Injuries And Deformities Of The Nose And Throat

Injuries And Deformities Of The Nose And Throat
By JOHN 0. ROE, M. D.,
OF ROCHESTER, N. Y.

INJURIES Of the nose may be considered under the following heads: (1) ,contusions, wounds, and burns; (2) fractures of the bones and cartilages and (3) dislocations of the bones and cartilages.

CONTUSIONS, WOUNDS, AND BURNS OF THE NOSE.

Contusions. Owing to the prominent and unprotected position of the nose, it is subject to frequent injuries. The most frequent of such injuries: are contusions caused by falls or by blows inflicted upon the nose with the fist or any bard substance. There is, according to the amount of the impinging force, more or less hemorrhage from the Dose, and ecchymosis at the point of injury. When the injury is confined to the upper part of the nose, it is followed by more extravasation of blood into the loose cellular tissues at the base of the nose and around the eyes, and also by much more swelling of the soft parts, than when the injury is confined to the end or lower part of the nose, owing to the firmness of the tissues in the latter region.

Treatment. When the injury is comparatively slight it, as a rule, gives rise only to moderate epistaxis, from the rupture of the capillaries of the pituitary membrane (usually at the juncture of the bony with the cartilaginous portion of the septum), which generally stops spontaneously. Severe lesions, and sometimes even slight injuries, will be followed by profuse and persistent hemorrhage, owing to the great vascularity of the pituitary membrane, or to a hemorrhagic tendency, requiring the application of pressure, ,or cold externally, or tamponing of the nose. The simplest manner in which pressure can be applied is by grasping the nose firmly between the thumb and forefinger as close to the face as possible. In this manner hemorrhage from the anterior portion of the nose can be immediately arrested; and at the same time by holding the head forward, so as to allow the blood to gravitate into the dependent portion of the nose, a clot is formed, which will favor the arrest of hemorrhage in the deeper parts.

In severe injuries there may be an effusion of blood between the lamina of the septum, causing what is termed a bloody tumor, which if allowed to remain until decomposition takes place, will result in abscess of the septum (Fig. 639). This should be incised through the nostril and thoroughly evacuated, and the cavity irrigated with bichlorid solution, I: 5000. Gentle presstire should then be applied to each side of the septum by means of a clamp having the arms covered with gauze or aseptic cotton, so as to obliterate the cavity and maintain coaptation until healed.

Wounds. Wounds of the nose may be divided into incised, lacerated, and punctured wounds, according as they are produced by cutting, blunt or bruising, or pointed instruments. They may affect the soft parts alone; the Soft parts and bones and cartilaginous framework; or the soft parts, hard parts, and pituitary membrane. They may also be so extensive as to involve the nasal fossae, the orbit, and the accessory sinuses of the nose, and even the cranial cavity.

(a) Incised wounds may vary from a slight cut of the skin to the complete severance of the organ. They may be vertical, transverse, or oblique.

Simple incised wounds of the skin are of importance only so far as they cause disfigurement. In case of vertical wounds the edges of the skin come together very readily and can be easily held in position by adhesive plaster or styptic collodion ; whereas in transverse wounds there is more retraction of the parts, which necessitates the uniting of the edges of the skin with fine sutures. Special care must be exercised when the inferior portion and wings of the nose are involved, because the elasticity of the cartilages of the alea tends to separate the parts, while the functional importance is great.

Transverse incised wounds, involving the deeper structure of the nose, may allow the end of the nose to drop down on the upper lip, held only by the septum and tissues at the base of the nose. In some instances a transverse incised wound may be so extensive as to pass through the nose, involving the deeper structure and the maxillary bones. Larrey reports a case in which with “un coup de sabre" the inferior half' of the nose, the corresponding two sides of cheek and upper lip, and the two maxillary bones were divided clear to the palate. The parts were carefully sutured in place, with complete recovery in forty five days.

In other eases the nose may hang by a slender pedicle or be completely severed. A number of cases are recorded in which the union took place when the nose was set on again after it had been severed for several hours. In Cagarlinge's' well known case it was detached five and one half hours, and in Garenot's case the severed end, which had been bitten off, was recovered from the sewer into which it had been thrown. It was cleansed with warm water, reapplied, and oil the fourth day was quite firmly united. In all cases, even if a number of hours have elapsed since the accident took place, attempts should be made at the restoration of the part by carefully cleansing the detached parts with warm sterilized normal salt solution, and scarifying or scraping the raw surface to encourage its attachment.

Galin and Hoffacker claim an advantage in waiting a short time before restoration of the severed end by reason of there being a complete arrest of hemorrhage. The surfaces can be thoroughly cleansed, and the danger of formation of blood clots between the surfaces will thereby be avoided. In attaching the severed portion the soft parts, including the cartilaginous portion, should be carefully stitched together, and the interior of the nose should be tamponed with antiseptic gauze to protect the parts from the inside and to maintain the nostrils in their normal form. The union, as a rule, takes place slowly; the end may remain cold and pale for twelve hours or even two or three days, and therefore we must not be in haste to regard the operation as a failure.

(b) Lacerated wounds are usually produced by blunt instruments, falls on angular or rough surfaces, projectiles, etc. Wounds from blunt instruments are usually attended with a fracture or dislocation of the nasal bones.

In case of projectiles, where a bullet comes from a lateral direction, it usually passes through the nose, involving both walls; but in case of spent bullets they may penetrate only one wall of the nose and lodge in the meatus, the orbit, in an accessory sinus, or they may penetrate the brain. In some cases the wad of a gun may be forced into the wound with the bullet and remain there as a foreign substance. In one case reported by Legouest, the wad of a gun was found astride of the septum. The skin cicatrized after its introduction and the accident was forgotten. There was a continuous fetid discharge from the nose, and after four years the wad was discovered during a rhinoscopic examination and removed. The treatment of lacerated wounds of the nose requires especial care to render the parts aseptic and to coasters the skin and maintain the normal contour of the nose, as far as possible.

(c) Punctured wounds are produced by sharp pointed instruments. In some cases the instrument or foreign body may enter through the nasal fossa and penetrate the cranial cavity through the cribriform plate of the ethmoid bone, without external manifestation of the injury. Punctured wounds of the base of the nose are frequently followed by emphysema of the soft parts, owing to the looseness of the connective tissue in this region. This takes place most frequently when the penetrating wound of the nose communicates with the nasal cavity, and the emphysema is caused by the air being forced through this opening under the skin when the patient blows his nose, or during forcible expiration through the nose. It accordingly appears quick] y, giving the sensation of a sharp, hot streak as the air is forced under the skin. It may be limited to the superior part of the nose, where the cellular tissue is quite loose, or it may extend to the eyelids, and sometimes to the neighboring portion of the face. Slender instruments, or such foreign bodies as knives, pencils, and the like, may penetrate the walls of the nose and break off, remaining in the wound.

Treatment. Simple punctured wounds of the external nose, as a rule, require only ordinary antiseptic care. In complicated cases, however, in which the end of the instrument has broken off and remains as a foreign body, it must be extracted either through the wound, from the interior of the nose, or removed through an artificial opening and the wound afterwards treated as an incised wound. Each case, however, must be treated according to the peculiarity of the conditions found. The emphysema of the face which sometimes accompanies punctured wounds of the nose usually subsides in a short time, although the disappearance can be hastened by poultices and compression.

Burns and Scalds. Burns and scalds of the nose do not differ in their nature and treatment from burns and scalds of other portions of the body. They are of special significance only so far as the resulting cicatrices cause distortion of the organ and contraction of the nasal passages. It is therefore during the healing process of the burn or scald that we should give particular attention to prevent any such complication.

The contraction of the burn can be overcome in a great measure by resorting to skin grafting before the wound is healed, thereby replacing the skin that has been destroyed and preventing the formation of cicatricial tissue, by which the edges of a wound are forcibly drawn together. Special care should be taken in this particular when the nasal orifices are involved. Ivory or vulcanite plugs or tubes should be inserted into the nostrils to keep the nasal opening, widely dilated, until all tendency to contraction of the tissues has passed. When, however, this contraction of the tissues has taken place and the nasal orifices have become greatly narrowed, the treatment to be adopted is described under the head of Stenosis of' the Nasal Passages.

FRACTURES OF THE BONES AND CARTILAGES OF THE NOSE.

Fractures and dislocations of the nose may vary, according to the severity of the injury, from simple displacement of some one of the bones of the nose, without wounding the skin, to compound comminuted fracture of the bones, attended with more or less destruction and escape of the bony fragments, resulting in marked distortions and permanent disfigurement of the nose.

Fractures of the bones of the nose are comparatively rare when we consider the prominent and exposed position of the nose and the frequency with which bodily injuries occur. This is accounted for somewhat by the yielding condition of the cartilaginous, portion of the nose, which more or less resists fracture, and the arched form of the osseous portion or bridge of the nose, which enables it to withstand a considerable amount of external force. The nose is also in many cases protected by the prominence of the frontal bone.

Fracture of the nose is more frequent in men than in women, and also more frequent in adults, Owing to the cartilaginous and more yielding character of the parts in the young.

Fractures of the nose always result from force applied externally, oftenest in the form of blows or falls directly on the nose. They are usually attended with lesions of the integument, and are frequently associated with fractures of the nasal process of the superior maxilla, together with dislocation or fracture of the nasal septum. In severe injuries the osseous portion of the nasal septum, together with the nasal bones, has been driven backward into the brain.

Such injuries are usually attended with severe hemorrhage and escape of cerebral matter, with all the symptoms of fracture at the base of the cranium, and are generally fatal.

Fractures of the bones of the nose are almost always bilateral, unilateral fractures, being rare. In some cases, when the force is applied entirely to one side, fracture of the bone on this side may be attended with dislocation of the bone on the opposite side, to¬gether with lateral dislocation of the nasal septum, as represented in Fig. 640.

Fractures of the nose may be divided into simple, comminuted, and compound. In simple fractures of the nose the line of the fracture may be vertical, oblique, or transverse, according; to the direction of the blow. In vertical fractures one fragment may slide under the edge of the other, the letter protruding sufficiently to form a ridge readily felt by the finger. In oblique or transverse fractures the lower fragment is depressed; the upper fragment remains unbroken and, accordingly, maintains its normal position.

In a comminuted fracture the fragments are more or less numerous, and in case it is compound they may escape through the wound and thereby be destroyed and lost. Simple fractures may exist without any resulting disfigurement; whereas comminuted or compound fractures may be followed by narrowing and obstruction of one or both nasal passages, and of one or both lachrymal ducts, causing lachrymal tumors and styllicidium.

The lachrymal bones may be fractured by a slight or very moderate blow, accompanied by discoloration of the eyelids; and sometimes emphysema of the cellular tissue of the orbit may take place, on blowing the nose, by the escape of air from the nostrils through the fractured edges of the bone.

Diagnosis. The diagnosis of fractures of the nose in some cases is extremely simple, whereas in other cases it is attended with great difficulty. Simple fractures of the nose may exist without displacement of the fragments, the latter being held in place by the periosteum, the soft parts, and the mucous membrane. The line of the fracture can often be felt under the finger as a slight fissure. In other cases it is manifested only by pain in the seat of the injury. When there is displacement of the fragments the protruding edges of the fracture form a ridge, which is not only readily perceptible to the finger, but can be seen on inspection. In order to determine the extent of the fracture and the condition of the part, the examination should follow the injury as speedily as possible, for the swelling of the soft parts so quickly supervenes as to make the diagnosis very difficult.

Vertical fractures can be detected by the careful movement of the lateral fragments against the edges of the unbroken portion. In oblique or transverse fractures, since the lower fragment becomes depressed, the edge of the unbroken portion is prominent. Often, in making a rhinoscopic examination the depressed portion of the bone can be seen projecting into the interior of the nose. In comminuted fractures the crepitation of the fragments is generally readily detected, but great care should be exercised when making the examination not to increase the displacement. In compound fractures the condition of the bony parts can be easily discovered by exploration with a probe through the wound. When the contused parts have become greatly swollen before the patient comes under observation, it is then usually necessary to wait until the inflammation and swelling have been reduced, before the exact condition of the part can be made out.

Two of the most prominent symptoms of fracture of the nose are epistaxis and emphysema of the tissues of the nose. Emphysema of the nose is indicative of rupture of the mucous membrane, through which opening air is forced into the tissues. It usually comes on rapidly when the patient blows his nose, as in the case of punctured wounds. It is generally limited to the region at the base of the nose ; although it may extend to the periocular cellular tissue (sometimes completely closing the eyes and throughout the face. In exceptional cases it may involve the tissues of the neck. It is detected by crepitation much as given by the edges of the broken bone. Epistaxis, which is almost always present, varies according to the extent of the injury, and may be very slight or very profuse, although it is never sufficient to endanger the life of the patient. It usually ceases spontaneously, although in severe cases tamponing the nose may be necessary to prevent weakening the patient from loss of blood. In these cases the presence of hemorrhagic exudates, which may accumulate between the hard and soft parts, should be recognized and evacuated to prevent purulent formations or septic infection and the breaking down of the lacerated tissues.

In all cases of fracture of the nose the gravity of the case depends entirely upon the brain complication. The secondary complications which may follow these injuries are deformities of the nose, injury to the lachrymal apparatus, impairment Of tile sense of smell (either from occlusion of' the nasal passages or injury to the olfactory nerve), and lack of' resonance in the voice, owing to the contraction of the nasal passages.

Treatment. In all cases of fracture of the nose the replacement of the fragments should be effected as speedily as possible, before swelling of the parts has supervened to prevent it ; for when the swelling is extensive it is frequently necessary to wait until it subsides before the fragments can be replaced. This can usually be delayed for three or four days with perfect safety, although if the case is seen early, much of tile Swelling can be prevented by attention to antiseptic and antiphlogistic measures.

In case the fracture is a compound one, we should attend carefully to the wound of the skin (as in case of lacerated wounds of the nose,) in order to prevent, as far as possible, disfigurement from resulting scars. Laceration of the mucous membrane should also receive attention and be rendered, as far as possible, aseptic.

In simple fractures the reduction is best accomplished with a smooth sound, placed in the interior of the nostril to raise the depressed fragments, and their coaptation is facilitated with the fingers on the outside of tile nose. When no sound is at hand and the nasal passages are sufficiently large to admit the little finger, it can be very advantageously substituted. In some cases the fragments are best and most easily adjusted by means of a pair of 9

smooth blade forceps, one blade placed in the nostril and the other outside, according to the plan of Weber, care being exercised Dot to use too much pressure ; and to avoid lacerating the tissue the blades can be covered with rubber or adhesive plaster. For this purpose Mollire uses forceps, with ivory blades. When the septum has at the same time become fractured or dislocated, it also should be put in place.

When the fragments have been replaced, they must be held with some form of retentive appa¬ratuse If the skin is unbroken, a piece of rubber adhesive plaster, cut of the shape to completely cover the nose, has been found by the author to be one of the most important aids in rendering the exterior' contour smooth and symmetrical. This is to be covered with a metallic form (Fig. 641), made of a sheet of aluminum cut the requisite size and shape, so that when bent the internal contour is the same as the normal nose, and of sufficient size to rest lightly over the nasal border of the superior maxilla. Before this form is applied to the nose, I usually cover and line it with adhesive plaster, which materially assists in holding it in place. It is then adjusted to the nose and securely held in place with adhesive straps, as shown in Fig. 642.

Various other methods have been devised for maintaining the fractured nasal bones in place. Thus Malgaigne has used moulds of lead, which have the disadvantage of being heavy. Hamilton uses gutta percha, but it is not readily adjusted to the desired shape of the nose. Weber employs strips of gutta percha, maintained in place by plaster. Dumreicher employs successive collodion bandages, applied to the nose. Walsham uses a mask of leather, moulded to the face with braces controlled by screws, to maintain the bones in place. Adams has devised a nasal truss attached to a headband, which is buckled firmly around the bead, with a padded arm controlled by screws resting against each side of the nose to hold it in position, as shown in Fig.

643. None of these methods, however, has given me the satisfactory results obtained by the simple method which I have described.

Numerous internal supports have also been em¬ployed for holding these bones in position after the deformity has been corrected. Hamilton packs the nose with pledgets of lint, to each of which is attached a thread for ready extraction. Packard employs plugs of bard rubber, placed inside the nostril. These methods have their advantages since no one plug large enough to maintain the bones in place can be introduced through the nasal apertures. For the purpose of maintaining the vault of the nose, Mason, of Brooklyn, has de¬vised a method of transfixing the nose with nickel or gold needles through the base, on a line with the maxillary junction. He then passes under the needles and over the nose a bandage of rubber. This is efficient to prevent spreading at the base of the nose, and at the same time to bold the nose snugly together and prevent depression of the vault. This is considered an exceedingly ingenious arrangement, and may be of service in some cases. After the parts have become solidified, at the end of seven or eight days, the needles are removed. Many discourage the employment of internal supports, because of the irritation which they cause. This objection is ill founded, for the reason that the irritation is invariably due to the excessive amount of pressure employed. Very slight pressure only is required to maintain the parts in position, because they are naturally immovable and there is no muscular tension to cause their displacement or any other force when the nose is thoroughly protected by a uniform external support. The fragments can most easily be maintained in place by means of an elastic spring placed in the nostril, the tension of which is regulated by means of a screw on the outside, as shown in Fig. 644.

Before the spring is inserted the interior of the nostril is carefully irrigated with an antiseptic solution and dusted with iodoform or some other strong antiseptic powder.

After the bones have been put into place a portion of iodoform gauze is made into a roll that will just fit the upper portion of the nasal cavity, and forced up into the vault sufficiently to hold the fragments in place in perfect coaptation with the external metallic mould that is placed on the outside of the nose. (Fit many cases, however, it is better to insert the internal support before the metallic form is applied.) Under this gauze is placed the tipper arm of the spring, the lower arm resting on the floor of the nose. The spring should be made of the proper size and shape to fit the interior of the nose; while the tension exerted is regulated by a screw at the lower end of the spring. The pressure in these cases should be just sufficient to support the part without causing pain. The lower arm of the spring is covered with rubber tubing, to prevent irritation of the soft parts. By this method the lower respiratory passage remains unobstructed, so that nasal respiration is not materially interfered with. The interior of the no. se also can be kept clean by frequent cleansing with an antiseptic wash until the fragments are united and the nose is self supporting.

In those cases in which the fractured bones are allowed to go unreplaced until firm union has taken place, re fracture of the bones becomes necessary in order to restore them to their normal position. This operation will be described under deformities of the nose.

Fracture of the Cartilages of the Nose. The lower portion of the nose is composed of two lower lateral shield cartilages, united in the center. These shield cartilages are connected with the nasal bones above by two tipper lateral cartilages, which maintain the contour of the central portion of the dorsum of the Dose, as shown in Fig. 645. In cases of moderate injuries to the nose these cartilages are rarely fractured; but when the injury is severe, particularly if inflicted by a more or less sharp body like the sharp edge of a board, fracture of the cartilages sometimes takes place. This is especially true of the tipper lateral cartilages, which maintain the contour of the dorsurn of the nose. Fracture of the shield cartilage is readily detected by the resulting deformity and by the crepitation which can be elicited by careful manipulation; but fracture of the tipper lateral cartilages is frequently so obscured by the attending swelling and inflammation that it is undetected, and only manifested by the resulting depression and deformity of the nose that follow after the inflammatory symptoms have subsided.

Treatment. in many cases of fracture of the shield cartilages the fragments are best held in place by means of the spring above described. When the fracture is in such a position that this cannot be readily maintained in place, a strip of vuleanite or celluloid can be moulded with heat 'Ind made to fit the nostril so as to maintain it in its normal position until the fragments are united. Perforated cork splints are also especially serviceable on account ,of their lightness and the readiness with which they can be fitted to the contour of the nostril. When these are not at hand the nostrils can be packed with antiseptic gauze, so as to maintain them in their proper form. It is advisable, however, to insert through the center an open tube for respiration (see Figs. 573, 574).

Fractures of the Nasal Septum. The nasal septum being composed of three pieces, as shown in Fig. 646, and as each one of these pieces may be fractured independently, we therefore can divide fractures of the septum into three groups: as the frac ture of the triangular cartilage, of the vomer, and of the perpendicular plate of the ethmoid.

The portion most frequently fractured is that of the triangular cartilage; it is always the result of traumatism. Fracture of the cartilage alone may take place as an independent lesion or it may be associated with dislocation of the cartilage at its attachment with the vomer, as shown in Fig. 647. Fractures of the cartilage are also frequently associated with hematoma, which is bilateral; the bloody tumor filling both nostrils, communicating through the fissure in the septum. Separation of the cartilage may take place from displacement of the fragments, although they will more frequently be found overriding each other. The diagnosis of this accident is important, as the integrity of the nose depends on its recognition and proper treatment. When there is no displacement it can be recognized only by the attendant pain, the greater mobility of the structures associated with swelling of the soft parts, and the fissure can be found by exploration with a probe. The crepitus can be found by careful manipulation of the parts. Displacement of the fragments is manifested by depression of the end of the nose, which is distorted to one side, producing a double deformity. Sometimes the end of the nose is flattened on the face. When the fracture is compound it is accompanied by more or less epistaxis, and sometimes by subcutaneous emphysema.

Fracture of the vomer alone is a rare accident, and from its situation and position displacement of the fragments does not readily take place; the line of the fracture can, however, be detected by a careful exploration with a blunt pointed probe, and on inspecting the nostril with the aid of a strong light it can sometimes be recognized by a hemorrhage point.

Fracture of the perpendicular plate of the ethmoid is usually accompanied by comminuted fractures of the bones of the nose, although substances penetrating the nasal cavity have been known to fracture this bone alone. The cribriform plate may also be fractured 'and the foreign body at the same time enter the cranial cavity, the latter being always a very serious accident. When the fracture of' the perpendicular plate exists alone it is usually at a point on a level with the vomer.

Treatment. When there is displacement of the parts, they should be first put in place by means of a pair of forceps with flat parallel blades, one blade being inserted into each nostril, and by gentle pressure the bones can then be restored to their normal position, aided by gentle manipulations. When there is displacement of the fragments to one side it is frequently necessary to insert an internal support only (in that side ; and when there is laceration of the mucous membrane also on that side of the septum, the best form of support is made by winding sublimate cotton around a metallic plate front 1 1/2 to 2 inches in length and of sufficient size to be inserted in the nostril, the nostril being first, however, irrigated with bichlorid solution, 1 : 5000, and dusted with iodoform. Other forms of support are frequently used for this purpose, as tubes made of hard rubber, (of soft rubber, of cork, or of metal, each of which is excellent in cases to which it is adapted; but in cases where it is necessary to maintain the support on] , on one side, leaving the other nostril free for respiration, the cotton plug having a metallie core to stiffen it for insertion, is preferable to all others. In cases in which it is necessary to maintain support on both sides a cotton plug can frequently be inserted in one nostril and a tube in the other.

DISLOCATIONS or THE BONES AND CARTILAGES OF THE NOSE.

Dislocation of the nasal bones is an accident of comparatively infrequent occurrence, and always occurs as the result Of blows against the nose, usually from a lateral direction. According to Marchant, dislocation of the nasal bones was recognized by Heister in 174 1) and by Bell in 1796; but the first published example Was by Bourguet in 18 51, and later by Longuet in 1881. In Bourguet's case, a man twenty two years of age was thrown against a sidewalk, striking on the left side of the nose. The tipper third of the nose was deviated to the right, the lower end remaining normal. The elevation, which was a dislocation of the nasal bones, was reduced by introducing the ring finger of the right hand into the nostril and exerting pressure on the outside, when the bone slipped into place and the dislocation did not recur. No deformity of the nose resulted.

A similar case recently came under my observation. A young lady, twenty two years of age, was thrown from her carriage, striking on the right side of her face, injuring the nose quite severely. There was considerable swelling of the nose, but no crepitation and no fracture of the bones of the nose could be detected The patient was very ill for a short time as a result of the accident, and it was feared that concussion of the brain bad taken place. On her recovery, both nasal bones were found dislocated to the left and the nose was quite crooked ; the right nasal bone was depressed, while the left nasal bone was thrown outward and upward, overriding the right, as shown in Fig. 640, forming a hump on that side. As the accident occurred four years before I saw her deformity was permanent, but was corrected by me according to the methods that will be described in the section relating to deformities of the nose.

In another case, a little girl about five years old, while coasting, was thrown from her sled, striking her nose against the edge of an iron railing, which drove the central portion of the nasal bones backward, dislocating them outward and leaving the nose in a flattened condition. Before surgical aid was secured the swelling of the nose so masked the injury that it was allowed to go uncared for. This resulted in a permanent flattening of the central portion of the nose and a bulging outward of the nasal bones.

Dislocation of the bones of the nose can readily be detected, first, by the deformity of the nose, and secondly, by the elevation of the dislocated edges, which can be felt as a ridge under the finger. The amount of dislocation varies usually with the amount of force exerted against the nose. There may be simple dislocation of one of the nasal bones, or all the various bones of the nose may be more or less dislocated to one side. In these cases the dislocation to one side is usually associated with fracture of the other, as shown in Fig. 640, against which the impinging force came. In some instances the cribriform plate of the ethmoid is fractured, and may be driven upward into the base of the brain.

Treatment. The reduction of dislocations of the nasal bone is most easily accomplished by placing a smooth sound in the interior of the nose, and by gentle manipulation with the finger on the outside the bone can ordinarily be slipped into place. In some cases, especially if the nostril is large, the little finger can be passed into the nasal chamber and the depressed bones elevated, as. in case of fracture of the nose. In this manner, with the thumb or finger on the outside of the nose, the dislocation can be reduced with great precision, as we are enabled by the sense of touch to detect the exact position of the bones. Usually there is no tendency for the dislocation to recur, owing to the lack of muscular tension on the part; but it is far better to apply a retentive apparatus to guard against such a possibility. This is best done by covering the whole of the nose with a piece of adhesive plaster, cut to fit, and by placing on the outside an aluminum form of the proper size and shape for the requirements of the nose, according to the plan described for the retention of fractured nasal bones. This is to be worn a short time, until the inflammation and swelling have subsided and the bones are firmly fixed in position.

Dislocations of the cartilages of the nose may be divided into dislocation of the external cartilages of the nose and dislocation of the internal or triangular cartilage forming the anterior portion of the septum.

(a) Dislocation of the external cartilages of the nose usually takes place from blows inflicted on the dorsum. of the nose. Owing to their elasticity and firm attachment the shield cartilages are rarely dislocated, but the upper lateral cartilages filling the dorsum of the nose are more subject to injuries and more frequently dislocated. Owing to the smallness of these cartilages and the swelling which masks the injury the dislocation frequently passes unnoticed until it is recognized by the depression of the dorsum of the nose, after recovery from the injury, as shown in Fig. 648. This accident can be recognized and properly treated only direct] after its occurrence and before swelling of the soft parts takes place, when the depression and the lack of support of the dorsum of the nose can be readily detected. The cartilage can then be forced into place and held there by gauze packed into the interior of the Dose at this point, supported by the spring described on page 1122, Fig. 644, together with adhesive plaster applied to the exterior of the nose.

(b) Dislocation of the triangular cartilage of the septum is of frequent occurrence. It takes place most often in children as the result of a fall upon the nose. In older persons it may result from a fall, blows upon the nose, or various accidents. The dislocation most frequently found is that at the juncture of the triangular cartilage with the perpendicular plate of the ethmoid. It consists in the sliding backward of the cartilage to the side of the bone, giving the septum the appearance of being deflected to that side, as shown in Fig. 647. Since the posterior portion of the. cartilage is thrown to one side, the anterior portion is naturally turned in the opposite direction, so that both nostrils are obstructed. There is often also dislocation of the lower border of the cartilage at its junction with the vomer, and also of the vomer at its juncture with the superior maxilla, projecting into the meatus on the side on which the dislocation takes place. This condition is readily detected by anterior rhinoscopic examination, and should be differentiated from ecchondrosis and other pathological conditions which frequently obstruct the nostrils. It is also readily seen that the convexity on one side is proportionate to the concavity on' the opposite side. The perpendicular plate of the ethmoid is very often deflected to one side, together with the triangular cartilage: but its dislocation alone can only result from great external violence or from foreign bodies penetrating the nasal chamber.

Treatment. This dislocation, if recent, can easily be put into place with the fingers, one finger being, inserted in each nostril and the parts held there by a tampon placed in the nostril into which the dislocation took place. In other cases the dislocation may be reduced by the use of a smooth bladed dressin forceps, or the blades of an ordinary Forceps covered with adhesive plaster to prevent wounding the soft parts. When the dislocation has become firmly fixed it can only be reduced by loosening the cartilage along its lower and posterior border. The parts are then forcibly put into position, and held there by a retentive apparatus. The success of the operation depends entirely upon the thoroughness with which the cartilage is loosened from its attachments, thereby preventing the tendency to return to its former position. In some cases it may be expedient to dissect out any redundant cartilage through a small incision made in the overlying tissue, reuniting the edges with fine sutures.

FOREIGN BODIES IN THE AIR PASSAGES AND ESOPHAGUS.

Foreign Bodies in the Nose. Foreign bodies found in the nose may be either animate or inanimate. They may be introduced from without or formed within the nose, as in the case of calcareous concretions termed rhinoliths.

Animate foreign bodies, such as leeches, flies, worms, etc., sometimes find their way into the nasal cavity; and other living creatures, such as maggots, may develop from the ova of flies deposited there; this more frequently occurs in tropical countries.

Inanimate foreign bodies may enter through the anterior nares, through the posterior nares, or through the walls of the nose.

Those that enter the anterior nares are chiefly such substances as beads, peas, stones, buttons, fruit stones, pieces of wood, coins, and, in fact, nearly every substance that it is possible to crowd into the nostrils may sometimes be found there. They are, however, usually introduced intentionally by mischievous children, lunatics, or hysterical women.

Substances that enter through the posterior nares are generally such as teeth, rings, fruit stones, pieces of bone, etc., which have previously been swallowed and afterward expelled from the stomach and thrown forcibly into the nares during emesis. Substances, such as pieces of cotton and portions of sponges left after plugging the posterior nares, are sometimes found there acting as foreign bodies.

Foreign bodies that enter through the wall of the nose are usually spent bullets, fragments of stone from blasting, or of iron from the bursting of guns. Splinters of wood forced through the walls of the nose have been extracted from the nasal cavity.

Symptoms. There is usually a more or less profuse sero mucous discharge from the nose, or if ulceration has taken place the discharge becomes muco purulent and bloody, and is more or less fetid. There is also more or less obstruction, according to the size of the body, and a swollen condition of the mucous membrane, sometimes attended by frequent attacks of sneezing and neuralgic pains of the face. In the case of peas, beans, etc., much presstire may be caused by the swelling of the body, and sometimes germination takes place.

Living bodies, such as maggots, termed in India “peenash," cause intense pain in the nose and frontal region, of a throbbing character, attended by a sensation of formication. There is swelling and edema of the face, eyelids, and palate, and epistaxis is usually present. Abscesses may form in the nose and destruction of bone may take place, leading to meningitis.

The diagnosis of foreign bodies in the nose is usually not difficult. If there is no history of the accident, which at best is unreliable, the occurrence of a unilateral fetid discharge from the nose should lead us to suspect the presence of a foreign body, especially in children. In adults it must be differentiated from syphilis and from disease of an accessory sinus, from which the discharge is almost always unilateral, and from sarcoma or carcinoma. If it is large and located in the anterior portion of the nose, a foreign body may be suspected by a bulging of the ala.

The question can ordinarily be very easily decided with the probe. In children a few whiffs of chloroform are advisable to quiet their fears; but in adults the use of cocain is all that is necessary, both for diagnosis and extraction. The treatment of foreign bodies in the nose consists simply in their removal, although, as Mackenzie observes, there is no occasion for undue haste. Before this is attempted, therefore, their nature, situation, size, and fixedness should be determined. Animate foreign bodies, such as insects and maggots, are best removed with chloroform. In fact, chloroform is the only effectual remedy. It should be diluted one half with water, on account of the pain caused in using it full strength. It is then agitated and injected at once before the water and chloroform separate. This was discovered by Dauzat, an apothecary's assistant in Mexico, in the year 1805. The vapor alone will sometimes cause a discharge of the maggots. If necessary to use it full strength, the dilution being ineffectual, general anesthesia should previously be produced with the vapor, as suggested by Mackenzie, to prevent the intense suffering.

Inanimate foreign bodies when lying somewhat loosely in the cavity are readily extracted with a pair of mouse toothed forceps; but when more or less embedded in the tissues they should be carefully raised from their bed by a suitably curved probe. Sometimes the use of stern utatories, a forcible blowing of the nose, or the use of Politzer's bag in the opposite nostril will cause the foreign body to be expelled. In some cases the method of Sajous will succeed where others have failed, which is by drawing a cotton or wool tampon through the nasal passage from behind.

When a foreign body is impacted in the nose it may be necessary to break it up by means of strong forceps, or by sawing it in two, or by drilling it.

When a foreign body is lodged in the posterior nares it can generally be forced down into the pharynx with a sound introduced through the nose, care being taken that it is not inhaled into the larynx or trachea, or swallowed.

Rhinoliths, or Nasal Calculi These consist in the deposition of the salts of the secretions of the nasal passage , forming more or less solid bodies, usually having for their nucleus some foreign substance which has been introduced from without. Occasionally they form around some inspissated secretion, favored by a gouty diathesis they enlarge slowly by accretion of the earthy salts to the surface, being composed mainly of phosphate of lime and magnesia, or chlorid of sodium, carbonate of lime, magnesium and sodium. They may attain considerable proportions, completely filling the naris, sometimes distending it like a foreign growth. From one patient I removed a rhinolith weighing 40 grains, having for its nucleus a small pledget of cotton. They are usually single, though in some cases there may be two or more. They are almost invariably unilateral. Their slowness of growth and the absence of history of the introduction of a foreign substance may cause them to remain undetected for a considerable period, the discharge, as in the ease I have mentioned above, being regarded simply as catarrhal. The condition with which they might most easily be confounded is necrosis of the bones of the nose as a result of syphilis.

Their attending symptoms, diagnosis, and treatment are practically the same as that of an inorganic foreign body in the nose, with which they are to be classed.

Foreign Bodies in the Larynx and Trachea. Foreign bodies entering the air passages may be either fluid or solid. Fluid foreign bodies comprise articles of liquid food and drink, pus from a ruptured tonsillar, retropharyngeal, or aryteno epiglottic abscess, blood entering during surgical operations or after an injury, and chyme or other vomited matter.

Solid foreign bodies comprise almost every conceivable substance that can possibly enter or pass through the larynx, and include both animate and inanimate bodies.

Among the most curious and interesting cases of animate bodies may be mentioned fish, held in the teeth during extraction of the hook, leeches entering while drinking water from pools or brooks, lumbricoids transferred from other parts of the body, flies inhaled while riding through them, and the epiglottis of a young woman which became impacted in the larynx while eating. The inanimate bodies that most frequently enter the air passages are fruit stones, pebbles, grains of corn, beans, coins, buttons, and the like.

The mode of entrance of foreign bodies may be either through the mouth, through the Deck or chest walls by fistulous openings, or from other portions of the body.

The entrance of substances into the air passages through the month generally occurs during mastication and deglutition, while the person is laughing or talking, or during sleep. Many cases of sudden death are reported where large pieces of meat or other substances have entered the larynx while eating, and caused immediate death from strangulation. Substances held in the mouth are sometimes suddenly drawn into the larynx while laughing or during a fright, or during any condition which causes a sudden inspiration. Such substances as blowgun darts, whistles, and the like are sometimes drawn into the larynx while the person is amusing himself with these substances. In some instances the substance becomes lodged in the pharynx during sleep. This occurs most often in children who go to sleep with toys, Coins, buttons, etc., in their mouths. One of the most interesting cases of this kind is reported by Johnston, where a toy locomotive was inhaled into the larynx of a child during sleep, requiring thyrotomy for its extraction (Fig. 649).

In adults one of the most frequent substances to enter the larynx is a tooth plate which has not been removed before retiring. Schwetter reports a case where the patient was not aware of the accident until he missed his teeth in tile morning. Corks held between the teeth during the administra¬tion of f anesthetics, and sponges used about the mouth during operations, have been drawn into tile larynx.

Substances entering through the neck or chest walls are most frequently flying fragments from explosions, bullets, and other projectiles; and portions of ill constructed tracheotomy tubes, not properly cared for and allowed to corrode, may become detached and fall into the trachea.

Substances lodged in the esophagus may ulcerate through into the trachea or pass into it through fistulous openings. Bronchial glands have also ulcerated through into the trachea and acted as foreign bodies.

The location and position of a foreign body depends much upon its size and shape. Sharp, penetrating objects are frequently found sticking in the supraglottic portion of the larynx. Large alimentary substances or angular bodies are usually found in the larynx. Flat bodies, such as coins and buttons, are usually found in the ventricles of the larynx; while small, round, and heavy bodies commonly descend into the trachea. Small bodies that enter the bronchi usually enter the right one, since the bronchial septum is on the left side of the median line, as first pointed out by Goodell of Dublin, as shown in Fig. 650. Of 98 cases collected by the writer, 58 were found to be in the right bronchus and 36 in the left. Of 156 cases, Bourdillet found that the foreign body was arrested in the larynx 35, in the trachea 80, in the right bronchus 28, and in the left bronchus 15 times.

Substances lodged in the trachea change their position more often than those in the larynx. Sometimes they play up and down, as in the case reported by Glasgow, where a toy balloon, which bad entered the trachea, moved up and down with each inspiration. Physical changes also take place in the foreign body. Mineral substances usually become more or less corroded. Corks, beans, grains of corn, and other dry substances absorb moisture and swell sometimes to double their original size, and in some instances seeds have been known to germinate in the air passages.

The symptoms of foreign bodies in the larynx vary from complete and instantaneous suffocation, as in the case of an impaction of a mass of meat, to an almost complete absence of manifestations, as in the case of small or smooth, non irritating substances.

The usual symptoms attending the lodgement of foreign bodies in the larynx are those of sudden choking, cough, and efforts at dislodging the substances. When the breathing is materially interfered with the patient often becomes excited and alarmed, and makes frantic efforts to obtain air. He grasps his throat, his eyes protrude, and his face becomes livid from the lack of oxygenation of the air.

Frequently these symptoms are occasioned only by the spasm of the larynx excited by the presence of the foreign body, and soon subside. In cases, however, due to mechanical obstruction, these symptoms continue until death ensues.

Small, sharp bodies, such as fish bones, pins, needles, and the like, which usually penetrate the upper portion of the larynx, excite more or less cough and cause much discomfort on swallowing.

Substances lodged in the larynx, but lying in such a position as not to obstruct respiration, are attended with more or less hoarseness and coughing, as in the case of coins, and in some instances tooth plates. These cause active symptoms only after congestion or inflammation has taken place.

Smooth, round bodies cause little irritation; while sharp or angular bodies cause inflammatory symptoms.

Foreign bodies finding their way into the trachea are usually manifested by a cough, dyspnea, and efforts at expulsion. If the dyspnea is continuous, it indicates that the foreign body has become impacted in the trachea or a bronchus ; if intermittent, that it is movable in the trachea; if there is collapse of one lung, that it occupies one of the bronchi ; or if there is interlobular emphysema of the lung, that there is laceration Of some portion of the air passages. Pain is almost always present, and may clearly indicate the location of the foreign body.

Sometimes the presence of the foreign body is manifested by frequent hemorrhages, emaciation, and all of the symptoms of phthisis, which cease on the expulsion or removal of the foreign body.

When a foreign body has been retained for a length of time, there is usually more or less fetor of the breath from decomposition of the foreign body or of the retained secretions. Frequently disease of the bronchi or pulmonary structure intervenes, and sometime , pericardial, mediastinal, or hepatic abscesses have resulted from ulceration and the extension of the inflammation to the surrounding structures.

The diagnosis of the case is greatly facilitated by the history of the accident. When there is no history, as in a case where the foreign body has entered during a period of unconsciousness, as in an epileptic seizure or sleep, reliance must be placed upon the physical examination. A laryngoscopic examination can be usually made. In the case of a “Punch and Judy” whistle' lodged in the lower part of the trachea of a boy eight years old, it was readily discovered. By the author by the aid of the laryngoscopic mirror. When a laryngoscopic examination cannot be made the larynx can be explored with the finger; and when in the trachea, auscultation will frequently reveal the presence and location of the body if a whistle, by a whistling sound, and if movable, by a "flapping noise" or Zwinger's " chattering bruit." When the air is excluded from one lung by reason of an obstruction of a bronchus, if it is in the right bronchus the lower lobe will be affected; while if in the left bronchus the entrance of air to the whole lung will be obstructed.

When the nature and location of the foreign body cannot readily be determined the X rays should be employed, for they may not only locate the substance, but also materially assist in its extraction by showing its form and position.

Dyspnea caused by a foreign body lodged in a bronchus is sometimes mistaken for a foreign body in the trachea; and in a case where death was almost instantaneous from the blocking of the larynx, the death might be attributed to epilepsy or apoplexy.

The prognosis of foreign bodies in the trachea is always more or less scrious. When death does not take place from suffocation serious inflammatory disturbance may arise, or there may be a sudden change of position of the foreign body, either in the larynx or trachea, which at any time may cause a fatal result. Small, smooth, non irritating bodies rarely produce serious results, and are almost always expelled spontaneously; whereas sharp, angular or pointed bodies, even though suffocation be not imminent, should be removed as soon as possible.

The general consensus of opinion of surgeons is that no foreign bodies should be allowed to remain any length of time in the air passages without the operation of bronchotomy. On the other hand, Weiss, from a collection of 1000 cases, mostly those reported to him privately, concludes that when the trachea and bronchus contain a foreign body, the patient will be more liable to recover if trusted to spontaneous expulsion. The statistics on this point are not of special value, for many patients die from suffocation who would have been saved by an operation, and many die after the operation when the foreign body might have been expelled spontaneously with recovery.

Substances entering the air passages are usually expelled through the opening by which they entered, although in many instances, like bullets, beads of grain, etc., they have entered through the chest or the esophagus and have been expelled through the trachea. In other instances substances like heads of grain have entered through the larynx and trachea and were expelled through abscesses of the chest wall.

Treatment. The first and most important indication is the removal of the foreign body; but the method of removal will depend largely upon its nature and location.

Expulsion through the natural passages is facilitated by the use of a little chloroform to allay the excitability of the patient and the irritability of the parts occasioned by the presence of the foreign body. Among the natural aids are the various expulsive efforts, such as sneezing, coughing, vomiting; and by inversion, aided by percussion and circussion of the chest. The use of the sternutatories and emetics, tickling the nose with a feather to promote sneezing, and of the throat to produce vomiting, have been employed from the earliest times. But little reliance, however, can be placed upon these methods.

In the case of movable bodies, such as coins, bullets, and similar weighty substances, inversion of the body will sometimes cause the immediate expulsion of the substance. The danger with which some regard this method from the impaction of the substance in the larynx is largely imaginary, for no case is reported where death has resulted. Of several methods of inversion the best is that described by Padley of Swansea: The patient is directed to sit on the elevated end of a bench, with his knees flexed over the end. He then lies backward on the inclined plane thus formed, and the coin drops into the mouth. Danger of spasm or impaction in the larynx is avoided by the ability of the patient to at once assume the upright position. The patient should inspire deeply and avoid speaking. A blow or slap on the chest will sometimes aid in the expulsion of a coin.

In the case of animate bodies lodged in the larynx, such as leeches and the like, they are best dislodged by swallowing turpentine or chlorid of sodium.

In some cases the introduction of an O'Dwyer tube is temporarily necessary to prevent suffocation from impaction or spasm of the larynx.

Extraction through the Natural Passages. This should be done with the guidance of the laryngeal mirror; when this is not possible the instrument can be guided with the index finger, as in the introduction of the O'Dwyer tube ( see page 1030). When the foreign body occupies the supraglottic portion of the larynx, Cusco's lever blade forceps or Mackenzie's angular forceps are the most serviceable; but when in the subglottic portion of the larynx or in the trachea, Seiler's or Mackenzie's (Fig. 651) tube forceps are the best. Mackenzie's tube forceps with the blade having a lateral grasp are especially serviceable for the removal of coins impacted in the larynx. Fig. 652 represents the well known case in which Grazzi removed from the larynx a two centesimi piece in this manner. Some rough or angular bodies lie between the vocal cords. It is not advisable to remove them through the larynx if there is danger of lacerating the larynx sufficiently to impair the voice permanently. Sometimes the removal can be accomplished only after the swelling has subsided under appropriate treatment.

When the foreign body is so located or impacted that it cannot be expelled or extracted through the natural passages, artificial openings must be resorted to. The various operations that are frequently called for are governed by the location of the foreign body; if in the larynx, thyrotomy or crico thyroid laryngotomy, or if in the lower part of the larynx, laryngo tracheotomy or tracheotomy; if in the trachea or bronchi, low tracheotomy.

When the trachea is opened the foreign body may be expelled either through the larynx or the tracheal opening, or it may be thrown up into the upper part of the trachea so as to be readily grasped with a pair of forceps. If the substance is in the larynx, it can now be more readily extracted, or it may be forced out of the larynx from below with a sound; or a piece of silk may be passed down from the mouth and a piece of sponge drawn up through the larynx from below.

Expulsion from the trachea is aided by turning on the face, inversion, succussion, and blowing into the trachea, or tickling it with a feather to excite cough.

The tracheal wound should be held widely open with suitable refractors such as Laborde's (Fig. 654), Golding Bird's (Fig. 655), or Minor's retractor.

If the foreign body is not immediately expelled, Wythe 's plan of stitching the edges of the tracheal wound to the integument is an excellent scheme to afford ready exit for the foreign body at any time. No tracheal cannula, of course, should be introduced. When the body is not expelled at once, it should be extracted by suitable instruments. Roe's tracheal forceps (Fig. 656), the stem being made of copper, so that it can be bent into any required position for reaching into a bronchus, is especially suitable. Gross's and Cohen's tracheal forceps are also serviceable instruments. Sometimes the position of the body can be ascertained by reflecting light, or tracheoscopy, and removed or dislodged with a hook made of a silver probe by bending up the end, and extracting with the aid of the finger.

Attempts at extraction should not be sufficiently prolonged to cause irritation of the part or exhaustion of the patient. We should rather wait for loosening and expulsion to take place. When this loosening does not take place and removal of the body must be effected, the operation of bronchotomy through the chest walls, as suggested by Quenu and Figueira, or the plan of reaching the bronchi through an opening in the chest wall from behind, by incising the third to sixth dorsal vertebrae, as proposed by Nesiloff, is to be considered.

Foreign Bodies in the Pharynx and Esophagus. Foreign substances of almost ever variety have been found in the pharynx and esophagus. They may enter through the mouth or through the neck, as in the case of gunshot wounds or the substance may be thrown up from the stomach and impacted in the esophagus.

Foreign bodies in the esophagus are usually arrested in the middle third where it is crossed by the left bronchus, or at the cardiac extremity, which is the narrowest portion of the tube.

Many pathological conditions favor the lodgement of foreign bodies in the pharynx and esophagus, such as inflammatory affections, diseased conditions of the tongue, tonsils, pharynx, larynx, and esophagus, which interfere with deglutition and induce the sudden bolting of food in large quantities.

Substances carelessly placed in the mouth frequently become lodged in the throat, and during sleep tooth plates and other substances often drop into the throat and become impacted in the esophagus; in some instances this takes place without the knowledge of the patient.

The symptoms attending the lodgement of foreign bodies in the pharynx and esophagus are usually dyspnea, laryngeal spasm, dysphagia, and pain in the region of the impaction.

Sometimes the dyspnea from the pressure of the foreign substance on the trachea is so great that it simulates the lodgement of a foreign body in the trachea or larynx. In nervous and excitable people the lodgement of such bodies in the throat or esophagus is sometimes purely imaginary, although all the symptoms of their presence are produced. In other instances foreign bodies have remained in the esophagus for years, entirely unsuspected, the disturbance caused by them being attributed to other causes. A pouch or diverticulum on one side of the esophagus will sometimes form for their lodgement, leaving the passage free, and sometimes they become encysted. Fig. 657 represents a tooth plate lodged in a diverticulum in the esophagus for nearly two years. Its presence was suspected, but it could not be detected during life.

Sharp and slender substances, such as pins, needles, heads of grain, may pass through the walls of the esophagus, migrate to other parts, and emerge through an abscess. Foreign bodies, however, that remain for any length of time frequently produce the death of the patient or alarming conditions, such as edema of the larynx, abscesses, ulceration and stricture of the esophagus, perforation or rupture of the walls of the esophagus, penetration of the pericardium, the heart, the pleural cavity, larynx, and trachea, or caries of the vertebra .

Diagnosis. Foreign bodies lodged in the pharynx and upper part of the esophagus may be detected by inspection of the neck, if the substance is sufficiently large to give it a bulging appearance, by laryngoscopic examination, by palpation with the finger, and by exploration with sounds or by the X rays.

In the lower part of' the esophagus the foreign body can be detected with the sound and by auscultation of the esophagus over the back during deglutition, where a peculiar gurgling sound is heard at the location of the foreign body.

The esophagus can also be inspected by means of Mackenzie's esophagoscope, or it can be electrically illuminated by Mikulicz's esophagoscope. Duplay's resonator is especially serviceable for the detection of metallic substances. The sound, having a metallic tube, is attached to the hollow metallic cylinder, from which the sound 'is conducted to the ear. The striking of the metallic end of the bougie against the metallic substance is so magnified that the slightest touch can be detected.

Treatment. Foreign bodies are removed from the pharynx and esophagus, first, through expulsion by natural means, as coughing, vomiting, and artificial digestion; second, by extraction bv moans of forceps, hooks, rings, and dilating probangs; third, by propulsion' with the sponge probang or by crushing the substance so that it will pass forward; fourth, by incision by pharyngotomy or esophagotomy.

The employment of emetics is not only ill advised but sometimes dangerous, owing to the liability of rupturing the esophagus or of lacerating it during expulsion in ease of sharp angular bodies. When small bodies are impacted it has been proposed that milk he ingested, and as soon as it has had time to form a firm curd be ejected by the action of a prompt emetic, so that it may sweep away the intruder. On the other band, soft, bulky food, like oatmeal, may be swallowed in the endeavor to sweep on the foreign substance, and such food should always be freely given after tooth plates and such bodies have entered the stomach.

For the removal of substances from the pharynx and upper part of the esophagus Fauvel's forceps (Fig. 658) and Bond's forceps (Fig. 660), as modified by the author, having a very narrow biting surface, are especially serviceable instruments. Moe's flexible stem forceps (Fig. 661) are especially adapted for removing substances from the lower part of the esophagus.

Roe's flexible spiral lever extractor (Fig. 662) and Graefe's ring coin catcher are most useful for removing coins, metallic disks, and similar substances.

Gross's bristle umbrella probang (Fig. 663), inserted beyond the foreign body while closed and then expanded before withdrawal, is an excellent instrument for general use, and is adapted for the extraction of a variety of small substances, such as fish bones, pins, and the like.

A great many different devices are often required for the removal of different substances, as Baud and Leroy devised passing drilled lead balls over the string to dislodge fish hooks and to protect the esophagus from the sharp ends during extraction.

In numerous instances similar ingenious devices have been resorted to for the extraction of different substances. In every ease, however, great care should be taken not to irritate or lacerate or Bruise the esophagus with the bite of the forceps or by the employment of too much force in extraction, lest serious inflammation be excited.

When a foreign body has become so firmly impacted in the pharynx or the upper part of the esophagus that it cannot be extracted per vias naturales, the operation of pharyngotomy or esophagotomy should be resorted to without delay. The rule laid down by Fisher is a safe one to follow viz. in every case in which the foreign body cannot be removed within twenty four hours after it has been impacted in the esophagus, external operations should be performed to obviate the danger of fatal internal complication.

Injuries and deformities of the pharynx and lower air passages are not of frequent occurrence in forms that need special consideration here. Wounds, whether of cut throat or other character, rather fall in the province of the general surgeon, except as inflicted by foreign bodies or laryngological surgery when they concerti the laryngologist largely as causes of severe and dangerous inflammation or edema. The latter condition sometimes ends fatally in the cachectic after the most trivial injuries, as in v. Ziemssen's case of a consumptive dying almost instantly after a prick of his ventricular band by a bit of inhaled tobacco leaf. Scalds or other burns of the throat, most commonly from the swallowing of caustic substances, may also require a prompt opening of the air passages in order to prevent suffocation, and prolonged antiphlogistic treatment to allay the inflammation excited, with ultimate operation to relieve the resulting stenosis.

Fracture of the larynx, generally of the exposed rostrum of the thyroid, as in cases reported by the author,' is occasionally seen, with not infrequently fatal result; while a cornu of the thyroid has at times been fractured by a blow or throttling pressure and dislocated inward, to be conspicuous in the supraglottic larynx cavity.

Stenosis of the larynx from pachydermia, trauma, or syphilitic cicatrisation may demand dilatation with the laryngeal catheter or such instruments as the author's forceps ( see page 1209).

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