 1: 5000, for the purpose of removing blood and rendering the parts aseptic.

Further treatment than this is unnecessary, and often this can be dispensed with by thoroughly cleansing the parts with an alkaline solution used before the operation.

In operating on adults anesthesia, except by cocain, is rarely required. After the growth is removed the conditions that may have resulted from the presence of the growth, such as deafness and the imperfection of speech in children, must be properly dealt with.

Formerly the galvano cautery was frequently employed in the removal of adenoid growths; but the danger of middle ear complications attending its use in the postnasal space and the greater or less difficulty in its application, together with the superiority of other methods has caused it almost entirely to fall into disuse for this purpose.

Harrison Allen, Hooper, and others raise the child into a sitting posture for operation and incline it forward to let the blood flow from the mouth and nose, Allen using generally the alligator forceps through the nose, guided by the finger in the pharynx, which is able also to squeeze out the softer masses as well as tear away the firmer. After the central mass has been removed, Hartmann's lateral cutting curette (Fig. 682) may be used for the removal of any marginal portions remaining in Rosenmuller's fossa or elsewhere. When there is recurrence of the growth it is due to some portion of this lymphoid tissue which has escaped removal.' In exploring and operating with the finger a guard (Fig. 683) is useful, and can sometimes supersede a mouth gag.

The removal of the faucial tonsil is called for in cases where it is enlarged sufficiently to project beyond the pillars of the fauces and cause obstruction or act as a foreign substance, or when the tonsil is not hypertrophied, but so diseased as to cause irritation of the fauces and more or less reflex disturbance. There are two principal methods for the reduction or removal of the tonsil destruction by means of caustic substances and excision with cutting instruments.

The caustics employed are Vienna paste, chromic acid, nitric acid, nitrate of silver, chlorid of zinc, and the galvano cautery.

Before the application of the caustic the tonsil should be anesthetized with cocain, or by the injection of Wilson's local anesthetic around the base of the structure. Where the Vienna paste is used, it is applied by mixing it with water to the consistency of a thick paste and rubbing it upon the tonsil with a small glass rod, care being taken that no paste be allowed to drop into the fauces.

Nitric acid is best applied with a very small pledget of cotton wound on the end of a probe, as may the saturated solutions of the other caustics ; or crystals of chromic acid, silver nitrate, or chlorid of zinc may be picked up or fused on the end of a probe.

The galvano cautery is most effectively employed by ignipuncture, using a slender pointed electrode (Fig. 568), which is thrust into the tonsil at several different places, rather than burning away the tonsil in toto.

None of these processes is to be recommended, however, except as a substitute for the knife when its use is not permitted.

The only positively satisfactory and effective method is excision. This may be done with a bistoury, with the tonsillotome, with the cold wire snare, or with the galvano cautery ecraseur.

The bistoury employed should be slightly curved and have a blunt probepoint to prevent the Abounding of the pillars of the fauces and to lessen the danger of cutting too deeply. The tonsil is removed by grasping it with a pair of forceps, dragging it from its base, and cutting off the diseased portion. In eases of flattened or lobulated tonsils the bistoury is a very practical instrument for the removal, especially in adults, although in many cases the writer gives preference to the cold wire snare.

In children where the tonsils are found plump and rounded the tonsillotome of Mathieu or Mackenzie is very serviceable, although in these cases, also, the cold wire snare is preferable.

In the use of the tonsillotome the patient is seated upright and the head held by the assistant. The tongue is depressed and the ring of the instrument is passed from below over the tonsil and well in behind it (Fig. 684).

The assistant presses with one finger on the outside of the neck directly over the tonsil, forcing it inward toward the fauces, so that it may the more fully enter the ring, and the guillotine knife is then carried through the tissue, cutting off more than a surface slice.

Before the tonsils are excised they should be thoroughly liberated from the pillars of the fauces by a curved blunt instrument. This I regard as an exceedingly valuable procedure, as the tonsils are so frequently adherent to the pillars that unless liberated there is danger of cutting the enlarged bloodvessels of the pillar, which, if wounded, may bleed profusely or cause the alarming hemorrhages that occasionally follow tonsillotomy in adults.'

When portions of the diseased tonsil escape removal, it is frequently necessary to finish the operation by grasping these portions with vulsellum forceps and removing them with the cold wire snare or bistoury.

In cases where hemorrhage is apprehended, the tonsil is best removed by means of the cold wire snare or galvano cautery ecraseur, as in no instance has hemorrhage of any considerable extent followed the use of the cold snare.

The removal of the tonsils with the cold wire snare or the galvano cautery snare is done in the same manner as the removal with the tonsillotome, except that the tonsil is drawn outward with a pair of vulsellum forceps passed through the loop.

Luc of Paris and Farnham of Boston have devised punch forceps for the removal of enlarged tonsils, which I have found in some cases serviceable, particularly in removing remnants of tonsils that have escaped excision. Bliss employs scissors to dissect away the entire structure and Pynchon does this with the galvano cautery knife.

In the removal with the galvanic snare allowance should be made in the adjustment of the loop for the portion of the tonsil that will slough away as a result of the burning.

In case of hemorrhage following excision of the tonsils the instrument always at hand and generally the most serviceable is the two large fingers of the hand corresponding to the side on which the operation is performed. The fingers are thrust into the tonsil, with the thumb pressing firmly on the outside of the neck. The writer has never seen a tonsillar hemorrhage that could not be controlled in this manner. In all ordinary cases the pressure for a short time will suffice for the complete arrest of the hemorrhage; but if there is a tendency to recur, pressure can be exerted in the same manner by Pendim's instrument.

With our present knowledge of tonsillotomy, the wounding of the deep blood vessels of the fauces sufficiently to give rise to such alarming hemorrhages can only be justified or excused by an anomalous distribution of the arteries, which ought to be recognized beforehand by palpation or by their visible pulsation on careful inspection.

Operations on the Lingual Tonsil. When the enlargement consists mostly in a vascular engorgement, the best method of reduction is with the curved galvano cautery electrode having a slender point. By the aid of the laryngeal mirror the large vessels can be singled out and destroyed separately by burning deeply. On healing the contraction of the tissues will cause obliteration of the intervening engorgement. For this purpose caustic agents are also used, such as chromic acid, nitric acid, and Vienna paste. These, however, are not to be advocated, as the use of them is painful and unnecessary.

Where the enlargement consists in hypertrophy of the interstitial connective tissue, it is best removed by excision. When the mass is more or less rounded and projecting, I have found the instrument devised by myself and termed a lingual tonsillotome, as represented in Fig. 685, exceedingly serviceable. The lower portion of the ring is caught under the lower edge of the growth between it and the epiglottis, and by pressing forward and downward the mass is forced through the opening, when the blade is shoved down and the whole mass severed, leaving a smooth surface.

In cases in which the hypertrophies are in the form of little lobules scattered about the base of the tongue, I have for a considerable time used the cold wire snare having a curved stem to pass over the base of' the tongue. But a small portion can, as a rule, be removed at a time, consequently 6 number of efforts are required to remove the entire mass. This method is, however, exceedingly satisfactory, causes little pain, and bleeding is rarely encountered.

In the removal of these growths it is important to adjust the instrument by aid of the laryngeal mirror, the tongue being drawn forward by the patient, in order to avoid injuring the epiglottis. Every portion of the growth should be removed, for if one or two small lobules remain behind, the irritation produced may be nearly as great as that caused by the whole mass.


Quinsy or peritonsillar abscess is rarely if ever a suppuration of tonsiltissue, as it was formerly considered, although generally the result of phlegmonous inflammation from tonsillar infection. Scarification of the tonsil itself is in most cases as needless, therefore, as in retro pharyngeal abscess. Fluctuation is to be sought by palpation, aided, if possible, by simultaneous ocular inspection, and incision should be made as soon as pus is detected or is clearly unavoidable. Harrison Allen probed carefully each tonsillar follicle, seeking a boggy point, and could. often thus find and evacuate the first drops of pus, to the great shortening of the affection. The relief to the patient may be great even before pus is formed, while with the evacuation of the abscess most of the pain and distress of the condition is at an end. The thin region of pointing may perhaps be better recognized by touch than by sight, and pulsation is to be felt for, both as to its indication of the proximity of large arteries and because an aneurysm might be opened by mistake. The incision should be free, usually in or just inside of the anterior half arch above the tonsil, entering the blade Dearly half an inch and cutting horizontally in toward the median line ; and vigorous use of the probe may be needed to fully enter and empty the flabby sac. Hot syringing with mild disinfecting solutions is usually advisable.

In the retro pharyngeal abscess it is easier to evacuate the cavity; and lest it should deluge the air passages and perhaps be drawn into the lungs, some open at its upper rather than at its most dependent portion. In these cases the possibility of extrinsic origin in adjacent lymph gland, mastoid or vertebral suppuration must not be forgotten, and search should be duly made for any such condition. Where the retro pharyngeal pointing is merely accidental and external operative intervention is needful, it may be better to drain outward without pharyngeal opening. In any of these cases the danger of wounding the large blood vessels of the neck is much greater than in tonsillotomy.


It frequently happens that the uvula is cut away because it is the supposed cause of irritation which in reality originates from diseased conditions, of other parts, and it is safe to affirm there is no organ in the body which is so often abused for fancied sins as the uvula.

It occasionally happens, however, that the uvula requires shortening, and for this purpose a variety of instruments has been devised: fenestrated instruments similar to the tonsillotome, curved scissors with the ends coming together first so as to prevent its slipping away, and others having a pair of claws to seize the cut portion to prevent its falling into the larynx. Some advise the use of the snare, in order to avoid any danger of hemorrhage, which sometimes, although very rarely, occurs.

The simplest and, as I consider, the best method of removing the elongated portion of the uvula is to grasp the end with a pair of mouse toothed forceps, pulling it gently forward, and with a pair of grape vine scissors cut it on the slant so that the cut surface looks backward. This is important for two reasons, first, it prevents food from coming in contact with the cut surface, and it directs the mucus or fluids from the nasal space forward upon the base of the tongue, thereby preventing it from falling into the larynx.

In cutting the uvula particular care should be exercised not to cut it too short, allowance always being made for considerable contraction after healing to prevent its becoming shorter than its normal dimensions.

After uvulotomy some cases of hemorrhages have been reported. Morgan collected a number of such cases scattered through medical literature, and .devised a clamp which can be applied to the end of the cut portion. This the writer has found in some cases exceedingly serviceable.


Papillomata and polypoid growths of the larynx are best removed by means of forceps, such as Mackenzie's (Fig. 686), guillotine, such as Stoerk's, or rongeurs, such as Krause's. The choice of instrument depends much upon the form and seat, of the growth and the facility of the operator.

The removal of foreign bodies is often a closely similar procedure, both being guided, as a rule, by the mirror. The reversal of the image will confuse an inexperienced laryngologist, and the patient may need some drill to secure steadiness and the co operation sometimes required; so some preliminary use of the probe is apt to be useful. Under cocain it is not commonly difficult to have the needful quiet for one or more attempts; but there is room for the exercise of the highest skill if prompt and full success is to be attained. Ample illumination is requisite, since much light will be cut off by the instrument, which is sometimes made with fenestrated jaws to lessen the obstruction to the view at the critical moment of seizing the object. Stoerk's tube furceps with its pistol grip is a very serviceable instrument, offering the minimum of obstruction and irritation by reason of its well planned curves. A guarded knife is sometimes employed as for laryngeal scarifications, to cut off growths; and the use of the chemical or galvano cautery has been elsewhere described (see page 1004).

Preparations for a tracheotomy should often be made before intralaryngeal operations are undertaken, since dangerous dyspnea or actual suffocation might at any time supervene.'

Laryngeal stenosis can often be dilated from the mouth by the passage of a suitable catheter, by divulsion with instruments like the author's dilator (Fig. 687), or by cutting and dilating, for which many instruments have been devised. (For Intubation by O'Dwyer's method, see page 1029.)


Tracheotomy, Thyrotomy, and Pharyngotomy. External opening of the air passages may be required for a number of conditions, chief among which is the prevention of suffocation by foreign body, false membrane, edema abductor paralysis, or neoplasm. As a provision against the entry of blood into the lungs, it may be done preliminary to operations not otherwise requiring, it ; and its previous performance when the larynx is to be removed divides the shock of that operation and anchors the trachea to tile external wound in a way that avoids some of the complications of the after treatment. The need for it may be so sudden that little preparation is possible, and use must be made of whatever instruments are at hand even a penknife having been successfully employed in an emergency. Morell Mackenzie carried an emergency cannula, the split obturator of which contained a sterile knife ready for immediate use.

Where extreme limitation of time exists, penetration of the crico thyroid membrane is usually indicated, for this structure is almost subcutaneous and generally devoid of vessels likely to cause troublesome hemorrhage. Additional space may be gained, if required, by cutting upward into the thyroid or downward through the cricoid; but without' this a sufficient respiratory opening can be gained for the emergency, and more extensive operation in this region is at great risk of permanently impairing the voice.

Tracheotomy is generally to be preferred if a persistent opening and the wearing of a cannula is called for; and the opening may be made high or low, as the conditions of the case dictate. The presence of the thyroid gland and its vessels generally complicates the matter, and the fatness of the neck increases the annoyance caused by the tube, especially if the opening is low down, where the trachea is deeper and remains of the thymus gland are present in the very young. Yet the low operation is generally preferred because the space above the isthmus of the thyroid is small ; and it is a decided complication to have to secure. this structure With double ligatures and divide it to make room (Fig. 688). The isthmus generally covers the second, third, and fourth tracheal rings, and a process may extend up to the hyoid. The simplest method of hasty tracheotomy is that of Durham, who lightly grasps the trachea between the thumb and finger, pressed down until both carotids are felt, and then dissects down upon it as it presses forward into the wound. The veins, ellgorged by the impeded respiration, are generally easily seen and pressed aside, and the trachea is quickly laid bare and opened, either directly or after fixing and lifting it with a tenaculum. By Bose's method the median skin incision is crossed by another at the level of the crico thyroid membrane, laying this bare, and the undivided structures in front of the trachea are peeled down sufficiently to give access to it. As it is important to incise the trachea, in the median line, great care should be taken to place the patient's neck and trunk straight, with the head drawn back over a rolling pin or other firm support and immovably held there. In case of foreign body a retractor similar to a nasal speculum may be used to hold the trachea open, or a suture may be passed through each side of the tracheal wound and drawn upon whenever coughing promises to expel the obstructing object. Such threads are a very great, aid in placing the cannula in position at the first, and still more if it is to be replaced later after withdrawal for any cause; so Bosworth advises them as a rule. A portion of one or more rings may be resected in order to secure a gaping wound, and the margin of the tracheal and cutaneous wound on each side can be stitched together and a tube thus dispensed with.

Usually the operation can be performed with deliberate division of successive layers of the overlying tissues upon a grooved director, with all possible blunt dissecting, until the trachea is bared at the desired point and all bleeding vessels secured by compression or ligation. Then with a tenaculum a firm and central hold of the trachea is secured and the knife point entered and the needful incision made upward and rather from within outward Turning the knife blade will separate the lips of the wound, while the fingertip above will hold wide the external wound and prevent blood from being drawn in with the first deep gasping inspiration. The cannula May now be slipped in along the finger, and its obturator, if used, promptly withdrawn as soon as it is in the trachea. The tube is then secured in place by tying the tapes attached to its neck plate around the patient's neck; and the external wound, if large, may be narrowed or closed around the tube by sutures.

General anesthesia is often quite unnecessary, as the patient is sufficiently narcotized by the semi asphyxiation. Chloroform is generally preferred because less irritating to the air passages and less liable to cause vomiting' with its dangers. Much care must be given to secure due warmth and moisture of the air entering by this shortened route, for fear of pneumonia, which may supervene from this, as from inspired blood, and may rob the operation of its life saving value. [Steam soaked air maybe needless or even harmful, but the room should be warm and certainly not too dry.] Artificial respiration may be required to start breathing [or to continue it if it should be interrupted after the first free inspiration, as will occasionally happen, as if from shock, on the free entrance of air] ; and the patient may need judicious stimulation for hours or days in order to rescue him from the profound carbonic acid poisoning which has taken place during the apnea. The inner tube must be removed and cleansed whenever impeded by mucus or false membrane, and a feather may be passed through the cannula and down into the bronchi to remove collections and to stimulate cough.

The operation may be exceedingly simple and easy, or may be, as characterized by Billrotb, one of the most difficult in surgery. Three or four assistants are desirable, each of whom must give full attention to his own duty, although it be the simple part of maintaining the head and neck in exact position. Full illumination, best secured by the concave foreheadreflector, is essential to the most skilful work. There must be no flurry or clumsiness at the crucial moment of introducing the tube, for many an operation has failed at this point serious damage being done to the tissues, bleeding reawakened, or false membrane pressed down and impacted. The Trousseau double tube with its quadrant curve is theoretically inferior to the more right angled and adjustable tube of Durham; but it is the one most often employed by Americans. A well made soft rubber tube can have ample lumen and be much more comfortable to the patient and less likely to cause sloughing from pressure. Fenestrated tubes may permit and even cause ingrowth of granulations, with troublesome resulting erosion; while such construction is needless since enough air generally passes around the cannula to furnish sufficient breath for phonation. Where bleeding is to be especially guarded against, Trendelenburg's or Gerster's dilatable tube may be used; but a tight fitting single tube can serve the same temporary purpose, and give place to one of better size at the close of the operation. Four sizes of tubes should be available, having an external diameter of ten, nine, seven, and five millimeters respectively.

The removal of the tracheotomy tube after its purpose has been served may prove quite a troublesome matter, for the patient may have such severe dyspnea as to compel its reintroduction, and this may be difficult or even impossible through the narrowed wound, necessitating enlargement of it or resort to intubation. As the trouble may be largely hysterical, there is room for much tact in forestalling or overcoming it; and careful laryngoscopic examination should be made, if possible, before this removal is attempted, to make sure that the parts are in condition to resume their function.

Thyrotomy' or laryugo fissure, often with preliminary tracheotomy, may be needed for the extirpation of broad based growths or' for foreign bodies impossible of removal by intralaryngeal methods. The cutaneous incision is to be made as for a high tracheotomy, from the hyoid bone to the cricoid ring; the rostrum of the thyroid is laid bare and divided centrally by gradually deepening cuts or by sawing if calcified. The mucous membrane :Should be exposed and all structures external to it divided and bleeding controlled before it is incised and the larynx opened, for very troublesome cough will be excited. The larynx cavity should be entered from below under good illumination with the forehead mirror, so that the vocal cords shall be seen and injury of them avoided. The purpose of the operation in extirpation of a growth or other step is to be then carried out after careful orientation, and the parts are brought together with all possible accuracy with silkworm gut sutures, the skin wound being separately stitched. The voice may be lost or permanently impaired by the operation, or not regained, as it sometimes might be, after consummate intralaryngeal work; yet if this latter is impracticable, the procedure is fully justified. Subhyoid pharyngotomy may be needed to gain free access to the supraglottic space or the entrance of the esophagus, and the opening may be made immediately below the hyoid bone or just above the thyroid cartilage. The incision is made at the chosen level and from one sterno mastoid to the other, and carried down through the muscles until the thyro hyoid membrane is freely exposed. This is entered laterally, and the epiglottis brought to view and drawn out of the wound after sufficient enlargement, when the region should be open to free access. If found requisite, the incision Cali be carried down along the sterno mastoid as a lateral pharyngotomy or esophagotomy. Great fear was at one time entertained as to any injury or removal of the epiglottis; but numberless cut throat injuries have demonstrated that it may be lost by injury as by disease with little serious result. Yet feeding should be by tube (see page 1032) or by rectum for several days after this operation.

Extirpation and Resection of the Larynx. Malignant growths of the larynx rarely admit of thorough extirpation by endo laryngeal methods, and as a speedily fatal result with great suffering is the only natural outlook, severe operative measures are justified in their removal. [When very limited, it may be feasible by laryngo fissure to extirpate the growth with preservation of the structure and the voice; but partial or total excision is generally needful if thoroughness is to be secured. This last is a serious measure, demanding much surgical skill and resource, which is often best done by the general surgeon rather than the laryngologist (see page 1113) ; yet many are better conversant with their cases than another can quickly become, and sufficiently versed in operative technic to make it well that they should direct if not perform the operation.]

Preliminary tracheotomy is generally advisable, and the patient may be allowed to recover fully and become habituated to the change before the graver intervention; although as performed by Perier and by Keen tracheotomy is not previously done. The larynx and upper portion of the trachea are sufficiently bared after free median incision and the grooved director passed behind the trachea, through the front of which a strong suture is passed just below the point selected as the lower limit of the excision. Traction upon this thread holds the trachea forward while it is cut across, and then draws it out of the wound; and a tightly fitting curved cannula is inserted and secured by tying the suture to a cleat upon it (Fig. 689). The anesthetic is transferred to this opening, while the larynx is lifted by a tenaculum and dissected up free from the esophagus and its upper attachments, and the excision completed according to the special requirements of the case. The trachea is stitched above the sternal notch into the wound, which is completely closed elsewhere if possible, the cannula being retained or not as the case seems to require. An artificial larynx may be later employed, although some patients have been able to talk without it.

Partial resection e. g., excision of one side of the larynx, is regarded as a much less grave procedure, which Bosworth advises as a first step after exploration by laryugo fissure, and if the growth appears limited to that side; while J. N. Mackenzie urges that the extirpation should be as total as of the breast, and should include all suspicious neighboring lymphatics.

In all these operations placing the patient in the Trendelenburg position may facilitate the procedure and greatly reduce its risks. Shock is to be met by full employment of injection or transfusion of warm neutral salt solution; and in ease of carbonic acid intoxication, simultaneous venesection with free bleeding has been employed with apparent advantage.

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