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Full text of "Operative surgery of the nose, throat, and ear, for laryngologists, rhinologists, otologists, and surgeons"

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Joseph C. Beck, M.D., R. Bishop Canfield, M.D., George W. Crile. M.D.. Eugene A. Crockett, M.D.. William 

H. Haskin, M.D., Robert Levy, M.D., Harris P. Mosher, M.D., George L. Richards, M.D.. 

George E. Shambaugh, M.D., and Georse B. Wood. M.D. 







COPYRIGHT, 191-4. 

(All Kit/lit* AVxr /TCI/.) 


This work was undertaken at the suggestion of many colleagues, 
with no little misgiving- on the part oi' the author. To lighten the 
burden and to make the publication more effective, it was divided among 
collaborators who were specially qualified i'or the assignee I topic.-. 

The endeavor has been to present the operative surgery of the 
nose, throat and ear, unaccompanied by any discussion of pathology, 
etiology or symptomatology. The method of operating, the indica- 
tions, the contraindications, after-treatment and results have been 
considered paramount for the purposes of this work. 

The illustrations are practically all original, the majority of them 
being 1 drawn expressly for this work. They are planned to make the 
text clear without too great a sacrifice of detail. 

The first volume deals with the more general subjects, such as 
the surgical anatomy of the nose, throat and ear, the external surgery 
of the throat, the direct examination of the larynx, trachea, bronchi, 
esophagus and stomach, and the operations made possible through 
its agency, and the plastic surgery of the nose and ear. 

Volume IT is to he devoted to the more specialized surgery of 
the nasal cavities, the pharynx and larynx, which has been developed 
during the years of laryngologic and otologic activity, since the laryn- 
goscope was devised. 

(irateful acknowledgment is here made to the many who have 
by their efforts, advice and encouragement rendered this publication 
possible, to Mr. A. Schwitalla, S. ,1., who was of great assistance in 
reviewing the text, to the collaborators, and to the publishers, whose 
patience has been most commendable. 

n. w. L. 


Professor of Otology, Rhinology and Laryngology, University of Illinois. 


Professor of Surgery, Western Reserve University. 

IIAXAT \V. LOEIi. M. 1).. ST. Louis. 
Professor of Ear, Nose and Throat Diseases, St. Louis University. 

Assistant Professor of Laryngology, Harvard Medical School. 

Associate Professor of Laryngology and Otology, Rush Medical College. 



r o \ T K N r s. 

(MIA I'T E K I. 


External Xose i 

Xasal Cavities >, 

Floor of the Nose Septum Nasi Roof of the Nose External Wall of the Xosc 
The Choamr. 

Accessory Sinuses of the Xose 11 

Frontal Sinus Maxillary Sinus Ethmoid Cells Sphenoid Sinus. 

Variations of the Sinuses in Size and Shape :!n 

Frontal Sinus Maxillary Sinus Ethmoid Cells Ethmoid Labyrinth Ante- 
rior Ethmoid Cells Posterior Ethmoid Cells Sphenoid Sinus. 

Superficial Area and Cubical Capacity of the Sinuses :\f, 

Optic Chiasm and Nerve 4u 

Xasolacrimal Duct 50 

I lypophysis ( Pituitary Body ) f,U 

Vascular Supply .'!' 

Arteries Veins. 

ImnTvation ~,'.\ 

Sympathetic System. 



Xasopharynx ."> 

Pharyngeal Tonsil. 

Oropharynx fiH 

Palatal or Faucial Tonsil Pillars and Lateral and Posterior Walls. 

Laryngopharynx 63 

Lymphatics of the Pharynx 64 

Nerves of the Pharynx 6~> 

Structures of the Pharyngeal Wall 66 

Superior Constrictor Muscle Middle Constrictor Muscle Inferior Constrictor 
Muscle Palatopharyngeal Muscle Stylopharyngeus Muscle Palatoglossus 
Muscle Azygos Uvula 1 Muscle Levator Palati Muscle Tensor Palati Muscle. 


Superior Division 7n 

Ventricular Bands. 

Middle Division 

Inferior Division 

Cartilages of the Larynx 71 

Cricoid Cartilage Arytenoicl Cartilages Thyroid Cartilage Epiglottic Car- 
tilage Lesser Cartilages. 



Articulations and Ligaments of the Larynx ..................................... 73 

Joints C'ricothyroid .Membrane Thyrohyoid Membrane Inferior Thyroary- 
tenoid Ligament Superior Thyroarytenoid Ligament Ligaments of the Epi- 

Muscles of the Larynx ......................................................... 75 

Cricothyroid Muscle Posterior Cricoarytenoid Muscle Arytenoid Muscle 
Lateral Cricoarytenoid Musclt Thyroarytenoid Muscle External Thyroary- 
tenoid Muscle Thyroepiglottic Muscle Internal Thyroarytenoid Muscle 
Action of the Muscles. 

Nerve Supply of the Larynx .................................................... 79 

Superior Laryngeal Nerve Internal Laryngeal Nerve External Laryngeal 
Nerve Recurrent or Inferior Laryngeal Nerve. 


Lymphatic System of the Neck .................................................. 79 

Suboccipital Group of Glands Mastoid Group Parotid Group Subparotid 
Glands Submaxillary Group Facial Glands Submental Group Retrophar- 
yngeal Group Descending Cervical Chain of Lymph Nodes Accessory or Su- 
perficial Descending Cervical Chain Supraclavicular Group of Lymph Glands. 


Topographic 1 Anatomy of the Anterior Cervical Triangle ......................... 85 

Sternocleidomastoid Muscle Submaxillary Salivary Gland Digastric Muscle 
Stylohyoid Muscle Facial Nerve Internal Jugular Vein Hypoglossal 
Nerve Common Carotid Artery Omohyoid Muscle External Carotid Artery 
-Superior Thyroid Artery Ascending Pharyngeal Artery Lingual Artery 
Facial Artery Occipital Artery Posterior Auricular Artery Internal Max- 
illary Artery Superficial Temporal Artery Internal Carotid Artery Pnen- 
mogastric or Vagus Nerve Superior Laryngeal Nerve Recurrent or Inferior 
Laryngeal Nerve Spinal Accessory Nerve Glossopharyngeal Nerve Pharyn- 
u-al Plexus. 



Introduction ................................................................. ( .i|t 

Development of the Temporal Hone ............................................. '.Hi 

Meat us Auditonus Externus ................................................... 102 

I'roce.ssus Mustoidcus ......................................................... 1<>S 

' 'a v ti m Tympani ............................................................... lit! 



Special I >i flic ult je S and Dangers ................................................ ll.'5 

Pneiniinnia Local Infection Mediastinal Abscess Vagit is Reflex Inhibition 
'i 'In- Heart ami Respiration Through Mechanical Stimulation of the Superior 
Laryimcal Nerves Selection and Care of Trach"al Cannula. 
Operations on the Trachea .................................................. i:!n 

Kiner;v ncv Tracheotomy Planned Tracheotomy - - Tracheal 
lei care dt the I'aii'iit Closure of a Tracheotomy Cicatricial Steno- 

c<>. \TK\TS. 

Surgery of the Larynx ................................................... ] ;;x 

Laryngectomy for Intrinsic Cancer Anesthetic in Laryngectomy - Technic of 
Laryngectomy Extrinsic Cancer of the Larynx Stenosis of the Larynx. 

Surgery of the Pharynx and Esophagus ......................................... 1 4S 

Cancer of the Pharynx and Esophagus Excision of the Tonsil for Cancer 
Cancer of the Pillars Stenosis of the Pharynx Esophagostoiny- Cancer of 
the Esophagus Diverticula of the Esophagus. 




General Considerations ........................................................ \~\~, 

Historical Contraindications Choice of the Anesthetic Cocainization Dif- 
ficulties of the Examination. 

Method of Making the Direct Examination ...................................... ir>8 

Passing the Speculum from the Corner of the Mouth Direct Examination with 
Counter Pressure Direct Examination Under Ether Instruments for Direct 
Examination Inhalation of Oxygen. 

Suspension Laryngoscopy ...................................................... 167 


r,ower Tracheobronchoscopy ................................................... 17" 

Contraindications to Lower Tracheobronchoscopy Anesthesia Position of the 
Patient Method of the Examination The Endoscopic Picture Interpretation 
of the Endoscopic Picture Choice of the Upper or Lower Route Dangt rs of 
Bronchoscopy Asepsis Size of the Tubes. 


Lower Bronchoscopy ........................................................... IS' 1 

Upper Bronchoscopy ........................................................... 1S7 

Anesthesia Method of Performing Upper Bronchoscopy Introduction of the 

Bronchoscope with the Patient Lying on His Back Upper Bronchoscopy with 

the Jackson Tubular Speculum and the Jackson Bronchoscope Introduction of 

the Bronchoscope with the Open Speculum. 
Examination in Children ............................................ IS'. 1 

Instruments Direct Laryngoscopy Method of Examination Lower Broncho- 

scopy Upper Bronchoscopy. 
Instruments for Bronchoscopy ........................................... 

Jackson Tubular Speculum Brunings' Elongating Bronchoscope Briinings' 

Elongating Forceps Batteries Aspirator for Removing Secretions Acquir- 

ing Skill. 
Direct Laryngoscopy for Diseased Conditions ........ 

Malignant Disease Non-Malignant Disease of the Larynx Tuberculosis of the 

Larynx Inflammatory Diseases Malformations of the Larynx, Congenital 

and Acquired. 
Retrograde Laryngoscopy ............. 

Tracheobronchoscopy in Diseases of Trachea and Bronchi. . 

Stenosis of the Trachea Treatment. 




Foreign Bodies in tin- Larynx -02 

Removal df Foreign Bodies from Trachea and Bronchi 203 

Choice of the Upper or Lower Route Indications Dangers Danger from 
Leaving Foreign Body Aloiu Results Symptoms Diagnosis Physical Signs 
Location Technic of Removing Foreign Bodies After-effects of Removal of 
Foreign Bodies. 


Esophagoscopy 210 

History Anatomy Structure Lymphatics Position Direction Diameter 
Length of Esophagus Distensibility Subphrenic Portion of the Esophagus 
Movements of the Esophagus Measurements of the Esophagus Contraindi- 
cations to Esophagoscopy Anesthesia Instruments General Examination of 
the Patient Technic of Esophagoscopy Under Cocain Anesthesia Position of 
the Patient Introduction of the Esophagoscope by Sight Introduction of the 
Esophagoscope by Means of a Flexible Mandarin or Bougie Introduction of 
the Esophagoscope 1'nder General Anesthesia Use of the Adjustable Speculum 
for Introduction of Esophagoscopo Passing the Jackson Esophagoscope by 
Sight Passing the Oval Tube by Sight Passing the Esophagoscope by Aid 
of a Mandarin or Flexible Bougie Appearance of the Normal Esophagus. 


Acute Inflammation 232 

Stenosis of Esophagus Due to Cicatrices 232 

Location of Strictures Diagnosis and Treatment of Esophageal Strictures 
Cases of Stricture Use of a Thread as a Guide in Esophageal Strictures 
After-care of Strictures of the Esophagus. 

Spastic Stenosis of the Esophagus 24n 

Esopliagospasm- Cardiospasm Phrenospasm. 

R<-nign New Growths of the Esophagus 247 

Treatment of Benign New Growths. 

Malignant New Growths of the Esophagus 24S 

\Mnptoms of Cancer of the Esophagus Diagnosis of Cancer of the Esophagus 
DiaLMiosis and Treatment of Cancel- of the Esophagus. 

i 'o m |>n s.-ion S teii ds is of the Esophagus 2"> 4 

I iif lam mat ion and Clcerat ion of the Esophagus 2f> 1 

Chronic Inflammation of the Esophagus- I'lceration of the Esophagus. 

leurosis of i he EsophaLMis LTitl 

Neurosis of the Esophagus Paralysis ;md Paresis of the Esophagus. 

uital Anomalii s of the Esophagus L'.'T 

Stricture of the Esophagus Divert iculuni. 
K ophagiiK 
in ili" E.--r ipl i at; us 

' Fon-k'Ji I'.odies Lodue Procedure to be Followed in Cases 

' : the Anesthetic Coins and Buttons in the Esoph- 
Pins in the Esopliagus Safely Pins in the Esopha- 




Gastroscopy ........................................................ L >71 

History Usefulness Instruments Technic of Gastroscopy Position of tin- 
Patient Passing the Gastroscope Area of the Stomach Which Can be Kx- 
plored Contraindications Dangers Difficulties. 

The Stomach as Seen Through the Gastroscope .................................. 276 

Normal Stomach Movements of the Stomach Gastritis Peptic Ulcer Malig- 
nant Diseases of the Stomach Gastroptosis and Gastrectasia. 



General Considerations ........................................................ 279 

History Important Factors Covering Defects Recording Cases Before, Dur- 
ing and After Correction. 


Rhinoplasty .................................................................. 288 

Classification of Nasal Deformities Method of Procedures in Nasal Deformi- 
ties and Malformations. 

Correction of Unilateral and Partial Deficiencies of the Nose ..................... 291 

Legg's Operation Koenig's Operation Von Esmarch's Operation Von Lan- 
genbeck's Operation Dieffenbach's Operation Von Esmarch's Operation 
Busch's Operation for Partial Loss of Tip and One Side of Nose Nelaton's 
Operation Syme's Operation. 

Correction of Total Loss ....................................................... 295 

Helferich's Operation (French Method). 
Correction of Sunken Bridge, Upturned Lobule or Tip, and Saddle-back .......... 298 

Roberts' Operation for Sunken Bridge with Upturned Lobule or Tip of Nose 

Roberts' Operation for Sunken Saddle-back Nose. 
Formation of a New Columella ................................................ 301 

Dieffenbach's Operation From the Dorsum of Nose (Hindoo Method) Lexer's 

Operation for Formation of Columella (from Mucous Membrane of the Upper 

Italian or Tagliacozzi's Method ................................................ 305 

Israel's Operation Dieffenbach's Operation Nelaton's Operation. 
Hindoo or Indian Method ...................................................... 310 

Thiersch's Operation for Total Loss of Nose Nelaton's Operation for Total 

Loss Koenig's Operation for Subtotal Loss Nelaton's Operation for Subtotal 

Loss Von Langenbeck's Operation for Collapsed Nose Schimmelbusch's Op- 

eration for Total Loss Schimmelbusch's Operation for Saddle-back Nose 

Sir Watson Cheyne's Operation Von Hacker's Operation Sedillot's Opera- 

tion for Total Loss. 
Double Transplantation Method ................................................ 

Steinthal's Operation for Total Loss Kausch's Operation for Collapsed Nose. 
Finger Method ................................................................ 

Watt's Operation for Subtotal Loss Wolkowitsch's Operation for Total Loss 

Von Esmarch's Operation for Collapsed Nose, Etc. 
Clavicle Method . 335 



Implantation Method 337 

Israel's Operation for Saddle-back Nose Goodale's Operation for Depressed 
Nose Ouston's Operation for Depressed Nose Below the Bridge Carter's Op- 
eration for Saddle-back Nose Beck's Operation for Saddle-back Nose Wal- 
sliau's Operation for Collapsed Ala? Lambert's Operation for Collapsed Alse. 

Paraffin Injections in Nose and Ear Deformities 344 

History Indication Results Technic of Injections Injections in Nasal De- 
ficiencies Injections in Kar Deficiencies Injections in Collapsed Ala\ 

Reduction Method 354 

Joseph's Operation for Reducing Hump, Length, Width of Nose, and Large 
Nostrils Kolle's Operation for Hump Nose Beck's Operation for Hump Nose 
Ballenger's Operation for Hump Nose Ballenger's Operation for Long Nose 
Roe's Operation for Hump Nose, Twist and Broad Ala or Large Nostrils 
Roe's Operation for Broad Ala? or Large Nostrils Beck's Operation for Hump 
Nose Kolle's Operation for Long Tip Nose. 

Prothetic or Artificial Noses 36l' 

Artificial Supports. 

Orthopedic Method 362 

Operations for Closing Perforating Septum 364 

Goldstein's Operation Hazeltine's Operation for Perforation of Septum Gold- 
smith's Operation for Closure of Septal Perforations. 


Classifications According to Kolle 366 

General- Consideration 367 

General Classification 367 

I'sual Operation for Macrotia Parkhill's Operation for Macrotia Cheyne and 
Burghard's Operation for Macrotia Goldstein's Operation for Macrotia 
Goldstein's Operation for Projecting Kar Beck's Operation for Roll Ear or So- 
called Dog Kar S/ymanowski's Operation for Reconstructing an Auricle 
Beck's Operation for Synechia or Auricle to the Mastoid Squama Roberts' 
Operation for Absence of Kar Simple Operation for Colobomata Green's Op- 
eration for Colobomata Monk's Operation for Prominent Kar Kolle's Opera- 
tion for Projecting Kar. 

Posiaurirular Deficiencies or Retroaiiricular Fistula 1 :!78 

Trautnianifs Operation for Closure of Posterior Deficiencies- --Von Mosetig- 
Moorliol! Operation Goldstein's Operation Kar Prothesis. 


.\>-uro|>la.-t> for Facial Paralysis 

Spin" -Fa< -ial and Periphero-Spinal to Descendens llypoglossi Anastomosis.. 

Facial-Spinal Anastomosis Facial-1 lypoglossal Knd to Side Anastomosis 
l-'acjal I lyjioulossal Knd to Knd Anastomosis Myeloplasty for Facial Paralysis. 


I'll;. PACK 

1. The cartilages of the nose; lateral view 

1'. The cartilages of the nose; anterior view 

:!. The orifices of the nose showing a dissection of the crnra medialia of the 

cartilagines alares niajores ;; 

4. Floor of the nose 4 

5. The sept inn nasi 5 

ii. The right outer wall of the nose c, 

7. The left outer wall of the nose with the concha media removed 

S. The choame and anterior wall of the sphenoid sinus viewed from behind. ... 1 

!. The left orbit : bone relations 11 

1(1. Left orbit with bone removed exposing the mucosa of the accessory sinuses.. lii 

11. Hones of the nose and orbits; external plate over frontal sinuses removed... i:', 

12. Floor of the anterior cranial fossa; bony roof of accessory sinus removed in 

part 14 

Coronal section through the nose and orbit l.~> 

Right lateral view of bones of the face with maxillary sinus and roots of the 

teeth exposed 17 

1"). Sagittal section through the right side of nose and maxillary sinus. External 


It). Sagittal section through the right side of the nose. Internal portion 

17. Sagittal section through the left side of the nose internal to that of Figs. 15 

and ItJ. Inner portion L'n 

IS. Sagittal section through the left side of the nose internal to that of Figs. 15 

and It). External portion _1 

l!i. Coronal section through nose and orbit three mm. anterior to the anterior 

wall of the sphenoid sinuses 

20-34. Lateral and superior reconstruction of the accessory sinuses of the nose.. 25-i'Ji 

:'.5-40. Plaster casts of sphenoid sinuses, placed in situ :',4-l!'.' 

41-55. Preparation showing relation of optic nerve to accessory sinuses of the nose. 4<i-4'j 

56. Right lateral wall of the nose with exposure of ihe saccus nasolacrimalis and 

ductus nasolacrimalis 5i> 

57. Coronal section through the sphenoid sinuses, removal of septum sinuum 

sphenoidalium and exposure of the hypophysis fil 

58. Median section through face of an adult man. showing the normal relations 

of the structures during quiet nasal respiration 56 

5!i. Median section through the face of an infant one month old. showing the rela- 
tions of the structures during quiet nasal respiration 57 

HO. Transverse section through the head of a child one month old just in front 

of the posterior pharyngeal wall 

The region of the palatal tonsil , 

Dissection of the region of the palatal tonsil from the outside 

Dissection showing the relation of the tensor palati and the levator palati 

muscles . 6S 



H4. Tlii- lateral external surface of the larynx .................................. <o 

65. The muscles of the laryngeal wall on the posterior aspect .................. 76 

;;. Diagrams illustrating closed and open glottis .............................. 78 

67. Dissection showing the upper deep cervical lymph nodes ................... 

6v Superficial dissection of the carotid triangle ............................... S6 

6'.<. Dissection of the pes anserinus of the facial nerve .......................... 

7". Deep dissection of the carotid triangle .................................... 

71. The relation of the palatal tonsil to the vessels and nerves of the carotid 

triangle .............................................................. -' 6 

7l'. Temporal hone from new-born ........................................... 101 

7:',. Temporal hone from child one year old .................................. 1"! 

74. Temporal bone from child three years old ................................ 103 

75. Temporal bone from child ten years old .................................. 103 

76. Frontal section through the adult temporal bone: the anterior part viewed 

from behind .......................................................... !"* 

77. Adult temporal bone showing the position of the antrum tympanicum and 

mastoid cells along the upper posterior wall of the external canal ......... 104 

7s. Horizontal section through the temporal bone viewed from above ............ 105 

7'.'. Section through mastoid process and external canal ....................... 105 

ML Section through temporal bone, showing the relation of the facial canal to 

the fenestra vestibuli and of the horizontal canal to the antrum .......... 106 

Section through temporal bone, exposing the facial canal ................... 107 

Adult temporal bone, showing anatomic relations after a complete tympano- 

mastoid exenteration .................................................. 107 

Adult temporal bone, showing the typical relation of the linea temporalis 

extending in a horizontal direction back from the external canal ......... 1 (| S 

Adult temporal bone, showing the linea temporalis making a marked curve 

down along the posterior border of the external meatus before turning 

backward . . .......................................................... 10T 

Adult temporal bone showing the linea temporalis making a curve upward 

at the posterior margin of the external meatus ......................... 110 

Section through mastoid process, antrum tympanicum, and external canal... Ill 
Pneumatic type of mastoid. Larger cells arranged along the periphery ...... Ill' 

I. Section through temporal bone. Section passes through antrum, vestibule 

and internal meatus ................................................... 11:: 

Section through temporal bone, showing relation of the horizontal canal and 

facial canal to the middle ear chambers; also relation of the carotid and 

ami Iml bar jugular is to the cavum tympani ............................. 111'. 

Section through the mastoid process, showing but partial pneiimat ization . . . 114 
Dipld-tic type of mastoid. Complete absence of pneumatic spaces. Antrum 

tympanicum contracted ................................................ 11 ; 

Section through adult temporal bone, showing persistence of infantile type 

v. it h absence ot pneumal jc spaces in the mastoid ........................ 115 

Section through adult temporal bone, showing the relations of the carotid to 

'I' 1 ' cavum t \inpani and the structures in the floor of the recessus opitym- 

paniciis ....................................................... 1 ],; 

S'-'-tjon through mastoid, cavum tympani. tuba auditiva, showing a large 

' ubal ce|| . - - 

1 IS 


Kid. r\i, I 

US. Section through temporal bone, showing relation of the bulbus jngularis to 

cavuin tynipani and relations of the cochlea and facial canal to the cavuin 

tympani l^u 

W. Horizontal section through the temporal bone seen from above li'j 

UMi. View of the posterior aspect of the temporal bone, showing bulbus jngularis 

extending to the upper margin of the petrous bone 

101. Tracheotomy under local anesthesia; novocaini/ing the skin 

In:.'. Tracheotomy. Incision through thyroid gland and trachea ]:>,;; 

lo;:. Tracheotomy. Xovocainizing the trachea from within l:;4 

104. Tracheotomy. After the operation \-.\~, 

10f>. Laryngectomy. Preliminary tracheotomy with iodoform gauze packing 141 

lot!. Laryngectomy. Five days after preliminary tracheotomy. Arrangement of 

tube for anesthesia 14l' 

107. Laryngectomy. Separation of the larynx from the esophagus 14:; 

108. Laryngectomy. Closure of pharyngeal opening 144 

10!i. Laryngectomy. Closure of wound with iodoform gauze packing 14f, 

110 Ksophagostomy. Ample incision of skin along the anterior border of sterno- 

mastoid muscle i r>2 

111. Ksophagostomy. Exposure of esophagus \~>?, 

IIH. Ksophagostomy. Esophagus stitched to skin ir>4 

11:1. Jackson's tubular speculum Ififi 

114 Diagrammatic representation of direct laryngoscopy 16o 

llf>. Position of second assistant and patient for endoscopy per os 161 

lit!. Bronchoscopy room at Massachusetts General Hospital 162 

117. Mosher's adjustable speculum 16:! 

118. Mosher's adjustable speculum 164 

li;i. Forceps for direct work upon the larynx 166 

ll'u. Killian's suspension apparatus 168 

121. Mosher's folding frame for suspension apparatus, closed 16( 

122. Mosher's folding frame for suspension apparatus, open 16H 

123. I'rethrascope used as a tracheoscope 170 

llM. Trethrascope used as a tracheoscope, showing individual parts 171 

12"). Jackson's bronchoscope 173 

126. Jackson's bronchoscope, with beveled end 173 

127. Cast of the interior of the trachea and bronchi, with their chief ramifications 

within the lung 174 

128. Cast of the interior of the trachea and bronchi, with their chief ramifications 

within the lung 1" 

1211. The arch of the aorta, with the pulmonary artery and chief branch of the 

aorta l~t> 

130. Showing the relation of the trachea to the great vessels of the neck. . 177 

131. Showing the divisions of the trachea, and bronchi 

132. Showing the relation of the main bronchi to the ribs and the chest wall (An- 

terior view ) 1 ' !l 

133. Showing the relation of the trachea and main bronchi to the chest wall and 

ribs ( Posterior view ) 

134. Diagram to show the bronchoscopic picture.. 

135. Diagrammatic drawing to show the bronchoscopic picture at various levels. . 

136. Horizontal section of thorax of man. aged f>7. at the level of the upper part of 

-i c 1 

the superior mediastinum 


KIi.. I'ACK 

i:'-7. Horizontal section of thorax of man. aged 57, immediately above the bifurca- 
tion of the trachea 18.") 

l:',S Horizontal section of the thorax of a man. aged 57. at the level of the roots 

of the limits 186 

l:!9. Horizontal section of the thorax of a man, aged 57, at the level of the nipples. 187 

140. Briinings' electroscope 191 

141. Rheostat and battery 19:! 

142. Coolidge's cotton carrier 194 

14::. Angular forceps for use with the adjustable speculum 104 

144. Mosher's alligator forceps 194 

145. Jackson's tube forceps 195 

146. Coolidge's forceps 195 

147. Killian's manikin for practicing bronchoscopy and esophagoscopy 196 

148. Hriin ings' elongation forceps 197 

149. Tips for Bninings' forceps 197 

150. Kxpanding tip for I'.riinings' forceps 197 

151. Mosln r's spiral wire forceps for removing papilloma of the larynx 198 

152. Mosher's triangular fenestrated tube 198 

15:1. Small bronchoscope for emergency intubation 199 

154. Pin with glass head in left main bronchus 208 

155. f'assolberry's pin cutter 2"9 

156. Section of the human esophagus (Moderately magnified ) 211 

157 Showing the relations of the esophagus from behind 212 

15s. View of the stomach in situ after removal of the liver and the intestine 213 

159. ("nd'T surface of the diaphragm 214 

I*'.' . Schema showing the range of motion of the gastroscope 215 

161 Jackson's esophagoscope 21S 

16u. Mosher's short length oval osophagoscope 219 

16:i. Mosher's < sophagoscope (short length) 22" 

164. Hood or cap which protects the lamp 22o 

165. Lonu conical plunger for Mosher's oval esophagoscope 22" 

166. Window plug for making the osophagoscopo air tight and ballooning the 

esophagus 22" 

K7. hifferent of Mosher's oval esophagoscopes 22" 

The normal < sophagus above the hiatus of the diaphragm, and with the dia- 

phraiMii cont racted I'L'!* 

Ksopha::oscope puslnd through the hiatus of the diaphragm and entering the 

subphronic portion of the esophagus l'l".i 

IT 1 * K-<,phai:oscopc carried tlirough the cardiac opening of the esophagus into the 

stomach ;j;_>'.i 

171 The , sophagus just above t lie hiatus of t lie diaphragm 229 

Norn. a I < sophauus (luring quiet breathiim 

Normal esophagus during deep respiration 

' ' ' ci in oi esophagus \\ it h scars rad iat ing from its lumen 

1 7.". 1 7"'> ' 'a re in (i ma of the esophagus 

1 7 i K done in iliciso|ihauus 

li' i ':.' ' : .;: i: i'-a ! (1 i hit or- with t u o i i ps 

I'.uni olive-l ipp( d in. tal hoimie 

Strict . ophaiiiis 

"i I'lummer's esophagcal whalebone bougies. . 


182. Whalebone stalT of Plummer's esophageal bougie .................. 239 

IS',',. Metal stalT carrying olive at tip; special wire carrier .............. L':',!i 

184. Mosher's two-bladed dilator with sliding- knife ............................. LMu 

185. Cardiospasm. Retouched tracing from an X-ray plate ............ I'll 

186 Apparatus for dilating the cardia ......................................... 243 

187. Cardiospasm. Print of an X-ray plate showing a dilated esophagus ..... 210 

188. Section of normal esophagus ( Low power) ................................ 24X 

189. Carcinoma of the esophagus .............................................. nr,n 

190. Section of careinomatous area (Low power) .............................. 251 

191. Section of careinomatous area (High power) .............................. 252 

192. Careinomatous stricture of the esophagus ................................. 252 

193. Cancer of the esophagus. Retouched tracing from X-ray plate .............. 253 

194. Forceps with punch tip .................................................. 255 

195. Mosher's curette ......................................................... 

196. Jackson's foreign body forceps ........................................ ... 

197. Penny lodged in the upper part of the esophagus of a child ................. 

198. Penny whistle in the upper part of the esophagus of a seven year old child. . 

199. Safety pin in the esophagus .............................................. 

200. Jackson's forceps for grasping and pushing open safety pins into the stomach 

for turning ........................................................... 

201. Schema showing Jackson's method of removing an open safety pin from the 

esophagus by passing it into the stomach ................................ 

202. Mosher's safety pin removing tube ....................................... 

20?). Mosher's safety pin forceps ............................................. 2~n 

204. Tooth plate in the esophagus ............................................. 27" 

205. Mosher's instrument for cutting a tooth plate or large pieces of bone ........ 271 

206. Jackson's bronchoscope, esophagoscope and gastroscope .................... 272 

207. Position of the right hand during the introduction of the gastroscope ....... 274 

208-210. Historical illustrations of Tagliacozzi's work .......................... 280 

217-222. Appliances and instruments employed by Tagliacozzi .................... 281 

22:!, Incisions and flaps for closing defects (Celsus ) ............................ 284 

Making Reverdin graft .................................................. 

Reverdin graft applied ................................................... 

Making and applying Thiersch graft ...................................... 2SO 

Stereoscopic photograph of plaster cast ................................... 2S7 

228-229. Legg's operation for correction of unilateral and partial deficiencies of 

the nose .............................................................. 291 

Kocnig's operation ................................................... 

Von Esmarch's operation ............................................ 292 

Von Langenbcck's operation .............................. 

Dieffenbach's operation .............................................. 

238. Von Esmarch's operation ................................................ 

239. Busch's operation for partial loss of tip and one side of nose ....... 294 

240. Xelaton's operation ........................... 

241-242. Syme's operation ............................................... 

243-244. Helferich's operation for total loss of nose ..... 

245-247. Roberts' operation for sunken bridge 1 with upturned lobule or tip of nose. 
248-251. Roberts' operation for sunkt n saddle-back nose .... 

252-25:]. nieftVnl;ach's operation for formation of new columella from the upper lip. 



2.">4-2.">. Operation for formation of now columolla from the dorsum of the nose. 

I Hindoo method ) 

2~>6-260. Lexer's operation for the formation of columella from the mucous mem- 
brane of the upper lip 

2H1-2G2. Italian or Tagliacoz/.i's method 

2t'.3. Italian or Tagliacozzi's method 

2;4-2tir>. Israel's operation 

2i;;-2tiS. Dieffenbach's operation 

20! Xelaton's operation 

27^-271. Xelaton's operation 

21- Hindoo or Indian method of flap formation 

273. Thiersch's operation for total loss of nose 

274-27'i. Xelaton's operation for total loss of nose 

277-27!*. Koenig's operation 

I'M i -L'Sl. Ke< Bail's operation for subtotal loss of nose, in cases of hacked noses. ... 

2S2-2Sr,. Xelaton's operation for subtotal loss of nose 

2SO-2S7. Von Langenbeck's operation for collapsed nose; making supports, espe- 
cially when soft parts are wanting 

288-2!*d. Sehimmolbusch's operation for total loss of nose 

2K1-2H3. Sehimmelbusch's operation for saddle-back nose 

i".' l-L'!t7. Sir Watson Cheyne's oi>eration. (Indian method.) 

2!*8-3dd. Von Hacker's operation. (Indian method.) 

3dl-:{d2. Sedillot's operation for total loss of nose. (Indian method.) 

3n:,-3d4. Steinthal's operation for total loss of nose. (Double transplantation 

method. ) 328 

3"."i-3ntj. Kausch's operation for collapsed nose. (Double transplantation method.) 329 

3o7. \\'att's operation for subtotal loss of nose 331 

3HX-311. Wolkowitsch's operation for total loss of nose. (Finger method.) 332 

312. Von Ksmarch's operation for collapsed nose or absence 1 of the promaxilla or 

an anterior perforation of hard palate 334 

3i:;-314. Clavicle method. ( Gustav Mandry. ) 334 

31.">. Israel's operation for saddle-back nose 338 

.", Ki-31 !i (loodalf's o])eration for depressed nose 33!) 

32o-:;L'l. Oust on's oiteration for depressed nose below the bridge 34(1 

".I'l'M' 1 Carter's ope rat ion for saddle-back nose M41 

:;^.V:;LM; Carter's openition for saddle-back nose 342 

Walshou's ojierat ion for collapsed ahe M44 

!2!" I'arafliiioina with attempted removal. Facing l>age 3yd 

''.'', Heck's paraffin syringe ;{f>l 

.losepii's operation for reducing hump, length, width of nose and large 

nost rils :!f)4 

!.">. Kol le's ope rat ion for hump nose 3r>r 

17. Heck's op( rat ion lor hump nose I'lfiTi 

I'.a I !' HL'i-r's o])i ra! inn for hump nose 3f> 7 

I'.alleuui r's operai ion for long nose 3. r >7 

II Ko"'s operation for hump, tuist and broad ala or large nostrils. (Illus 

t rat id by Heck.) :',f8 

17. Hoe's operation for broad ala- or large nostrils. (Illustrated by Heck.).. .'{(id 

H"<-k's op" rai ion for hump nose :{(io 

1 Koll'-V operation tor lonu tip 3(!1 


3f>2-3r>f>. Prothetic or artificial noses 

356-358. Goldstein's operation for perforation of septum 

359-361. Hazeltine's operation for perforation of septum 

362-364. Usual operation for maerotia 

365-366. Parkhill's operation for maerotia 

367-368. Cheyne and Hurghard's operation for maerotia 

369-371'. Goldstein's operation for niacrot ia 

373-376. Goldstein's operation for projecting far 

377-379. Heck's operation for roll ear or so-called dot; ear 

380-381. Szymano\vski's operation for reconstructing auricle 

382. Heck's operation for synechia of auricle to mastoid 

383-386. Roberts' operation for absence 1 of ear 

387-388. Simple operation for colobomata 

389-390. Green's operation for colobomata 

391. Monk's operation for prominent oar 

392-393. Koile's operation for projecting ear 

394-397. Trautmann operation for closure of posterior deficiencies 

398-401. The von Mosetig-Moorhoff operation for posterior deficiencies 

402-403. Goldstein's retro-auricular plastic 

404. Celluloid artificial ear 

405. Incision for spino-facial anastomosis 

406. Spino-facial and peripbero-spinal to descendens hypoglossi anastomosis 

407. Heck's nerve tracing forceps 

408. Facial-hypoglossal end to side anastomosis 

409 Facial-hypoglossal end to end anastomosis 



By Hanaii \V. Loch, M. I). 

External Nose. 

The external nose (nasus) which projects downward and forward 
from the forehead, between the eyes, presents two lateral and one 
inferior surface, all triangular in shape, and a superior surface which 
varies considerably in size and contour. As seen in Fi.ii's. 1 and i! the 
root of the nose (radix nasi ) is that portion projecting for a short 
distance downward from the forehead, and the bridge of the nose 
(dorsnm nasi) is the superior surface extending from the root to the 
tip of the nose (apex nasi). 

The supporting" framework of the nose is composed of bones and 
cartilages, united by connective tissues. It is lined with mucous mem- 
brane and covered by muscles and integument. 

The nasal bones and the frontal processes ( processus frontales 
maxilla?) of the maxilla? which constitute the bony framework of the 
external nose are attached by strong connective tissue fibres to the 
lateral cartilages (cartilagines nasi laterales) at the apertura piri- 
formis (Figs. 1, 2, 9 and 11). Each of these cartilages is triangular in 
shape with the apex downward, and is attached to the cartilage 
of the septum (cartilage septi nasi), and to its fellow on the oppo- 
site side. A variable number of sesamoid cartilages (cartilagines 
sesamoidese) are found between the lateral nasal cartilage and the 

*For the convenience of readers, structures are designated by their usual English names. However, 
the B.X.A. nomenclature is given in the text and exclusively in the figures in order to follow recognized 
authority in terminology. 

The figures accompanying this chapter have been made from drawings of Mr. Tom .Tones, with the 
exception of Figs. 20 to 34, inclusive. Acknowledgment is gratefully made to Dr. I). M. Schoemaker for 
the dissections illustrated by Figs. 1, 2 and 3. The remaining preparations, except those illustrated by 
Figs. 9, 11 and 12, were made by the author. 











Fig. 1. 
Thf cartilages of the nose; lateral view. 



SF PTI .!. si 





greater alar cartilage (cartilago alaris major). The. lessar alar car- 
tilages (cartilagines alarcs minores) arc small cartilaginous plates, 
variable in iiuinl)er, which lie between the greater alar cartilage and 
the maxilla. 

The greater alar cartilage (cartilago alaris major), very variable 
in shape and extent, constitutes in large measure the framework of 
the lower lateral portion of the external nose, and that of the ala 
(cms laterale). The medial portion (cms medialc) (Fig. .') winds 
around the anterior inferior portion giving to the naris its rounded 
appearance. It is loosely connected with the cartilage of the septum. 
A mass of connective tissues lies behind and below the .u-reater alar 
cartilage forming a considerable portion of the ala (tola snbciitanea ). 




The orifices of the nose showing a dissection of the crura inedialia of 
the cartilagines alares majores. 

Nasal Cavities. 

The anterior portion of the nasal cavities, between the ala and the 
septum, is called the vestibule (Figs. .'>, (5 and 7). It is covered with 
squamous epithelium and contains numerous stiff hairs known as 

The nasal cavities, right and left, are hollow spaces between the 
bones of the head and face, extending backward from the vestibule to 
the nasopharynx, and from the floor of the cranial cavity above to the 
roof of the mouth below. 

Floor of the Nose. The bony floor, narrowest at its anterior 
extremity, becoming wider posteriorly and then narrower at the 
choanae, is formed by the palatal process of the maxilla (processus 
palatinus ossis maxillaris) and the palatal process of the palate bone 
(processus horizontals ossis palatini). The suture between these 
bones divides the floor into two unequal portions, the anterior three- 
fourths approximately being maxilla and the posterior one-fourth 


palate bone. ( Fig. 4.) The eanalis incisivus which opens on the 
septum just above, ])enetrates the floor in its anterior portion convey- 
ing the nasopalatine nerve and artery to tlie roof of the mouth. The 
sinus maxillaris may he seen external to the lateral wall of the nose 
extending below the level of the Moor. (See also Fig. 1.'!.) 

Septum Nasi. The septum nasi forms the inner wall of each nasal 
cavity, approximately in the median line. It may be straight, but 
more often it is bent to one side or the other or irregularly deviated 
in one or both nares. It is divided into three parts, the bony (septum 
nasi osseum), cartilaginous (cartilagineum) and membranous (mem- 
branaceum) septum (Fig. 5). The membranous portion (septum mobile 
nasi) separates the vestibule from its fellow, and is made up of the 




'' -|'.V-L' 





Fi S . 4. 
Floor of the nose. 

ernra medialia of the two greater alar cartilages, with their attach- 
ments to the septum nasi, covered by a mucocutaneous investment. 'Die 
cartilaginous portion (septum cartilagineum) is formed by the 
cartilage of the septum and the cartilage of Jacobson. The cartilage 
of the septum is more or less quadrilateral in form and is attached 
posterosuperiorly to the perpendicular plate of the ethmoid (lamina 
perpendieularis ossis etlimoidalis), posteroinferiorly to the groove ol 
t!ie vomer, inferiorly to the anterior part of the crista nasalis maxilla; 
and to Jacobson 's cartilage, and superiorly to the nasal bones and the 
lateral cartilages. From the posterior angle a projection extends back- 
ward often for some distance, known as the processus sphenoidalis 
scpti cartila.innei. Jacobson V cartilage (cartilage vomeronasalis 


Jacobsoni) lies between the cartilage and the voinei 1 , and the nasal 
crest of the maxilla. 

The bony portion is composed of the perpendicular plate of the 
ethmoid, the rostrum of the sphenoid (crista sphenoidalis), the vonier, 
the maxillary crest (crista nasalis maxilla 1 ), aixl the palatine crest 
(crista nasalis ossis palatini). 

The perpendicular plate of the ethmoid extends downward and 
forward from the cribriform plate of the ethmoid (lamina cribrosa ossis 





















Fig. 5. 
The septum nasi. 

ethmoidalis) having attachments with the nasal spine (spina nasalis) 
of the frontal, the nasal bones, the cartilages of the septum, the vomer 
and the rostrum of the sphenoid. 

The vomer constitutes practically the whole of the posterior and 
inferior part of the septum, articulating below with the nasal crest 
of the maxillary and palate bones, anteriorly and superiorly with the 
cartilage of the septum, Jacobson's cartilage and the perpendicular 
plate of the ethmoid, and superiorly with the rostrum and body of the 



sphenoid. Its superior margin divides into two wings, alae vomeris, 
by which it is attached to the sphenoid. The posterior border forms 
the dividing boundary of the two choanae or posterior nares. (Fig. 8.) 

The rostrum of the sphenoid takes part in the formation of the 
septum. In the specimen illustrated (Fig. 5) it is triangular and 
considerably larger than usual. 

The maxilla furnishes but a small part of the nasal septum, the 














Fig. 6. 
The outer wall of the right nasal cavity. 

crista nasalis, which by its articulation with the vomer, Jacobson's 
cartilage, and the cartilage of the septum, comprises the inferior portion 
of the septum, corresponding to the extent of the maxillary portion of 
The floor. In its anterior half it presents the canalis incisivus for the 
passage of the nasopalatine nerve and artery. Its most anterior pro- 


jection is tlio anterior nasal spine (spina nasalis anterior). (Figs. 4 
and 5.) 

Corresponding with the nasal crest of the maxillary is a similar 
projection upward from the horizontal plate of the palate bone. It 
lies behind the nasal crest of the maxillary and articulates with it at 
the sutura palatina transversa. Posteriorly it presents the posterior 
spine (spina nasalis posterior). 

Roof of the Nose. The roof of the nose is constituted from before 
backward by the following bones: the nasal, the frontal, the ethmoid 
and sphenoid. The lamina cribrosa of the ethmoid (Figs, 5, \'2, 45, 4b', 
48, 50, 53, 54 and 55) which conveys the filaments of the olfactory nerve 
(Figs. 44 and 47) from the cranial cavity into the nasal cavity is almost 
horizontal. It is composed of very hard bone which is easily recog- 
nized by the operator on account of its resistance to the instrument. 
The sphenoid ordinarily constitutes but a small part of the roof of 
the nose just behind the ethmoid, likewise the frontal which lies just 
anterior to the ethmoid. Anterior to the sphenoid in the angle between 
it and the ethmoid, there is a space called the recessus sphenoethmoid- 
alis, which receives the opening of the sphenoid sinus. 

A probe with its end tipped slightly downward will readily enter 
the sphenoid if it is passed backward about 7 cm. along the roof to 
the recessus sphenoethmoidalis. As a rule to accomplish this, it is 
necessary to resect the middle turbinate. Figs. 6 and 7 show very 
clearly the possibility of using this method. 

External Wall of the Nose. The maxilla and palate which are 
united vertically, with their attachments, the inferior turbinate (con- 
cha nasalis inferior), lacrimal, ethmoid and sphenoid, constitute the 
outer wall of the nose. The inferior turbinate and the middle tur- 
binate (concha nasalis media) (Figs. 6, 7, 15, 16, 17 and 18) are 
attached to the crista conchalis and crista turbinalis of the 
maxilla and of the palate bone. The superior turbinate (concha 
nasalis superior) and supreme turbinate (concha nasalis suprema), 
which is present in about one-third of the cases, run parallel to the 
middle turbinate, but are continuous with the lateral mass of the 
ethmoid from which they project backward for a short distance. The 
inferior turbinate and middle turbinate extend about the same dis- 
tances forward, constituting by far the greater portion of the projection 
from the external wall. A line drawn along the superior border of the 
middle turbinate and extended to the anterior wall divides the nose 
into two unequal parts, a superior comprising 1 about one-fifth and an 
inferior about four-fifths. The superior and supremo turbinates are 
much smaller and shorter than the other turbinates. They spring from 


the lateral mass of the ethmoid in the posterior third of the nasal wall. 
However, all of the tiirbinates extend about the same distance backward. 
The choana? therefore are in relation with the posterior ends of the 
inferior and middle tiirbinates. (See Fig'. 8.) The superior and 
supreme tnrbinate lie just above the superior choanal level. Upon 
examination through the anterior naves, the inferior is visible for from 
one-half to its whole length, the middle ordinarily at its anterior end, 















Fig. 7. 
The outer wall <' the left nasal cavity with the concha media reinov 

and the superior and supreme are not visible unless extensive atrophy 
i- present oi' unless the middle tnrbinate has been removed. 

The inferior tnrbinate is attached to the biennial, const it ill ing a 
portion of the wall of the nasolacrimal canal, and to the ethmoid; it 
serves to decrease the si/e of the orifice of the maxillary sinus. 

The tiirbinates are covered with mucous membrane, continuous 
with the mucous membrane of the external wall of the nose. It is 



thickest over the inferior and middle turhinates, made so by the large 
number of venous radicles which are present. These have been variously 
designated as turbinate bodies, Sehwellkorper (by /uckcrkandl) 
(plexus cavernosi conch arum ); they are of great imporlance in the 










Fig. 8. 
The choans and anterior wall of the sphenoid sinus viewed from behind. 

physiologic action of the nose, more particularly in connection with 

There is a small elevation on the outer wall just anterior to the 
middle turbinate known as the agger nasi. It is sometimes the seat of 
an anterior ethmoid cell. It is by entering through the (niter wall at 
the agger uasi that Mosher recommends that the ethmoid cells be 
curetted without disturbing or necessarily removing the middle tur- 


binate bone. Below this is a slight depression known as atrium meatus 
medii, which extends backward and downward into the middle meatus. 

By virtue of the turbinate ledges on the external wall, the nasal 
cavity is divided into three meatuses, the inferior, middle and 
superior (Figs. 6, 13, 17 and 18). 

The inferior meatus, below and lateral to the inferior turbinate 
bone, receives the lacrimal secretion through the orifice of the naso- 
lacrimal duct, in its anterosuperior portion. None of the accessory 
sinuses opens into it. 

The middle meatus contains the orifices of the frontal and 
maxillary sinuses, and of the anterior ethmoid cells. These orifices in 
the main open into the infundibulum, a hollowed out space below the 
maxillary attachment of the middle turbinate and between the bulla 
ethmoidalis and the uncinate process of the ethmoid bone (Figs. 7 and 
13). The frontal and one or more of the anterior ethmoidal cells open 
usually through its anterior and upper portion. 

The maxillary sinus opens as a rule posterior to the orifice of the 
frontal sinus. It not infrequently lies in such a position that discharge 
from the frontal and ethmoid cells passes directly through the in- 
fundibulum into the maxillary sinus. The opening of the maxillary 
is not always single; one or more accessory orifices may be present, 
but they open into the middle meatus. The infundibulum communi- 
cates with the middle meatus through the hiatus semilunaris. 

The superior meatus contains the openings of most of the posterior 
ethmoid cells. Occasionally one is found above the superior turbinate. 
Behind and above this is the opening of the sphenoid in the spheno- 
ethmoidal recess. 

The Choanae or posterior nares which are the openings 
of the nose into the nasopharynx are oval shaped and fairly sym- 
metrical. They are formed by the vomer internally, the horizontal 
plate of the palate inferiorly, the vomer and sphenoid superiorly, and 
externally by the processus pterygoideus. 

Fig. 8 is an illustration of the choana* from behind with the 
inferior portion of the anterior wall of the sphenoid sinus cut away 
so as to show the nasal cavity projecting above the upper level of 
the clioawr. It also serves to show the relation of the sphenoid 
sinuses to the choana', the nasal cavities, and the optic nerve. 

Posterior to the choana' on each lateral wall of the pharynx is 
the opening of the Fiislachiaii tube. In children the nasal cavities 
are relatively -mailer than in adults for the reason that the turbinatcs 
are far larger in proportion. 



Accessory Sinuses of the Nose. 

The accessory sinuses of the nose are cavities in the maxillary. 
frontal, ethmoid and sphenoid bones, which are lined with a niucosa 
continuous with that of the nose; they communicate with the nasal 
cavities in places more or less definite. 

In order to understand their different relations, it is advisable to 
study the bones which form their walls. 















Fig. 9. 
The left orbit: bone relations. 

The two nasal bones united at the sutura internasalis and the 
two maxillary bones united at the sutura intennaxillaris. together 
with the corresponding nasal bones at the sutura nasomaxillaris form 
the apertura piriformis, or the entrance to the bony nose to which the 
soft parts of the external nose are attached (Fiirs. 1) and 11 ). The nasal 
bones above form the portion of the roof of the nose which lies anterior 



to the frontal with which they articulate at the nasofrontal suture. 
The maxilla constitutes the anterior, external and posterior Avails of 
the sinus maxillaris which it encloses. It articulates externally with 
the malar (os zygomaticum) at the sutura zygomaticomaxillaris. It 
is extended into the orbit and assists in forming its floor by articulating 
with the lacrimal, ethmoid and sphenoid bones. In the orbit, as shown 








Fit;, in. 
Left orbit with bone removed exposing the inucosa of the accessory sinuses. 

in Fiir. !', the sinuses are visible where the bone has been cut away, 
the ethmoid in the biennial and ethmoid bones, the frontal in the 
frontal bone, and the sphenoid in the sphenoid bone. A realistic view 
of the sinuses is seen in Fig. 10, in which the decalcified bone in tin; 
specimen illustrated has been removed leaving the mucosa of the 
sinuses intact, the frontal, anterior and posterior ethmoid and the 
sphenoid, from before backward, and the maxillary below. From these 


figures it is easy to observe how an inflammation of the ethmoid cell- 
may result in a periorbital abscess. 

In Fig. 11, the outer plate and cancellous tissue over the frontal 
sinuses have been cut away leaving the sinuses free with a thin cover- 
ing of bone. The sinuses are somewhat larger than the average, but 
their relation to the adjacent bone structure is well shown. 










O R 3 I T A L I S 





Fig. 11. 
Bones of the nose and orbits: external plate over frontal simisrs removed. 

The roof of the nose and of the orbits from the endocranial side 
is presented in Fig. 12. The relations of sinuses to the lesser wing 
of tbe sphenoid bone, the pituitary fossa (fossa hypophyseos), the 
optic chiasm, the frontal, and the cribriform plate of the ethmoid bone 
are shown. The frontal sinuses, anterior and posterior ethmoid cells 
and sphenoid sinuses are shown in succession. 



A clearer understanding of the cells from this aspect may be 
secured from Fig. 52, which is made from a specimen which was pre- 
pared after decalcification by removing the endocranial bone covering 
from the sinuses, leaving the mucosa intact. The relation of the optic 
nerve to the two sphenoid sinuses and to the last posterior ethmoid 
cell is well brought out in this illustration. 

Frontal Sinus. The frontal sinus is the most anteriorly placed of 

















Fig. 12. 
Floor of the anterior cranial fossa; bony roof of accessory sinus removed in part. 

all the accessory sinuses of tin- nose. Il varies ureatly in si/e, but 
conforms in some measure to a uniform plan in that the si/e laterally 
depends upon how many recesses more or less resembling one another 
are present. Thus there may be one, 1 wo, three or even four of these 
](.( esses present. The frontal sinus lies between the two plates of the 
frontal hone. Its anterior wall forms the prominence of the forehead 



above the eyebrows. (See Fig. 11.) The posterior and superior wall 
separates it from the frontal lobe of the brain, the inferior from the 
orbit. The irregularities in the anterior wall are well shown in this 
figure, as well as the relation to the orbit and the foramen supraor- 












_ - SINUS 






Fig. 13. 
Coronal section through the nose and orbit. 

bitale. Radiographs show the extent and shape of this wall and are 

therefore required before radical operative procedures are undertaken. 

The relation of the posterior and superior wall to the brain lias 

been studied extensively by Onodi, who found that this wall of the 


frontal sinus may extend over the gyms frontalis superior, gyms 
frontalis medius and gyms frontalis inferior. The inferior wall is in 
relation with the orbit (Fig. 13) and reaches often far back into the 
ethmoid labyrinth. As a rule it extends but a short distance pos- 
teriorly over the orbit while laterally it is usually limited to the inner 
and middle thirds, although in some instances it may reach the outer 
third. The septum between the two frontals is seldom directly in the 
median line, on which account either sinus may extend beyond it. 
The cavity is often subdivided by more or less complete septa which 
have the effect of establishing pockets in what would be otherwise a 
smooth cavity. Fig. 11 shows how irregular it may be. The sinus 
opens into the middle meatus by way of the infundibulum through 
an elongated canal (Figs. 7, 15, 16, 17 and 18) or simply as a foramen 
directly into the infundibulum. A very characteristic formation of the 
upper portion of the infundibulum is shown in Figs. If) and 16, in which 
it lies behind an anterior ethmoidal cell, quite similar in appearance. 
In Fig. 16, the frontal is seen opening into the infundibulum through 
a canal. There has been considerable confusion in the application of 
the terms infundibulum and hiatus semilnnaris. Onodi includes under 
the term hiatus semilunaris, the entire space between the nncinate 
process and the bulla ethmoidalis of the ethmoid bone, and accepts the 
designation of Killian, recessus frontalis, for the sharply outlined fossa 
into which the frontal often opens. Where a canal is present, he terms 
it ductus nasofrontalis. It is quite common for one or more ethmoid 
cells to open with the frontal through the infundibulum, furthermore the 
orifice of the maxillary sinus may lie in such a position that it receives 
the pus which Hows from the frontal sinus and ethmoid cells, giving 
the impression that suppuration of the maxillary sinus is present. 

Maxillary Sinus. The maxillary sinus as will be seen in Fig. 14, 
is a cavity in the maxilla interposed between the alveolar process and 
the orbit and the external wall of the nose and the malar process. A 
portion of the anterior wall has been cut away bringing the cavity into 
view. That portion of the alveolar process covering the roots of the 
teeth has been cut away, to show their relation to the floor of the 
sinus. In the specimen illustrated the roots of the three molai> and 
two bicuspids are in dose relation with the sinus, two of the roots of 
the second molar making indentations into the floor. The cuspid 
lies anterior to the sinus, but it extends above the floor. 

The floor of the sinus is by no means smooth or regular; as a rule 
there are bony septa present which divide it into pockets. Hence 
puncture through the alveolus will not necessarily result in satis- 
factory drainage. The floor of the nose is generally on a higher level 
than that of the sinus. (See Fiirs. 4 and 1.".. ) 



The posterior limit of the maxilla separates the maxillary sinus 
from the zygomatic fossa (fossa infratemporalis). The Hour of 
the orbit in part constitutes the roof of the sinus and the external 
wall of the nose, its internal wall. The canal for the infraorhital nerve 
forms in most instances a ridge on the roof of the sinus; however, the 
ridge may not be well marked and may be even absent. (Fig. !..'>.) 

The opening of the sinus into the middle meatus is on the internal 
wall, generally in its upper part; at times there are accessor}' openings. 






Fig. 14. 

Right lateral view of bones of the face with maxillary sinus and roots 
of the teeth exposed. 

Hence it is that pus in this sinus is evacuated through its openin; 
readily in the recumbent position; pus coining from the middle meatus 
may be determined to come from the maxillary sinus if it appears or 
increases when the head is lowered and the face is turned towards the 
side examined. This brings the orifice into the most dependent position 
and thus permits pus to How out more readily. The position is not 
conducive to the flow of pus from the frontal sinus or the anterior 
ethmoid cells. 



The maxillary sinus may bo opened surgically: 

1. Through the alveolar process by removing- a tooth or in some 
instances without the removal of a tooth. 

2. Through the anterior wall (in the fossa canina) in the mouth. 

3. In the middle or inferior meatus, with or without resecting a 
part of the inferior turbinate. 

4. By cutting away a part of the margin of the apertura piri- 
formis through the nose and continuing the excision by removing a 















Fig. 15. 

Sagittal section through the right side of nose and maxillary sinus. 
External portion. 

part of the external wall of the nose below the attachment of the 
inferior turbinate (Canfiold's operation). 

Ethmoid Cells. The ethmoid cells are divided into two groups, 
the anterior which open into the middle meatus and the posterior which 
open above the middle turbinate, generally in the superior meatus. 

There is no uniformity as to the number, position or sixe of the 
cells in either group. They lie in the bony wall between the nasal 
cavities and the orbit, the frontal and sphenoid sinuses, and between 
the floor of the cranial cavitv and the middle turbinate. 



Sometimes an ethmoid cell may extend into the middle turbinatc 
forming 1 what is known as a concha hnllosa. Such a cell as a rule 
has it opening in its upper part, and therefore drainage is unsatis- 
factory when any affection is present which causes it to fill up with 
fluid. The bulla ethmoidalis (Figs. 7 and ].'{) contains one or more 
ethmoid cells, generally belonging to the anterior group, although occa- 
sionally one is found opening into the superior nieatns. 

In the specimens illustrated in Figs. 15 and 1(5, a sagittal section 
has been made, so as to cut through the anterior attachment of the 







FOSSA,, - ' 









* v SPIN A 



Fig. 16. 
Sagittal section through the right side of the nose. Internal portion. 

inferior tnrbinate to the maxilla, which is shown free except for its 
attachment to the palate bone. The middle tnrbinate is shown articu- 
lated with both the maxilla and palate bone. The micinate process 
which assists in closing up the inner wall of the maxillary sinus 
projects downward from the lateral mass of the ethmoid. As will 
be noted it partakes in part of the general celhilar arrangement of the 
bone in this position. 

The frontal opening into the infundibulum ethmoidale is well shown 



while adjacent anterior etlimoidal cells are quite typical. Behind these 
are the posterior ethmoid cells, and posterior to them, the sphenoid. 

The specimen shows the pterygomaxillary canal throughout its 
entire extent. It will be observed that the upper part of the canal, 
where the sphenopalatine ganglion lies, may be entered by plunging 



















Fit;. 17. 

Sagittal section through the left side of the nose internal to that of 
Fis. If! and 1'!. Inner portion. 

a needle into the outer wall of the nose just above the posterior 
extremity of the middle tnrbinate. 

An ethmoid cell lies anterior to the inl'iiiidibiilnm running par- 
allel to it and resembling it in shape and si/e. As has been already 
reported by the writer, a probe is likely to enter this particular type 
of cell, ti'i vin.u' the surgeon the impression that he is in 1 he frontal sinus. 
Sometimes this cell or another anterior ethmoid cell mav project far 

the frontal sinus, constitntinii 1 what is known as a bulla frontalis. 


Tlio arrangement of the ethmoid labyrinth is shown in Figs. 17 
and IS, which illustrate the 1\vo sides of a sagittal section of Ihe nasal 
cavity made internal to the one in the specimen illustrated in the last 
two figures. On one side the posterior portions of the tnrbinate are 
left with their articulation with the palate hone, and on oilier their 
maxillary attachments are preserved. 

Sphenoid Sinus. The figures show two very large- sphenoid 
sinuses, the right extending anteriorly to the left side far beyond the 










Fig. 18. 

Sagittal section through the left side of the nose internal to that of 
Figs. 15 and 16. External portion. 

median line, and the left posteriorly almost as far. The sphenoid 
sinuses occupy a greater or less amount of the body of the sphenoid. 
The two sinuses are not uniform in size, shape or relation. 

A sphenoid sinus may extend but slightly to the opposite side, 
and sometimes it may grow to such an extent on the opposite side, 
that the other sphenoid is reduced to an exceedingly small size. On 
the other hand the last posterior ethmoid may almost entirely replace 
it. It mav extend almost as far back as the Gasserian ganglion, and 



to the basillar process of the occipital, and as far forward as the 
canalis options. Sphenoid sinuses of various sha])es and sizes are illus- 
trated in Pigs. of) to f>5. 

The walls of the sphenoid sinus vary in thickness not only in 
different individuals, but also in the two sinuses of the same head. 
This statement pertains more especially to the superior wall, the 
effect of which is to bring the pituitary body and optic nerves much 





















V\K. in. 

Coronal section through nose and orbit three nun. anterior to the anterior 
wall of the sphenoid sinuses. 

closer 1o otic sinus than to Ilic oilier. The external wall, generally the 
thickest, lies between the sinus and the middle cranial fossa, and adjoins 
tin- sinus cavcrnosus and the carotid artery. The following nerves in 
addition to the optic are found in relation with the external wall, abdu- 
cens, oculomotor, trochlear, ophthalmic and maxillary (Fig. 8). 
The posterior wall articulates with the basillar process of the 
occipital. The inner wall or septum sinuum spheiioidalium is frequently 


in the median line, but from what lias already been stated, it may bo 
exceedingly irregular in its position. (Fig. 57.) 

The anterior wall is in relation with the nasal cavity (rocossus 
sphenoethmoidalis) and the posterior ethmoidal cell. In the section 
(Fig. 19) the walls of the nasal cavities have been cut away .'! nun. 
anterior to the sinus, showing the relation of the anterior wall to the 
nasal cavities and the posterior ethmoid cells. The turbinates, four 
in number on each side are cut close to their posterior extremity. The 
clioanai are visible in the depths. Their position with respect to the 
sphenoid sinus and to the posterior portion of the nasal cavity is well 
shown. It will be observed that much of the nasal cavity lies 
above the choamr, quite as great in size from below upward as the 
choanae themselves. This figure shows how the sphenoid may be 
opened with or without the destruction of the posterior ethmoid cell. 
Compare this with Fig. 8, which gives a view of the sphenoid anteriorly 
from the pharynx. 

The orifice of the sphenoid sinus, while always opening into the nose 
above the superior turbinate, varies considerably in its position. The 
following table shows the distance between the inferior margin of the 
opening, and the lowest level of the floor, and the highest level of the 
roof respectively, in fifteen heads measured by the writer: 




(In Millimeters.) 

















































These figures show a wide variation, and yet it may be said that 
the orifice, as a rule, is midway between the roof and the floor. This is 
true for twenty out of thirty sinuses. 

In xix, xx, right, the orifice is in the upper third ; in VH and xvi, 
right, and ix, xvi and xvm, left, it is in the lower third; in the other 
twenty-three instances it is in the middle third. 

It is relatively highest in head xx, right, where its distance from the 
roof is one-tenth of that between the roof and the floor. It is relatively 
lowest in ix, left, where it opens in the lower quarter of the anterior 

The relation of the cavernous sinus and of the third (oculomotor- 
ins), fourth (trochlearis), fifth (trigeminus), sixth (abducens) and the 
vidian nerves to the sphenoid sinus has been carefully studied by 

He found that the body of the sphenoid is covered above and 
laterally by the dura mater with the cavernous sinus between its ex- 
ternal and internal surfaces, occupying a position for the most part 
above and lateral to the body. Within the cavernous sinus are found 
the internal carotid artery, and the third, fourth and sixth cranial 
nerves, the first division of the fifth lying in the lower part of its lateral 
wall. The sixth and third division of the fifth are the only ones of 
these nerves that are not at times in close association with this cell, 
that is, separated from it by a very thin layer of bone, and even the 
third division of the fifth is sometimes also in close association with 
it. The sixth is uniformly placed on the lateral aspect of the carotid 
while within the cavernous sinus and is always removed from this bony 

The fact which determines the relations of these nerve trunks to 
the sphenoid sinus is the si/e of the cavernous sinus rather than the 
si/c of the sphenoid sinus. A large sphenoid sinus prolonged hack- 
ward and outward may closely approach the third division of the fifth 
in the foramen ovale or even the (lasseriaii ganglion. (Set 

The second division of the fifth is in close associat 
sphenoid sinus when it extends laterally to the fora me 
The first division of the fifth comes into close associat 
sphenoid sinus anteriorly when the cavernous sinus is sn 
direction. 'The third and fourth nerves may be in relal 
sphenoid si mis when it is prolonged outward into the 
process or lesser wing of t he s 
these relations in the sphenoid a 
when the si in is is prolonged into 
m ; i ir n a ) . 

'I In- close association ol the sphenoid sinus with the second di 



Fig. 20. (Head VI.) 

Fig. 21. (Head VII.) 

Fig. 22. (Head VIII. > 
Lateral and superior reconstructions of the accessory sinuses of the nose. 



Fig. 23. (Head IX.) 

Fig. 24. (Head X.) 

Fig. IT). (Head XI.) 
Lateral and superior reconstructions of the accessory sinuses of the nose 


Fig. 26. (Head XII.) 

Fig. 27. (Head XIII.) 

Fig. 28. (Head XIV.) 
Lateral and superior reconstructions of the accessory sinuses of th* nose. 



Fig. 29. (Head XV.) 

Fis. 30. (Head XVI.) 


<if 111. 

sinuses of tin 1 nose 



Fig. :\'2. (Head XVIII.) 

Fig. 33. (Head XIX.) 

Fig. 34. (Head XX.) 
Lateral and superior reconstructions of the accessory sinuses of th nosi 



vision of the fifth in the foramen rotnndmn may bo established as early 
as the third year of life, and with the vidian nerve in its canal as early 
as the sixth year. 

Variations of the Sinuses in Size and Shape. 

The reconstruction method is perhaps the best for illustrating the 
variations in size and shape of the sinuses. Reconstructions of the 
sinuses in fifteen heads are shown, right, left and superior. In Figs. 20 
to 34 inclusive, the central illustration is the superior view, the right 
shows the left set of sinuses, and the left the right set (so placed in 
order to make orientation easy). The anterior ethmoid cells are repre- 
sented by dotted lines and the posterior by broken lines. The other 
sinuses are drawn with solid lines, as they are obvious, viz., in the 
central illustration the maxillary are the most external, the frontal an- 
terior, and the sp,henoid posterior; in the lateral, the frontal is 
superior, the sphenoid posterior, and the maxillary inferior. The 
ethmoid cells of each group are drawn as if they constituted a single 
sinus, except where the cells were too far distant from the group. 
As the figures are reduced to one-half the natural size, it is easy to 
estimate the extent of the sinuses. 

In the central figures the extent of the sinuses anteroposteriorly 
and laterally is shown, and in the right and left figures, superoin- 
foriorly and anteroposteriorly. The corresponding diameters may be 
thus determined. 

Frontal Sinus. While there is a great diversity of shapes to be 
found in the different frontal sinuses, there is rather more uniformity 
of shape and size in the two frontals of the same head. The dimen- 
sions in millimeters are as follows: 


(In Millimeters.) 

















Anteroposterior Superoinferior 




























































42 37 






















41 2f> 
















up as 

Tlic variations in the size of the IVontals may be 

Ran^o, anteroposterior 9 to .'5.'!, superoinforior 14 to .">!, lateral 7 
to 42. Usual, leaving out five highest and lowest, anteroposterior ID 
to '26, superoinferior 2(5 to 40, lateral 17 to 30. Average, antero- 
posterior 21, superoinferior .'54, lateral 2.'). 

The largest sinus is that of xiv (Fiji 1 . 28) ri.u'hl, in which the 
diameters are 2(5, 45, 42, and the smallest that of xv (Fi,u\ 29) ri.u'ht, 
having the diameters 9, 14, 7. 

Maxillary Sinus. As a rule the maxillary sinuses in a .u'iven head 
are fairly uniform in size and shape; the dimensions of the maxillary 
sinuses are shown in the following table: 


(In Millimeters.) 

Distance of 








floor of 



H. I.. 








39 40 








40 42 








32 30 








17 20 








39 37 








40 40 








34 29 








37 40 





' > '' 



37 42 





2 3 



40 33 





3 3 



25 26 








35 37 








35 26 








36 42 








36 35 







The variations are as follows: 

Rauii'e, anteroposterior diameter 17 to 42, superoinforior 1< to 4,. 
lateral 8 to 33, orifice to floor 14 to 40. Usual, leaving off highest and 
lowest five, anteroposterior 29 to 40, superoinferior 2S to 42. lateral 
19 to 30, orifice to floor 21 to 36. Average, anteroposterior :>s. supero- 
inferior 38, lateral 23.8, orifice to floor 29. The largest is vn ( 'Fi.u'. 21) 
left, 42, 47, 29, the smallest is ix (Fi.ii 1 . 23) riii'ht, 17, 17, S. It will be 
noted that leaving out a few of the extremes, the maxillary sinuses are 
more uniform than anv of the other sinuses. 


Ethmoid Cells. To show the groat complexity of the ethmoid cells 
and the variability of their size and shape, it has been deemed advis- 
able to consider the diameters of the ethmoid labyrinth and of the an- 
terior and posterior groups of cells respectively. The dimensions are 
as follows: 


(In MillimeU'rs.) 

Labyrinth Anterior Ethmoid Posterior Ethmoid 



c I 
K '" 




6 '*" 

^ "33 

< ~ 

c | 











22 ' 
































































33 ! 























































































! 23 




















































i 22 














3 :> 







'' 3 





























































28 ' 



1 20 























Those figures show the following: 

Ethmoid Labyrinth. K'smgv, anteroposloi-ior diameter L'L' to 7)4. 
superoini'erior 17 to 7>!>, lateral !' to L'S. I sual, leaving out live highest 
and lowest, antoropostorior '27 to 4.'!, superoinferioi 1 -'.'> to .">(>, lateral 1:2 to 
L'O. Average, antoropostorior .'17), suporoinforior .'Jl.O, lateral Hi..'!. 

The largest is that of xiv (Fig. l'S) left, 4l, 7)7, L'S, and the small- 
est, xvn (Fig. :$1 ) left, J, is, 10. 


Anterior Ethmoid. Ran.uv, anteroposterior ! to 40. >uperoinfcri(.r 
7 to ")7, lateral 7 to L'!). Fsual, leaving out live highest and lowe>t. 
anteroposterior 1.4 to L'7, snperoinferior 17 to .'14, lateral !' to 1 s . Aver 
aii'e, anteroposterior L } 1, superoinferior 2~)A>, lateral 14. 

The largest is that of xiv ( Fi.u'. -S) left, .'!(), .")(), I'll, and the small 
est that of xvn ( Fi.u'. .'11 ) ri.n'ht, !, 1!, 7. 

Posterior Ethmoid. Ran.uv, anteroposterior l.'l to .'!.'!, >upero 
inferior (5 to oS, lateral S to L'S. Fsual, leaving out five highest and 
lowest, anteroposterior 17 to L'(i. su]>eroinferior 17 to .'11, lateral 11 to 
.IS. Average, anteroposterior L'L'..'l, snperoinferior L'.'l.-'l, lateral 14.7. 

The largest is that of vn ( Fii;'. L'(i) left, :',(), :i(i, L'O, and the smallest 
that of xn (Fii>-. L'(i) ri^ht, IT), (i, S. 

Sphenoid Sinus. -There is a tremendous variation in the dimen- 
sions of the thirty sphenoid sinuses, as shown in the following table; 


(111 MillillH'UTS.) 



































































'> ~ 















































2 i 



The anteroposterior diameter varies from '2 mm. in > 
riu'ht, to 4'J imn. in vn ( Fi.u'. -1 ) riu'ht: the superoinferioi' trom 4 in N 
(Fi-. I'D) ri.i'lit, to ;>S in xiv ( Fi.ii'. L'S ) ri.ii-lit: lateral from L' in \ 
% J9) riii'lit, to .'!.") in xm ( b'i.u'. L'7) ri^ht. 

The sphenoid sinus of xv ( M^. 'JiM ri.u'ht, is by far t 
with diameters '2, 4 and '2: the next smallest liein.u- xn ( Fi.u'. '-Mil riii'ht. 
with diameters 1), S and 7. That of vn ( Fiir. -1) ri.u'lit, is the largest 
with diameters 4'2, '2'2 and :U: while that of vi ( Fiu 1 -'> riu'ht. i- next 
largest, with diameters .'!."), .'1(1 and .">!. 


The average diameters of the thirty sinuses are as follows: 
Anteroposterior 21.5, superoinferior 22.8, lateral 18.4. Excluding five 
extremes, smallest and largest, the range of the remaining twenty, 
which may be considered as common, is as follows: Anteroposterior 
14 to 32, superoinferior 17 to 27, lateral 11 to 27. 

Fix. :!.-). ( Head VII.) 
Piaster casts of sphenoid sinuses, placed in situ. 

A glance at the reconstruction of the sphenoid sinuses (Figs. 20 
to 34) shows the great variety of sixe and shape. The right sphenoid 
xv (Fig. 29) is hut little larger than its opening into the nasal cavity, 
which is in its accustomed position. It is replaced almost, entirely by 
the left sphenoid, which is in relation with the optic chiasm, and both 
nerves. Both sphenoids of vn are exceedingly large (Fig. 21) and 
extend far behind the optic chiasm, sharing this feature with vi (Fig. 


L'O) right, xn (Fig- -<>) h'H, xm (Fig. L'7) left, XYII (Fig. :!1 ) riulil, 
and xix (Fig. IV,}) right. 

Thoro is likewise .^i-cat disparity in tin- sixe of the two sphenoid 

Fig. 36. (Head XII.) 
Plaster easts of sphenoid sinuses, placed in situ. 

sinuses in vi (Fig. '20), XH (Fig. _()), xiv (Fig. JS), xv (Fig. :M>) and 
xix (Fig. 33). 

In xvi neither sphenoid is in relation with the left optic nerve 
(Fig. 30). A large 1 posterior ethmoid cell replaces the left sphenoid 
which is greatlv reduced in si/.e. 



Superficial Area and Cubical Capacity of the Sinuses. 

In order to determine the superficial area and cubical capacity 
of the sinuses, it is necessary to make casts of them and subject these 

Fit;. III. ( Head XIV.) 
faster cast:- of sphenoid sinuses, placed in situ. 

to some standard of measurements. liraniic and ( 'lasen found the 
cubical capacity hv \'olnmetric measnrejnents of metallic casts of the 
sinuses. The writer presented ;i method at the International Larynu'o- 


.. i 

o^'ioal Congress in Berlin in 1!)11, by \vliicli both tin- 
capacity and flic superficial area (for the first lime) were determinable 
from plaster casts made of the sinuses (except the ethmoidal) in serial 
sections, and then properly united according to the methods used by 

Fig. :',8. ( I load XXIII.) 
Plaster casts of sphenoid sinuses, placed in situ. 

dentists. A number of illustrations of such casts of the sphenoids are 
here presented, the casts beinir placed in proper position in the lowest 
section. A far better understandinir of the extent and variability of 
the sphenoid sinuses is secured by this method than by any other. 



It will be observed that the sphenoid sinuses although showing little 
resemblance to one another in the different heads, are fairly uniform 
in shape and size in VH (Fig. 35), xxm (Fig. 38) and xxxv (Fig. 40). 

Fig. ::i). (Head XXVI.) 
Plaster casts of sphenoid sinuses, placed in situ. 

These are all large except xxin. The greatest difference is to be seen in 
xri (Fig. 30) in which the right sphenoid is reduced to a cavity 2 by 2 
by 4 nun. xiv (Kig. 37) and xxvi (Tig. 3!)) show considerable difference 
in the size of the two sphenoids. 


The results of the measurements mav he summari/ed ;is follow 

Superficial Area in 
Square Centimeters. 

Cubical Capacity in 
Cubic Centimeters. 









:!2 :! 

r> . r, 







Fig. 4U. (Head XXXV.) 
Plaster casts of sphenoid sinuses, placed in situ. 



Optic Chiasm and Nerve. 

The relation of these structures to the nose and accessory sinuses 
is of importance from the standpoint of both pathology and surgery. 







Fig. 41. (Head VI.) 
Preparation showing relation of optic nerve to accessory sinuses of the nose. 




" - SINUS 


Kit;. \'2. I Head VII.) 
IMv-panit ion sliowing relation of optic nerve to accessory sinuses of the nose. 



The author has made a study of this in the fifteen heads illustrated 
in File's. 41 to .">,") inclusive. These are the same heads of which recon- 
structions were made as shown in Fi.u's. l'0 to .'54 inclusive. 










Fig 43. (Head VIII.) 
Preparation showing- relation of optic nerve to accessory sinuses of the nose 












Fig. 44. ( Head IX.) 
Preparation showing relation of optic nerve to accessory sinuses of the no; 



The optic cliiasm in these heads is in the main in relation with one 
or both sphenoid sinuses. It is directly upon the roof in heads vi (Fig. 
41) both sides; vn ( Fii>\ 4:2); xn ( Fig. 47) both sides; xm (Fig-. 48) left; 


I / 













Fig. 45. (Head X.) 
Preparation showing relation of optic nerve to accessory sinuses of the nose. 


\ / 





Fig. 4. (Head XI.) 
Preparation showing relation of optic nerve to accessory sinuses of the nose 


xv (Fig. 50) Ici't; xvii (F 
xix (Fig. 54) both sides. 

It lies considerably above the 
4!)) left; xvi (Fig. 51) left. 

It lies posterior to the sphenoid sinus in vm ( Fig. 4i! 

52) right ; xvm ( 
f in vm ( Fiir. 4.'! 

i-. 5.'!) left; 
eft; xiv ( Fiir. 
both sides; 

ix (Fig. 44) both sides; x (Fig. 45) both sides; xi (Fiji 1 . 4(1) both side>; 
xm (Fig. 4S) right; xiv (Fig. 4!)) both sides; xvi ( Fig. 51) both side-; 
xvn (Fig. 52) left; xx (Fig. 55) both sides. 

It is thus seen that in more than half of the instances the chiasm 
lies posterior to the sphenoid cavity. Special attention is called to 
vi, vii, xii, xm, xvn, xix, where a considerable portion of the sphenoid 
cavity lies beyond the anterior margin of the optic ehiasni. Xo other 
cells among these specimens come into relation with the optic ehiasni. 

The optic nerve may be described as passing externally 1'roni the 
ehiasni along the roof or lateral wall of the sphenoid sinus in slight 
relation, usually with the last posterior ethmoid cell, and from thence 
to the bulbils opticus through the periorbita. 

It may be divided into a sinus portion and a free portion, t'nder 
the former term, I include that part of the nerve in immediate relation 
with the accessory cavities of the nose or (arbitrarily) within ."> mm. 
of the sinus wall. 

The following measurements show the length of the nerve in the 
different beads: 


(In MilliiiK'trrs.) 

















Free Portion. 

Sinus Portion. 











2 3 






















































































The following variations are obtained: 
Optic nerve: range. .'54 to 55; usual, leav 
five, 40 to 48; average 44. 

g off highest and lowest 


Free portions: range, 12 to .'>S; usual, leaving off highest and low- 
est five, 15 to 2.'>; average '20. 

Sinus portion: range, 17 to .'>2; usual, leaving of highest and low- 
est five, 21 to 2S; average 24. 

It is therefore clear that, at least in these heads, the sinus portion 
of the optic nerve is a trifle greater than the free portion. 

There does not appear to be any correspondence between the 
length of the optic nerve and the extent of accessory cavities. 

Where the sinus is very large, the optic nerve has its origin in 
the chiasni on the roof of the sphenoid, some distance anterior to the 
posterior wall of the sinus, as for instance in vr (Fig. 41) right; vn 
(Fiii 1 . 42) both sides: xn (Fig. 47) left; xm (Fig. 4S) both sides; 
xx (Fig. 55) both sides. 

Where the sinus is small, the optic nerve leaves the chiasni ,u - en- 
erally behind the sinus, as seen in vm (Fig. 4.'>) ; ix (Fig. 44) both 
sides; x (Fig. 45) both sides; xvi (Fig. 51 ) both sides. Head xvm (Fig, 
5.'!) is somewhat at variance with this rule, but, under any circum- 
stances, it does not appear possible to assign the variation of the sinus 
as an explanation for the varying si/e of the optic nerve, nor for the 
relation which the sphenoid opening bears to the optic nerve. 

The following table of measurements shows this difference. 


(In Millimeters.) 



14 1-1 

X ~> 

11' 11 

Kan i:e, ~2 above to 14; usual, leaving off highest and lowest live, 
'2 below and II; average (i. 

In two instances xvm ( l-'iu'. .").'!) both sides, and xi\ (l^i.t;'. 54) right, 


the orifice is above the lower surface of the optic, and in xin ( Fix. 4*) 
left, it roaches the same level. In nine instances out of the thirtv, tin- 







Fig. 47. (Head XII.) 
Preparation showing relation of optic nerve to accessory sinuses of the nose 










Fig. 48. (Head XIII.) 
Preparation showing relation of optic nerve TO accessory sinuses of the nose 



optic nerve lies within .'> mm. of the level of the orifice of the sinus. 
When the optic nerve lies so near the level of the orifice of the 












Fig. 4!. (Head XIV.) 
Preparation showing relation of optic nerve to accessory sinuses of the nose. 








Fig. r.ii. ( Hi ad XV. ) 
Preparation showing relation of optic nerve to accessory sinuses of the nose. 


sphenoid, it is in a far more vulnerable position than when its distance 
is greater, for the orifice represents the possible height of pus in 
sphenoid empvema with an open orifice. 











Fig. 51. (Head XVI.) 
Preparation showing relation of optic nerve to accessory sinuses of the nose. 








Head XVII.) 

Preparation showing relation of optic nerve ro accessory sinuses of the nose 



The optic nerve as a rule comes into relation with the postero- 
external aiii>'le of the last posterior ethmoid cell at its roof, and from 
this point it passes in an external direction through the periorbita to 












Fig. 5::. (Head XVI 1 1.) 
Preparation showing relation of optic nerve to accessory sinuses of the nose. 





Fig. .VI. ( ilr;i(l XIX. I 

'reparation sliowiiig relation of optic nerve to accessory sinuses o 


the l)iilbus. The space between the nerve and the ethmoid labyrinth 
increases in almost direct proportion as the nerve approaches the 
bulbus, and its junction with the bulbus is generally the position of 
greatest distance between the nerve and the ethmoid labyrinth. 

In only one case, xn (Fig. 47) does the anterior ethmoidal cell 
come in close relation with the optic nerve, replacing a posterior 
ethmoid cell which lies below it. The relation which the nerve bears 
to the last posterior ethmoid, when that cell replaces the sphenoid, 









Fig. 55 (Head XX.) 
Preparation showing relation of optic nerve to accessory sinuses of the nose. 

is very characteristic, for in the two instances in which this replace- 
ment is present in the heads examined, xvi ( Fig. ")1 ) and xvm 
(Fig. 53), the nerve is found to run along the external wall of the 
cavity. This increases the ethmoid portion very considerably, chang- 
ing it from a course along an angle to one along a wall which it follows 
in an almost surprising manner. This probably explains the cases of 
optic neuritis which complicate an ethmoiditis without an accompany- 
ing spheuoiditis, as in the writer's case of blindness cured by ethmoid 



The frontal sinus is relatively distant from the optic nerve, the 
nearest point being, as a rule, at the inner side of the orbit, and here 
it is much further away than the corresponding- anterior ethmoid cells, 
which ordinarily lie anterior to it at the level of the optic nerve. In 
some instances, however, the frontal sinus may extend for a consider- 
able distance backward; for example VH, x, xi, xn, xv, xvn, xvm, xx. 
In all the cases the sinus is much closer to the optic nerve than where 
the sinus remains anterior. 

In all the specimens the periorbital fat makes a close relation 
with the maxillary sinus impossible, although, in some instances, the 
distance is less than 1.0 mm. 

Nasolacrimal Duct. 

The increasing disposition to treat stenosis of the nasolacrimal 
duct by operation through the nose justifies a study of its topographic 






Ki^ht lateral wall of the nose with exposure of the saccus nasolacrimalis 
and ductus nasolacrimalis. 



relations in the nose. The superior and inferior canalicula- lacrimales, 
whicli start at tlie pnneta laeriinalis, convey the tears into an expanded 
pouch called the saccus laeriinalis closed above and bcin.i;' continuous 
below with the ductiis nasolacriinalis which itself opens just below the 
maxillary attachment of the concha inferior. 

The saecus laeriinalis lies in the fossa lacrimalis between the 
crista lacrimalis anterior and the crista laeriinalis posterior (Fiu's. !), 











Coronal section through the sphenoid sinuses, removal of septum sinuuin 
sphenoidalium and exposure of the hypophysis l>y enttin.u away the bone of 
the posterior wall of the left sphenoid sinus. 

11). It extends to the canal (canalis nasolacriinalis) and merges into 
the ductus nasolacriinalis which runs between the lateral wall of the 
nose and the maxillary sinus. 

The illustration ( Fi,u'. .")(>) shows the course of the sac (the ripper 
expanded portion) and the duct alonir the external wall of the nose. 
In the specimen, the bone of the external wall has been cut away 


leaving the sac and the duct free as far as its opening below the in- 
ferior turbinate. It is to be observed that they lie anterior to the 
middle turbinate and anterior and inferior to the first ethmoid cell 
which is here exposed. 

Hypophysis (Pituitary Body). 

The location of the pituitary body or hypophysis behind the sphe- 
noid sinuses, makes it a factor in intranasal surgery. It lies in the fossa 
hypophyseos of the sphenoid bone (Fig. 56). It consists of an anterior 
grey portion, ectodermic in origin, and a posterior white portion, epider- 
mic in origin, connected by the infundibulum with the third ventricle. A 
reflection of the dura, diaphragma selhe, which stretches from the an- 
terior to the posterior clinoid processes separates the hypophysis from 
the optic chiasni and optic tracts, which lie just above it. The 
infundibulum penetrates the dura behind the optic chiasm and between 
the right and left optic tracts. Laterally the cavernous sinus surround- 
ing the internal carotid artery comes into relation with the pituitary 
body and the adjacent structures. Anteriorly and inferiorly it conies into 
relation with the sphenoidal sinus, as shown in Figs. V_* and 56. 
Figure 57 is an illustration of a preparation made by cutting away 
that part of the roof of the sphenoid sinus forming the hypophyseal 
fossa and the dnral investment, leaving the pituitary body free in the 
cavity. The septum between the two sinuses has also been removed. 
The specimen shows how the hypophysis may be safely exposed by an 
(iidonasal operation through the sphenoid sinuses. 

Vascular Supply. 

Arteries. The arteries of the external nose have their origin 
mainly from the arteria maxillaris externa. Branches of the arteria 
ophthalmica and arteria septi communicate with the network from the 
arteria maxillaris exlerna. The frontal region is supplied by the arteria 
ophthalmica, the arteria frontalis and the arteria supraorbitalis. 

The nasal cavities and the accessory cavities are supplied by the 
branches of the arteria ophthalmica, arteria maxillaris interim and the 
nrteria maxillaris externa. 

The arteria sphenopalatina, terminal branch of the arteria maxil- 
laris interim passes from the fossa ptcrygopalat ina through the for- 
amen sphenopalatimim into the nasal cavity, giving off the arteria' 
nasales posteriores and the arteria' nasales posteriores septi (nasopala- 

The branches of these vessels supply the inferior, middle and 

THE Sl T K<iK'AL ANATOMY OK 'I 1 1 K NoSK. ,)'.} 

superior turbinates, the mucosa of the inferior and middle meatus, the 
sphenoid sinus, and also a portion of the septum. 

The arteria etlunoidalis anterior and the arteria ethmoidalc 
posterior leave the orbit through the foramen ethmoidalis anterius 
and the foramen ethmoidale posterius respectively, enter the cranial 
cavity passing under the dura and perforate into the nose through the 
lamina cribrosa supplying the ethmoid cells, and the upper portion of 
the lateral nasal wall and septum. 

The arteria alveolaris superior, and arteria alveolaris posterior 
and the arteria infraorbitalis su])])ly the inucosa of the maxillary sinus 
and the periosteum of the maxilla. 

Veins. The venous network of the external nose is connected with 
that of the vena facialis anterior and vena ophthalmica, the following 
veins collecting the supply, vena nasofrontalis and vena angularis. 

The veins of the nasal cavities and the accessory cavities are con- 
nected with those of the nasopharynx, eye, dura, while those of the 
mucosa of the concha are connected with the plexus cavernosus in addi- 

The venous supply in this region is collected by the vena etlunoid- 
alis anterior and the vena ethmoidalis posterior which enter the vena 
ophthalmica superior and the vena ophthalmica inferior. 


The nervus olfactorius sends its filaments (fila olfactoria) about 
twenty in number, through the lamina cribrosa and they supply the 
inucosa of the superior and middle upper part of the turbinate and the 
septum in the corresponding position. 

The first and second branches of the nervus trigeminus supply the 
nasal mucosa. The nervus ethmoidalis anterior and nervus ethmoidalis 
posterior originate from the first, and the nervus sphenopalatinus and 
nervus infraorbital from the second. 

The nervus ethmoidalis posterior which is accompanied by a small 
branch from the sphenopalatine supplies the mucosa of the sphenoid 
sinus and posterior ethmoid cells. The nervus ethmoidalis anterior has 
three branches, the ramus septi supplying the upper portion of the 
inucosa of the septum, the ramus lateralis, the middle turbinate and 
anterior portion of the inferior turbinate and posterolateral wall of 
the nose and the ramus anterior to that of the anterior portion of the 

The nervus infraorbitalis gives off the nervi alveolares superiores 
which supply the mucosa of the maxillary sinus and anterior part of 
the floor of the nose. The ganglion sphenopalatinum gives off the nervi 


nasales which supply the upper and posterior portion of the lateral wall 
of the nose, the niucosa of the superior meatus/and the superior and 
middle turbinates and ethmoid cells. 

The nervi nasopalatini are branches of the ganglion splienopala- 
tinuin which sup])ly the posterosuperior portion of the septum. The 
rei'vus nasopalatiims is the largest branch of the sphenopalatine. It 
passes down the septum to the canalis incisivus and supplies the adja- 
cent portions of the septum. 

The nervus ethmoidalis anterior supplies the niucosa of the an- 
terior ethmoid cells and frontal sinus; the nervi alveolares supcriores 
the maxillary sinus; the nervus ethmoidalis posterior and the nervi 
nasales the posterior ethmoid cells; and the nervi nasales the sphenoid 

Sympathetic System. Fibres from the plexus caroticus pass 
through the ganglion sphenopalat'mum which gives off fibres which are 
distributed to the posterior two-thirds of the inferior and middle 
turbinate and nasal septum. 


Bv (}KOI:<;K B. WOOD, M. I). 


The pharynx, which is a funnel-shaped tube, is divided for con- 
venience of description into three portions, the. nasopharynx, oro- 
pharynx and the laryngopharynx. During <|iiiet inspiration with the 
month closed it presents anteriorly in order from above downward 
the posterior mires or choamr, the soft palate with its anterior pillars 
attached to the tongue and its posterior pillars to the lateral wall of 
the pharynx, the epiglottis (the tip of which is almost in contact with 
the uvula), the laryngeal opening, the posterior surface of the arytc- 
noid bodies, and on each side of these, the pyriform sinuses. Each 
lateral wall presents the Eustachian prominence with the opening of 
the Eustachian tube, posterior to this the fossa of Rosenmiiller and be- 
low, the lateral folds of the pharynx. The posterior wall is a smooth 
surface showing small deposits of lyniphoid tissue and is continuous 
above with the vault, which arches forward to the upper part of the 
choaiue. In the vault is situated the large mass of lymphoid tissue 
which is designated the pharyngeal tonsil. The pharynx is greater 
in its lateral than in its anteroposterior diameter, the greatest breadth 
being just above the soft palate. 

The Nasopharynx. 

The nasopharynx extending from the vault to the lower border 
of the soft palate is an open cavity, the lateral, superior and posterior 
walls of which are rigid. The choaiur or posterior nares are two oblong 
spaces taking the place of practically the whole of the anterior wall. 
The vault or fornix of the pharynx forms the roof of the cavity and is 
occupied in part by the pharyngeal tonsil. 

The Pharyngeal Tonsil, composed of lymphoid tissue, varies ex- 
tremely in size and shape. It may consist simply of a few small eleva- 
tions scarcely noticeable to the naked eye, or it may be a large pendant 
mass filling the greater part of the nasopharyngeal cavity. In shape 




it may be a more or less distinct rounded elevation, placed directly in 
the middle of the vault just behind the upper level of the choanae and 
the upper part of the nasal septum, or it may be diffused, spreading 
from the vault out into the fossa of Rosenmiiller, downward on the 
posterior pharyngeal wall, and latterly to the lateral folds. 

On each side of the pharyngeal tonsil, and at about the level of 
the posterior end of the inferior turbinal is the pharyngeal orifice of 

Fig. r,8. 

Median section through face of an adult man, showing the normal 
relations of the structures during quiet nasal respiration. 

1, Frontal sinus; '2, Anterior palatal pillar: '.'>, Posterior palatal pillar; 
4, Sphenoid sinus; ~>, Posterior edge of nasal septum; 6, Fossa of Jtosen- 
miiller; 7, Pharyngeal tonsil; 8, Ostium of Kustarhian tube; It, Dotted line 
showing contour of the tongue; 10, Salpingopharyngeal fold; 11, Plica 
triangularis; 1L', Palatal tonsil; I/!, Lateral pharyngeal fold: 14, Epi- 
glottis; ir>, Ventricular band; Ki, Vocal cord. 

the Eustachiau tube. The opening is quite large, funnel-shaped, with 
a small end of the funnel directed towards the tympanum. Above and 
behind the opening is the Kustacliian prominence, consisting of a 
rounded ridge formed by the projection of the Rustachian cartilage. 


The anterior margin of the opening is much less prominent than the 
posterior and this fact helps greatly in Ihc introduction of the Eu- 
stachian catheter. Extending downward from the posterior margin 
of the Eustachian tube is a fold of mucous membrane, the salpingo- 
pharyngeal fold, which is gradually lost in the lateral wall of the 
pharynx, or it may be continuous with the lateral pharyngeal fold. A 
somewhat similar ridge, but much less marked, is the salpingopalatine 
fold which runs from the anterior border of the Eustachian orifice 
downward and forward to the palate. Contraction of the levator palati 






Median section through the face of an infant one month old, showing 
the relations of the structures during quiet nasal respiration. 

1, Superior turbinate; 2, Middle turbinate; 3, Inferior turbinate; 4, 
Anterior palatal pillar; 5, Body of sphenoid bone; 6, Eustachian tube; 
7, Pharyngeal tonsil; 8, Posterior palatal pillar; 9, Dotted line showing 
contour of the tongue; 10, Plica triangularis; 11. Epiglottis; 12, Ventricular 
band; 13, Vocal cord. 

muscle produces an elevation known as the levator cushion which 
presses to a greater or less extent against the lower border of the 
Eustachian orifice. Behind the Eustachian prominence is a wedge- 
shaped depression called the fossa of Rosenmiiller, or the lateral recess 
of the pharynx. This depression gradually disappears on the lateral 
wall of the pharynx at about the level of the soft palate. It tends to 
accentuate the Eustachian prominence and the salpingopharyngeal 
fold. In the middle of the vault of the pharynx is a sinus running up 
behind the pharyngeal tonsil. This sinus is called the bursa pharyngea, 
and is supposed by some to be the remnant of the lower portion of the 



pouch of Hatlike. It is, however, simply an occlusion sinus formed by 
the adhesion of folds of the pliaryngeal tonsil. 

The vault of the pharynx receives its blood supply chiefly from 
the pliaryngeal branch of the vidian artery. The branches of this 
artery anastomose with the ascending pliaryngeal, and the pharyngeal 
branch of the pterygopalatine. The pterygopalatine is a branch of the 
internal maxillary, while the ascending pharyngeal comes directly from 
the external carotid. The veins follow roughly the course of their cor- 
responding arteries and open into the pterygoid plexus which is situ- 
ated partly on the inner surface of the internal pterygoid muscle, and 

Fig. 60. 

Transverse section through the head of a child one month old, just 
in front of the posterior pharyngeal wall. The neck hai; been twisted so 
that the larynx is thrown somewhat to the left. Illustration shows the rela- 
tion of the epiglottis to the uvula. 

1, Pharyngeal tonsil; 2, Nasal septum; 

:>, Uvula: 4, Epiglottis; 5, 

partly around tin- external pterygoid muscle. The pterygoid plexus 
empties posteriorly into the internal maxillary vein and anteriorly into 
the deep facial vein. 

The lymphatic drainage of the vault of the pharynx is through a 
rather close mesh of lymph vessels, which drain either into the rctro- 
pharyngeal lymph gland, or into the posterior or external group of the 
deep lateral chain, the vessels passing posteriorly to the large vessels 
of the neck, and behind the rectus capitis anticus muscle. 

The nerve supply of the pharyngeal vault is derived from the 
pharyngeal branches of Meckel's ganglion. 


The Oropharynx. 

The division between the nasopharynx and oropharynx is a very 
movable one consisting' of the free edge of the soft palate. The upper 
surface of the soft palate forms an anteroinferior wall to the naso- 
pharynx, while the inferior surface is directed towards the month, hi 
the infant the lower border of the soft palate reaches almost to the 
epiglottis, but in the adult there is more space between the epiglottis 
and the palate which is tilled in by the dorsum of the tongue. The an- 
terior wall of the oropharynx is, therefore, made up of the uvula, phar- 
yngeal portion of the dorsum of the tongue and the epiglottis. The 
lateral diameter is about twice the anteroposterior diameter, but both 
of these- distances are constantly changing, according to the action of 
the palatal and pharyngeal muscles. The lateral wall of the oro- 
pharynx generally presents a more or less marked perpendicular ridge 
of lymphoid tissue, sometimes spoken of as the lateral pharyngeal fold. 

Palatal or Faucial Tonsil. The palatal tonsil, more generally 
spoken of as the faucial but less correctly so, is situated in a fossa be- 
tween the anterior and posterior palatal or faucial pillars. Both in 
size and shape, the tonsil varies extraordinarily. To understand this 
variation we must study the development of the organ. Probably the 
first recognizable sign of the faucial tonsil is to be found in the embryo 
at four months. At five months there is a distinct vertical groove 
about '2 mm. in height, at the bottom of which a small mass of adenoid 
tissue has already developed and in this mass minute slit-like impres- 
sions can be found. In the embryo at eight months the form of the 
tonsil is fairly constant. At this time the tonsil does not project be- 
yond the surface and is covered anteriorly by a fold called the plica 
triangularis or operculum. This fold divides a little above its middle 
into two distinct branches, one running anteriorly to the tongue form- 
ing a fold called the plica pretonsillaris, and another running poste- 
riorly passing round the base of the tonsil anlage called the plica infra- 
tonsillaris. The space bounded by these two folds above, and by the 
tongue below, is called the fossa triangularis. The upper part 
of the plica triangularis is continued above the tonsil until it 
meets the posterior pillar of the fauces and in this position i> 
called the plica supratonsillaris. At this time the tonsillar mass 
is irregularly divided into three lobes by two fissures, running 
from below and behind upward and forward. The lower and middle 
are merged into one another in front and the upper and middle less dis- 
tinctly so behind. At the junction of the two lower the plica triangu- 
laris becomes adherent to the tonsillar mass, and in this wav a recess 


is formed above and slightly to the front of the superior convolution 
which later develops into the supratonsillar fossa. In the majority of 
children at birth this typical condition can be recognized only with 
difficulty, as the tonsil is already beginning to take on the irregularity 
of growth which is one of its characteristic features. After birth the 
development of the tonsil is very irregular, and its final shape and size 
depend upon the position and amount of adenoid tissue present. In 

4 r 

Fig. 61. 
The region of the palatal tonsil. 

1, Supratonsillar fossa; 2, Uvula: ?>, Posterior palatal pillar: 4, Kpi- 
glottis; .">, Plica supratonsillaris; 6, Dotted line showing the subsurface extent 
of the tonsil; 7, Anterior palatal pillar made prominent by traction on 
ihe tongue; X. Plica triangularis ; It, Cut surface of tongue, traction being 
made df; \vn\vard. 

the majority of cases the greatest amount of development takes place 
in tin; lower two lobes. These by their growth project outward and 
finally hide from view the superior lobe which can be found only by 
looking deep into the supratonsillar fossa. If the adenoid tissue de- 
velop:- in the supratonsillar margin, a distinct tonsillar mass will be 
found in the palate, ;md its growth downward leaves a listuloiis tract 
running upward from the hilnm of the tonsil. The plica triangularis 


may remain rudimentary in which case it can scarcely he seen, or it 
may develop so as to cover to a greater or less extent the anterior 
portion of the tonsillar mass. In those cases in which the development 
involves chiefly the superior lobe the snpratonsillar fossa becomes al- 
most obliterated. The vagaries of the growth of adenoid tissue in the 
various parts of the tonsil determine the shape and sixe of the tonsillar 

The tonsil is separated from the surrounding 1 structures by a dis 
tinct fibrous capsule. This capsule surrounds the tonsil on all sides 
except the mesial free surface. At the front it runs inward beneath the 
plica triangularis over the surface of the tonsil almost to the line where 
the plica merges into the tonsillar mass. Behind it terminates at the 
free edge of the posterior pillars, above it reaches to the supratonsillar 
margin, but below it does not come quite to the surface epithelium, as 
there is very apt to be a thick lymphoid deposit just below the tonsil. 
The capsule sends strong fibrous trabecuhe into the substance of the 
tonsil which carry the blood vessels, lymphatics and nerves. An im- 
portant peculiarity of the operculum or plica triangularis is that in the 
fully developed tonsil it is attached firmly to the tonsillar mass only 
close to its very edge, and can be readily separated from the capsule 
which covers the front of the tonsil. 

The crypts are ingrowths of the surface epithelium, their lumina 
being formed by the desquamation of a central core. These crypts vary 
both in number and in sixe but they generally run deep into the ade- 
noid mass, terminating usually close to the capsule, and they may com- 
municate more or less with each other. They are as a rule larger and 
more numerous in the upper part of the tonsil. In the usual type of 
tonsil the growth of the two lower lobes forms a dee]) pocket close to 
the capsule, with its opening in the supratonsillar fossa. This pocket 
is not in the true sense of the word a cry] it, but is rather an inclusion 
recess similar to that which forms in the palate from overgrowth of 
the supratonsillar margin. 

The tonsil is surrounded externally by the pharyngeal aponeu- 
rosis which is rather loosely associated with the capsule. Ex- 
ternal to this is the superior constrictor muscle of the pharynx. Still 
further externally is the buccopharyngeal fascia, a thin and in places 
ill defined layer which surrounds the constrictors of the pharynx and 
the outer surface of the buccinator muscle. Immediately beyond this 
rather thin covering, the tonsil is in relation with a space filled with 
loose fatty areolar tissue. The outer wall of this space is formed by 
the internal pterygoid muscle; its posterior wall by the prevertebral 
muscles and the internal wall by the pharynx. This triangular space 



is irregularly <livido<l into two smaller spaces by the stylopliaryngeus 
muscle, and external to this by the styloglossus muscle. The faucial 
tonsil is in relation with the anterior of these two divisions, while the 
internal carotid artery is placed well back in the posterior division. 
The internal carotid is never closer than l.f) cm. from the wall and 
the pharynx is more or less separated from it by the interposition of 
the stylopharyngeus muscle. The external carotid artery lies about 2 
cm. from the lateral wall of the pharynx, and lias interposed between 
it and the tonsil a portion of the parotid gland, and the whole of the 

Dissection of the region of the palatal tonsil from the outside 1 . 

1, Capsule of palatal tonsil; 2, Facial artery; '!, I lypei^lossal nerve; 
4, Superior thyroid artery: f>, Tonsillar branch of facial artery; (!, Occipital 
artery; 7, Internal care>tiel artery; 8, Lingual artery; !(, External carotid 
arte-ry; 10, Spinal acce>sse)ry nerve; 11, Common care>tiel artery; 1_. De- 
scendens hypo^leissi nerve; II!, Pneuniogastric nerve. 

musculature of the styloid process. It must be remembered, however, 
that the outer surface of an enlarged and embedded tonsil is not in 
the same plane as the pharynu'eal wall, and it thus may come in much 
closer relation to the large blood vessels in the neck than the above 
description would lead one to suppose. Furthermore, the facial artery 
quite frequently, after branching from the external carotid, has a de- 
cided upward bend before it sweeps outward to pass around the rainus 
of the jaw. When this upper bending is marked, the loop of the artery 
formed comes in close relation to the inferior portion of the ton 


sil, making it possible to wound this artery during o|)eration> on the 
tonsils. The only muscle intervening between it and the tonsil is the 
superior constrictor. The two carotid arteries, however, are sep- 
arated from the tonsil by the stylopliaryngeus and the styloglossus. 

Tbe blood supply of the tonsil comes chiefly through the tonsillar 
branch of the facial artery. The lower part of the tonsil, however, 
may be supplied from a branch of the lingual, sometimes coming from 
the dorsalis lingua*, and sometimes from the main lingual trunk. Oc- 
casionally tbe palatine branch of the ascending pharyngeal supplies 
the posterior upper part. The internal maxillary also contributes to 
the blood supply of the tonsil through a small branch coming from the 
posterior or descending palatine. The division from the facial gener- 
ally breaks up into two or three branches which penetrate the capsule 
and which again break up into numerous branches before entering the 
tonsil with the trabecuhe. Sometimes almost a plexus of arteries is 
formed in the outer layers of the capsule by the anastomoses of the 
supplying blood vessels. 

The nerve supply of the tonsil is through a special branch of the 
glossopharyngeal, which, uniting with branches from the pharyngeal 
plexus forms what might be called a small tonsillar plexus. 

Pillars and Lateral and Posterior Walls. The anterior palatal 
pillar or anterior pillar of the fauces is a fold caused by the prom- 
inence of the palatoglossal muscle, while tin- posterior pala- 
tal pillar, or posterior pillar of the fauces, is formed by the 
palatopharyngeal muscle. Behind the posterior palatal pillars on 
each side of the pharynx is found a more or less well-marked mass of 
lymphoid tissue, longitudinal in shape, generally spoken of as the 
lateral fold of the pharynx. This longitudinal elevation appears to be 
a continuance downward of the salpingopharyngeal fold, its promi- 
nence, however, is due not to a prominent muscle but to the lymphoid 
tissue, which according to Cortes at times resembles the structures of 
the faucial tonsil, possessing crypts and other of its peculiar histologic 
characteristics. On the posterior pharyngeal wall we find a varying 
number of isolated patches of lymphoid tissue, spoken of as lymphoid 
follicles. These small lymplioid structures are more numerous in the 
upper part of the throat, and seem to be an irregular downward ex- 
tension of the pharyngeal tonsil. 

The Laryngopharynx. 

The laryngeal portion of the pharynx, or the laryngopharynx, ex- 
tends from the epiglottis down behind the larynx to the level of the 
sixth cervical vertebra. This corresponds about to the lower border 


of the cricoid cartilage. Below the arytenoid cartilages the walls of 
the laryngopharynx are in apposition except during the act of swal- 
lowing. In front of the epiglottis and on the base of the tongue is an 
accumulation of lyniphoid tissue called the lingual tonsil. The varia- 
tion in size and shape of the lingual tonsil is very marked. Generally 
it is scarcely more than a rather close aggregation of separate nodes, 
giving simply a roughened appearance to the base of the tongue. 
Sometimes, however, it develops in two lateral masses which may be so 
large as to be more or less pendulous. 

Below the lingual tonsil there are two depressions, the bottom of 
which represents the junction of the epiglottic mucous membrane with 
that of the tongue. These depressions are called vallecula\ The val- 
lecuhr are separated by a distinct fold of mucous membrane, the median 
glossoepiglottic fold, or as it is sometimes called the frenuin of the epi- 
glottis. Each is bounded externally by another fold of mucous mem- 
brane, the lateral glossoepiglottic fold. 

The pyriform sinuses are deep depressions somewhat boat-shaped, 
elongated in a vertical direction, placed on each side of the upper part 
of the larynx between the ala of the thyroid cartilage and the thyro- 
hyoid membrane on the outside, and the arytenoepiglottic fold on the 
inside. They are bounded anteriorly by the lateral glossoepiglottic 
folds, and posteriorly pass gradually down into the laryngopharynx. 

The blood supply of the laryngopharynx is derived solely from the 
external carotid, and chiefly through the ascending pharyngeal 
branch. Other contributory branches are the ascending palatine branch 
of the facial, and the tonsillar branch of the facial, also the posterior 
palatine and pterygopalatine brandies of the internal maxillary, and 
sometimes a few twigs from the lingual. The smaller veins from the 
pharynx pass into a pharyngeal plexus which may be found between 
the biiccopharyngeal aponeurosis and the constrictors. This plexus 
anastomoses with the pterygoid plexus above, and empties below 
cither into the internal jugular or into the facial vein. 

Lymphatics of the Pharynx. 

The lymphatics of the pharynx consist of a network beneath the 
pharyngeal epithelium and the superficial layer of the mucous ciitis. 
This network is probably most marked on the posterior surface of the 
larynx and in the pyriform sinuses; it is also very rich in the pharyn- 
U'eal tonsil but very scanty near the esophageal opening. A less im- 
portant network is found in the muscular tissue. 

The superior collecting trunks generally pass first to the rctro- 
pharyngeal lymph glands. They may, however, pass by these glands 


and terminate in the deep cervical lymphatics, and according 1o I'oirer, 
into the anterior group, hut according to the researches of the author, 
both anatomic and clinical, they terminate in the posterior group. 

The middle collecting trunks drain the mucous membrane of the 
tonsillar region. These vessels perforate the muscular coat just above 
the great cornu of the hvoid bone, and terminate in the anterior glands 
of the internal jugular group near the posterior belly of the digastric 

Tlie inferior collecting trunks drain the lower part of the pharynx 
running under the mucous membrane, and tend to converge in the 
pyriform sinuses. They here unite \vith the superior lymphatics of 
the larynx and with them end in the glands of the internal jugular 
group just below the digastric muscle. 

The lymph vessels of the soft palate are very numerous, forming 
a fine network which is more or less continuous with that of the neigh- 
boring structures. This network is richest in the uvula. There are 
separate collecting trunks from the superior and inferior surfaces and 
from the faucial pillars. The collecting trunks from the superior sur- 
face are more or less united with the collectors from the nasal fossa- 
which may be divided into ascending trunks and descending trunks. 
The former pass around the pharynx and terminate in the retropharyn- 
geal lymph glands; the others pass down through the posterior pillars 
and terminate in the internal jugular glands near the digastric muscle. 
The collecting trunks from the inferior surface run downward through 
the anterior pillars and joining the collectors from the vault of the 
palate terminate in the internal jugular glands near the digastric 
muscle. The collectors of the anterior pillar unite with those from the 
inferior surface, and the collectors from the posterior pillar with the 
descending trunks of the superior surface. Occasionally some of the 
lymphatic vessels from the posterior pillars terminate in the glands 
of the internal jugular group as high up as the bifurcation of the 

Nerves of the Pharynx. 

The nerves of the pharynx, both motor and sensory come mainly 
from the pharyngeal plexus. This plexus which lies just beneath the 
mucous membrane is formed by branches from the glossopharyngeal. 
from the pneumogastric and from the superior cervical ganglion of 
the sympathetic. The pharyngeal branch of the pneumogastric is 
really derived from the accessory portion of the spinal accessory. Tin 
faucial tonsil receives a branch directly from the glossopharyngeal, 
while the surrounding region and the soft palate are supplied by the 


posterior and external palatine branches of Meckel's ganglion. The 
vault of the pharynx and the structures around the orifice of the Eu- 
stachian tube are supplied by the pharyngeal branch of Meckel's 
ganglion. The mucous membrane on the external posterior wall of 
the larynx is supplied by the superior laryngeal nerve. 

The Structure of the Pharyngeal Wall. 

Surrounding 1 the mucous membrane of the pharynx is a distinct 
layer of connective tissue, the pharyngeal aponeurosis. This fascia 
varies in thickness being usually strongest where the muscular wall of 
the pharynx is weakest; and it gradually thins out as the lower end 
of the pharynx is approached. Above it blends with the periosteum 
at the base of the skull, and is attached to the Eustachian tubes, the 
margins of the posterior nares and to other portions of the skull from 
which the pharyngeal constrictors arise. At the sinuses of Alorgagni, 
that crescentic space between the base of the skull and the upper bor- 
der of the superior constrictor, the fascia is very strongly developed. 
Externally, the pharyngeal aponeurosis is intimately associated with 
the constrictors, and forms the capsule of the faucial tonsil. 

The muscular wall of the pharynx is made up of two strata, the 
internal or circular layer consisting of the three constrictors, and an 
external, or more properly longitudinal layer, consisting of fibres 
from the stylopharyngeus and from the palatopharyngeus muscles. 
The three constrictor muscles appear as modified cones, the middle 
overlapping the superior, and the inferior overlapping the middle. 

Tin- Superior Constrictor Muscle arises from 1lie lower half of the 
posterior border of the internal pterygoid plate, below this from the 
pterygornandibular ligament and from the internal surface of the man- 
dible just back of the last molar tooth. It is also attached anteriorly to 
the mucous membrane of the floor of the mouth. The upper fibres of the 
muscle curve upward and are inserted into the plmryngeal spine of 
the occipital bone. This arching of the upper fibres forms a crescentic 
interval in the pharyngeal wall called the sinus of Morgagni. Through 
this opening pass the Kustachian tube and the levator and tensor palati 
muscles. 'Die middle and inferior fibres of the superior constrictor 
pas> posteriorly, radiating upward and downward to be inserted into 
the median raphe on the posterior wall of the pharynx. The lower 
fibre.- are overlapped by the middle constrictor, 

The Middle Constrictor Muscle, somewhat smaller than the snpe 
rior, ari>es from the stylohyoid ligaments and from both the small 
and n'reat corniia of the hyoid bone. Its fibres, radiating upward and 
downward, pa-s posteriorly to be inserted into the median raphe of 

the pharynx. Tlio lower fibres arc overlapped by Hie upper fibres of 
the inferior. The interim! laryn^en I artery and nerve pass through 
tlie interval between tlie superior and middle constrictors. 

The Inferior Constrictor Muscle a rises from flic obli(|ue line of the 
thyroid cartilage and from the sides of the cricoid. Ifs fibres radial- 
ing mostly upward, pass posteriorly to Ite inserted into the median 
pharyngeal raphe. The lower fibres blend with the musculature of 
the upper end of the esophagus. At the lower edge of the muscle the 
external laryngeal artery and nerve come into relation with the larynx. 

The longitudinal muscular fibi'es of tlie pharynx are made np of 
two distinct muscles, the palatopharyngeus and the stylopharyngeus. 

The Palatopharyngeus Muscle forms the posterior faucial pillar. 
It is composed of two layers, a thin posterior superior sheet spread- 
ing through the substance of the soft palate, and a thicker antoroin- 
ferior layer which arises from the posterior border of the hard palate. 
These two layers partially envelope the azygos uvula 1 and levator 
palati muscles. They unite at the lower edge of the soft palate where 
they receive additional fibres from the Eustacliian tube and passing 
downward, spread out in a thin sheet in the wall of the pharynx. The 
posterior fibres, under cover of the middle and inferior constrictors, 
are inserted into the aponeurosis of the pharynx and some fibi'es 
decussate with those of its fellow of the opposite side. The anterior 
fibres are inserted into the posterior border of the thyroid cartilage 
and anteriorly merge into the stylopharyngeus. 

The Stylopharyngeus Muscle arises from the base of the styloid 
process. Passing downward and forward between the two carotid ar- 
teries it penetrates the pharyngeal wall between the superior and middle 
constrictors. It is inserted by a broad base into the superior and poste- 
rior border of the thyroid cartilage, its fibres being here continuous 
with the palatopharyngeus. It is also inserted into the pharyngeal 

The soft palate and uvula may be considered as the anterior wall 
of the pharynx. They are made up of a muscular fold covered by mu- 
cous membrane. 

The muscles which constitute the soft palate consist of five pairs 
the palatopharyngeus (already described), the palatoglossus, tlie 
axygos uvula*, the levator palati and the tensor palati. 

The Palatoglossus Muscle is placed directly beneath the mucous 
membrane of the tongue, the anterior palatal pillar, and the anterior 
surface of the palate. It is a thin sheet of muscular fibres which arise 
from the under surface of the soft palate, some of its fibres blending 
with those of its fellow of the opposite, and passes downward to. form 



the anterior pillar of the fauces. It is inserted into the sides of the 
tongue, and blends with the styloi^lossus and deep transverse fibres of 
the tongue. 

The Azygos Uvulae Muscle is found between the layers of the 
palatopharyngeus and arises from the posterior nasal spine and the 
aponenrosis of the soft palate. The two narrow bundles unite as they 
proceed downward to the tip of the uvula. 



Dissection showing the relation of the tensor palati and the levator 
palati muscles. The levator is cut permitting the soft palate to be drawn 

1, Kustachian cartilaK''! -, Tensor palati muscle; ',",, Levator palati 
muscle; 4, Ilamular process; f>. Internal pteryn'oid muscle; 6, Middle 
constrictor of pharynx; 7, Posterior palatal pillar; 8, Sphenoid sinus; !>, 
Middle turbinate; 10, Inferior tnrbinate; 11, Tendon of tensor palati mus- 
cle; l~2. Insertion of levator palati muscle; II!, Cut edi;e of velum palati; 14. 
Palatal tonsil: 1"., Section of tongue. 

The Levator Palati Muscle arises from the inferior surface of the 
apex of the petrous bone dose to the carotid canal. Its fibres forming 
a rounded belly, run parallel to and in close approximation with the 
under surface of the Kustachiaii tube, to which, however, it is not at- 
tached. It is inserted in a radiating manner into the soft palate below 

the ostium of the tube. The action of this muscle on the Kiistachian 
tube is not exactly understood. The contraction of the muscle by in- 
creasing its circumference tends to raise the floor of the tube, which, 
by decreasing the perpendicular width of the lumen of the tube, in- 
creases the horizontal, and this probably increases the patulency of 
the tube. 

The Tensor Palati Muscle is the real abductor or dilator tuba-. It 
arises in part from the scaphoid fossa of the internal pterygoid plate 
and the alar spine of the sphenoid bone, and in part from the outer sur- 
face 1 , or the hook-like border of the cartilaginous wall, and the membran- 
ous part of the Eustachian cartilage. Running downward so as to form 
an acute 1 angle' with the 1 cartilaginous portion of the tube, the muscle 
ele'sevnels between the internal pterygoid muscle and the internal ptery- 
goid plate 1 . It te'rminate's by a rounded tendon which passes around 
the 1 hook of the 1 hamular process and is inserted beneath the levator 
palati into the pe>sterie>r be>rder of the hard palate, as well as the apo- 
ne'urosis of the 1 soft palate. The 1 action of this muscle, by pulling on 
the cartilaginous hoe>k of the* Eustachian tube, tends to slightly unfold 
it, which action increase's the' lume'ii of the' tube. 

The 1 nerve supply to the- musculature of the pharynx is chie'fly 
through the spinal ace-essory by way of the' pharyngeal plexus. This 
plexus supplier the constrictors of the' pharynx, the 1 palatoglossus, the 
palatopharyngeus, the 1 azygos uvula 1 , and the levator palati. The ten- 
sor palati is supplied from the otic ganglion, the stylopharyngeus by 
the 1 glossopharyngeal neM've, and the 1 infVrior constrictors receive 
branches frenn the 1 vagus through the external and recurrent laryugeal 


The 1 larynx should be looked upon as the upper part of the trachea, 
especially modified for the 1 preulue'tieHi of the 1 ve>ice sound. Its 
construction is such as to permit the instant approximation and adjust- 
me'iit of two elastic bands, the 1 voe-al cords. These may be thrown into 
the required vibrations by a column of air forced up through the tra- 
che'a. To accomplish this purpose numerous joints, ligaments and 
muscles are necessary. By reason of the be'auty and perfection of the 
arrange'ine'iit of these various strue'tures the larynx is one of the most 
interesting organs of the 1 body to the anatomist. It is situated in the 1 
me'dian line of the 1 nevk just in front of the 1 esophagus, and is very 
loosely attached to the surrounding strue'tures. ( )u each side poste- 
riorly are the' large vessels of the ue'ck, and above 1 are the hyoid bone 
and tongue. 


The interior of the larynx opens into the lower portion of the 
pharynx just back of and below the base of the tongue. The aclitus 
laryngis is obliquely placed facing upward and backward. It is bor- 
dered above by the epiglottis, on each side by the arytenoepiglottic 
folds, and posteriorly by the mucous membrane covering, the carti- 
lages of AVrisberg (cuneiform cartilages) and of Santorini (cornicula 
laryngis). These cartilages surmount the arytenoid cartilages and 
follow their movements. 

The interior of the larynx is divided into three parts by the false 
and true vocal cords (ventricular and vocal bands). 

Superior Division. 

The superior division of the laryngeal cavity is compressed later- 
ally where the ventricular bands or false cords separate it from the 
middle division. The anterior wall is formed in greater part by the pos- 
terior surface of the epiglottis. The upper part of the posterior sur- 
face of the epiglottis is concave except the tip which is turned slightly 
forward. Below, the epiglottis shows a distinct swelling, the cushion 
of the epiglottis. This swelling corresponds in position to the thyro- 
epiglottic ligament. The lateral walls are smooth except for two slight 
vertical elevations, the anterior being due to the cuneiform cartilage 
and the posterior to the anterior margin of the arytenoid cartilage and 
the cartilage of Santorini. The shallow grove between these eleva- 
tions is called the philtrum ventriculi of Merkel. The anterior of 
these elevations runs to the posterior end of the false vocal cords while 
the posterior passes downward to the true cords. The narrow pos- 
terior wall is formed by the interarytenoid fold and varies in breadth 
according to the degree of approximation of the arytenoid cartilages. 

The Ventricular Bands, or false cords, form a partial floor of the 
superior division of the larynx. In front they arise from the angle 
between the two wings of the thyroid cartilage, and they reach back- 
ward only to the swelling on the lateral wall causer! by the cuneiform 
cartilages. They are never in apposition and they never obscure the 
maririn of the true vocal cords from view. The chief support of this 
fold of mucous membrane is the thin superior thyroarytenoid ligament 
and a few muscle fibres. The distance in the adult male larynx from 
the ventricular band to the summit (if the arytenoid cartilages is about 
one half inch and to the tip of the epiglottis one and a half inches. 

Middle Division. 

The middle division of the larynx is limited above by the 
cords and below bv the true. ( )n each side and covered bv the 


tricular bands is the laryngeal sinus or ventricle of Morgagni. !t> 
cavity is somewhat larger than its opening and it roadies from the an- 
terior angle of the ahr of the thyroid cartilage hack to the anterior 
border of the arytenoid cartilage. This ventricle of Morgagni is ex- 
tremely variable both in shape and size. It may consist simply of a 
single broad pocket extending upward between the ventricular band 
and the ala of the thyroid cartilage or it may be a branched structure 
with a varying number of terminal crypts. Occasionally there exists 
a short branch directed downward from the main pocket. The walls 
of the sinus contain quite a largo deposit of lymphoid tissue and fre- 
quently if not always definite germinating follicles are present so that 
the whole structure is very similar to a large tonsillar crypt. The 
upward extension of the sinus is quite commonly spoken of as the 
laryngeal saccule and it does not usually extend upward beyond the 
border of the thyroid cartilage, though in rare instances it may reach 
to the posterior part of the hyoid bone. 

The True Vocal Cords are shorter but more prominent than the 
false and extend from the angle formed by the ala 1 of the thyroid to 
the vocal processes of the arytenoid cartilages. In cross section the 
cord is prismatic with the free edge pointing upward, as well as to- 
ward the median line. In front, the cords meet and form the anterior 
commissure. Posteriorly, they end at the vocal processes of the ary- 
tenoid cartilages, but their surface lines an 4 continued over the median 
side of the arytenoid cartilages, joining posteriorly to form the poste- 
rior commissure. The true cords with the opening between them con- 
stitute the true glottis, or rima glottidis which is generally designated 
the glottis. 

Inferior Division. 

The inferior division of the larynx is somewhat flattened laterally 
above and below where its walls slope outward and downward from 
the vocal cords. Its walls are in greater part made up by the inner 
surface of the crieothyroid ligament. 

Cartilages of the Larynx. 

The Cricoid Cartilage is the lowest and is placed directly on top 
of the trachea. It is shaped somewhat like a signet ring, with the signet 
part or posterior lamina projecting from the upper side and the upper 
edge sloping rather gradually downward and forward to form the ante- 
rior circle. The ring is circular below corresponding to the shape of the 
trachea, but above it is somewhat laterally compressed. On top of the 
posterior lamina are two oval convex facets which look somewhat out- 


ward as well as upward. Tlioy are tlio articulating surfaces for the ary- 
tenoid cartilages and are separated by a faiut median notch. On the 
posterior surface are two depressed areas for the attachment of the 
posterior crieoarytenoid muscles. On the posterior part of the lateral 
surface of the cricoid, a vertical ridge runs downward from the aryte 
noid articulation. On this ridge, just above the lower border of the 
cartilage is a circular facet for articulation with the inferior horn of 
the thyroid cartilage. The inner surface of the cricoid is smooth. 

The Arytenoid Cartilages, two in number, are perched on the ante- 
rior part of the summit of the posterior lamina of the cricoid. They 
are irregularly pyramidal in shape and have three surfaces and a base. 
When the cartilages are in position for phonation one surface faces 
directly toward the median line, another posteriorly and the third out- 
ward and forward. The posterior and anteroexternal surfaces are 
somewhat concave, slightly triangular, narrowed vertically and fairly 
even. A small sesamoid cartilage is frequently found invested by the 
perichondrium on the external border of the arytenoid cartilage. The, 
apex is directed upward, but is curved slightly inward and backward. 
There are two important processes, one the external inferior angle 
called the processus muscularis, and the other the anterior inferior 
angle called the processus vocalis. 

The Thyroid Cartilage makes up the greater part of the frame- 
work of the larynx. It consists essentially of two large ala' joined to- 
gether in front, but separated posteriorly by the interposition of the 
posterior lamina of the cricoid and of the two arytenoid cartilages. 
The anterior junction involves only the lower two-thirds of the whole 
height of the ahe, leaving a well-marked notch in the median line. At 
the bottom of this notch, the thyroid cartilage forms the most anterior 
portion of the larynx, and the prominence due to its projection is 
called the pomiini Adami. There is great variation in the angle of the 
junction of the two cartilages. In infants it is more of a curve than an 
an.irle, while the average for the adult male is about !H) and for the adult 
female almost 120 . The superior border of the ala is convex upward, 
while the lower border is almost straight. The posterior free edge 
of each ala is prolonged upward almost to the hyoid hone, form- 
ing the superior cornii and downward to the articulation facet on 
the side of the cricoid forming the inferior cornii. < )n the exter- 
nal surface of each ala somewhat posterior to its middle is a 
rid.u'e runiiin.u 1 diagonally from above, behind, downward and forward. 
It is usually spoken of as the oblique line and begins above at a prom- 
inence just below the superior border of the ala called the superior 


tubercle. It ends on the inferior border in another prominence called 
the inferior tubercle. 

The Epiglottic Cartilage is a thin lamina of yellow elastic carti- 
lage shaped somewhat like a broad and warped paddle, with its handle 
below terminating in the strong thyroepiglott ic ligament. Its surface 
is irregularly indented by depressions and there are numerous perfo- 
rations running through the cartilage. Its upper end is free, rising 
just behind the base of the tongue. 

The Lesser Cartilages of the larynx are six in number. The two 
cartilagines triticea 4 are small nodules situated just above the superior 
cornu of the thyroid cartilage in the lateral thyrohyoid ligament. Tlie 
cartilages of Santorini or the corniciilate cartilages, two in number, 
are perched on the apices of the arytenoid cartilages and are enclosed 
in the posterior part of the arytenoepiglottic fold of mucous membrane. 
In this same fold, immediately external to the cartilages of Santorini, 
are the cartilages of \Vrisberg or the cuneiform cartilages. They are 
inconstant structures but generally ])resent. 

Articulations and Ligaments of the Larynx. 

The laryngeal joints with their ligaments form one of the most 
interesting anatomic features of the larynx. 

Joints. The cricothyroid joints are diarthrodial with a pivotal 
and also a gliding movement. The circular facets on the internal sur- 
face of the inferior cornu of the thyroid cartilage are bound fast by a 
capsular ligament to the corresponding' slightly elevate<l circular facets 
on the sides of the cricoid cartilage. The ])osterior part of the capsular 
ligament is strengthened by a ligamentous thickening. The crieoaryte- 
noid .joints are more complicated but are also diarthrodial. They, too, 
possess a pivotal movement as well as a lateral gliding motion, and. ac- 
cording to some authorities, a slight anteroposterior rocking motion. 
The articular facet of the cricoid is convex while that of the arytenoid 
is concave. Both articular surfaces are elliptical and they never accu- 
rately coincide with one another. There is a distinct capsular ligament 
which is strengthened posteriorly by a prominent band, which limits 
the anterior rocking motion or displacement of the arytenoid cartilage. 
The lateral gliding motion of this joint, permits the two arytenoid car- 
tilages to approach one another or separate, thus closing or opening the 
posterior third of the glottic chink. The pivotal movement allows the 
vocal process to move toward or away from the median line causing 
adduction or abduction of the vocal cords. 

There are two important membranes in the larynx, the cricothy- 


void and the thyrohyoid. These lie in the intervals between the carti- 
lages as their names designate. 

The Cricothyroid Membrane is an important structure and con- 
sists of three portions; two lateral divisions and a central. These di- 
visions are all attached below to the upper border of the arch of the 
cricoid cartilage. Their upper attachments, however, are very dif- 
ferent. The central portion which is somewhat triangular in shape, 
is strong, tense, and elastic. The base is attached to the upper border 
of the anterior part of the cricoid arch and the narrowed top to the 
lower border of the thyroid cartilage. The lateral portions form the 
side walls of the snbglottic part of the larynx and are lined internally 
only with mucous membrane. They arise below from the upper border 
of the cricoid cartilage and passing internally to the ahr of the thyroid 
find their upper termination in the whole of the length of the inferior 
thyroarytenoid ligaments, the supporting band of the true cords. In 
front, the thyrohyoid membrane is also attached to the inner surface 
of the thyroid ahr near the notch, and behind to the vocal processes of 
the arytenoid cartilages. The lateral cricoarytenoid and thyroaryte- 
noid muscles lie directly on the outer surface of the lateral part of 
the cricothyroid membrane. 

The Thyrohyoid Membrane is attached along the upper border of 
the thyroid cartilage and to the internal surface of the hyoid bone. Its 
central or anterior portion is thick and elastic and forms the median 
thyrohyoid ligament. This ligament is attached below to the thyroid 
notch and above to the upper margin of the posterior surface of the 
hyoid bone. Where the ligament passes behind the bone a bursa is 
generally found separating the two. Posteriorly the hyoid membrane 
terminates in a strong cord-like ligament; the lateral thyrohyoid liga- 
ment. This ligament runs from the tip of the great conm of the hyoid 
bone to the extremity of the superior conm of the thyroid cartilage. 
It contains the small cartilago triticea. The inner surface of the thyro- 
hyoid membrane is covered by the mucous membrane of the pharynx, 
while the epiglottis is separated from the median thyrohyoid ligament 
by a cushion of fat. 

There arc two thyroarytenoid ligaments, the inferior and supe- 

The Inferior Thyroarytenoid Ligament is really the thickened up- 
per border of the hiteral parts of the cricotliyroid membrane. It is 
the supporting ligament of the true vocal cords and is attached ante- 
riorly to the middle of the thyroid angle close to its fellow, while pos- 
teriorly it Mends with the vocal process of the arytenoid cartilage. 


This ligament contains numerous yellow clastic fibres and sometimes 
near its anterior end a small nodule of elastic cartilage. 

The Superior Thyroarytenoid Ligament is a much less important 
structure and while thinner and weaker is longer than the inferior. 
It supports the ventricular bands. It is attached anteriorly to the thy- 
roid angle; just above the inferior and posteriorly to a small tubercle 
on the anterior surface of the arytenoid just above the processus vo- 
calis. There are a few elastic fibres in it but it is mostly composed of 
fibrous tissue, which is more or less continuous with the supporting 
fibres of the arytenoepiglottic fold. 

Ligaments of the Epiglottis. The epiglottis is fastened to the 
body of the hyoid bone by an irregular broad elastic band, the hyoepig- 
lottic ligament. From the inferior narrowed end of the epiglottis a 

l - 




Fig. 64. 
The lateral external surface of the larynx. 

1, Superior cornu of thyroid; 2, Posterior lamina of cricoid; ?>, Inferior 
cornu of thyroid; 4, Strengthening band of capsular ligament; 5, First 
ring of the trachea; 6, Ala of thyroid; 7, Superior tubercle of thyroid: 8. 
Oblique line of thyroid: 9, Central part of cricothyroid membrane: 10. 
Oblique portion of cricothyroid muscle; 11, Horizontal portion of the crico- 
thyroid muscle. 

strong thick ligament, composed of elastic tissue, the thyroepigiottic 
ligament, runs to the posterior surface of the thyroid angle just below 
the notch. Besides these two true ligaments the epiglottis is fastened 
to the tongue by three folds of mucous membrane, the median and two 
lateral glossoepi glottic folds. These have already been described. 

The Muscles of the Larynx. 

Under this head will be described only those muscles which have 
both their origin and insertion in some part of the larynx itself. AVhile 


some of them are contained entirely within the cavity bounded by the 
ala of the thyroid, the ericothyroid, the arytenoid and the posterior 
ericoarytenoid arc on the external surface of the larynx proper. 
The Cricothyroid Muscle arises from the anterior surface of the 
cricoid arch and the lower adjoining border and radiating upward and 
backward usually separates more or less distinctly into two divisions. 
The anterior of these divisions crosses the ericothyroid interval more 
perpendicularly than the posterior and is inserted into the lower ed^e 
and the neighboring inner surface of the ala of the thyroid. The pos- 





Fig. 65. 
The muscles of the laryngoal wall on the posterior aspect. 

1, Arytenoepiglottic muscle; 2, Cartilage of Santorini; ?>, Arytenoideiis 
obliquus muscle; 4, Aryteuoideus transversus muscle; F>, Cricoarytenoideus 
posticus muscle; 6, Epiglottis; 7, Retrohyoid bursa; 8, Thyrohyoid muscle: 
!. Thyroepiglottic muscle; Id, Thyroid cartilage; 11, Thyroarytenoideus 
muscle; 12, Cricoarytenoideus lateralis muscle; 13, Articular facet for 
inferior cornua of thyroid; 14, Cricoid cartilage. 

tcrior division is inserted into the anterior aspect of the inferior cornu 
of the thyroid. The cricot hyroid is sometimes rather closely associ- 
ated with the inferior constrictor of the pharynx. 

The Posterior Cricoarytenoid Muscle arises by a broad base from 
a depression which covers almost the entire half of the posterior sur- 
face of the crieoid lamina. Its fibres, con vermin 14- as they ascend in a 
slightly lateral direction, arc inserted into the posterior surface of 
the muscular process of the arytenoid. 

The Arytenoid Muscle consists of two parts, a superficial oblique 
layer and a deep transverse layer. 


The oblique arytenoid is a paired muscle, one muscle crossing the 
other in the median line on the posterior aspect of the larynx. Kach 
muscle consists of a narrow bundle which arises from the posterior 
side of the muscular process of the arytenoid and, running obliquely 
upward, passes around the outer side of the summit of the opposite 
arytenoid cartilage. Some of the fibres are here inserted into the ary- 
teuoid but many continue upward into the aryteuoepiglottic fold, as 
the arytenoepiglottic muscle, and are joined near the epiglottis by 
fibres from the thyroepiglottie muscle. 

The transverse arytenoid is a transverse sheet of muscle beneath 
the oblique, stretching between the posterior aspect of the outer bor- 
der of each arytenoid cartilage. Some of the fibres are apparently 
continuous with tlie fibres of the thyroarytenoid. 

The Lateral Cricoarytenoid is somewhat smaller than the poste- 
rior. It springs by a rather broad base from about the middle third 
of the upper border of the lateral part of the cricoid arch and also 
from the neighboring part of the cricothyroid membrane. Its fibres 
running backward and upward converge to be inserted into the front 
of the muscular process of the arytenoid cartilage. 

The Thyroarytenoid Muscle consists of two parts, an external and 
an internal, which, however, are closely blended. A large part of the 
lower border of this muscle is closely associated with the upper border 
of the lateral cricoarytenoid. 

The External Thyroarytenoid Muscle is a broad sheet just within 
the ala of the thyroid cartilage and spreads from the upper surface of 
the lateral cricoarytenoid to above the level of the vocal cord. It arises 
in front from the lower half of the thyroid ala close to the angle and 
also from a portion of the lateral cricothyroid membrane. Its fibres 
running backward parallel with the vocal cord are inserted for the 
greater part into the muscular process of the arytenoid cartilage. A 
few fibres pass around this cartilage and are continuous with the trans- 
verse fibres of the arytenoid. 

The Thyroepiglottic Muscle is really an off-shoot from the upper 
border of the external thyroarytenoid which turns upward to be in- 
serted into the upper part of the arytenoepiglottic fold and the free 
margin of the epiglottis. 

The Internal Thyroarytenoid Muscle is triangular in cross sec- 
tion and closely associated with the vocal cord. It arises from the 
thyroid angle in front and is inserted first by several muscular slips 
into the vocal cord itself and second into the outer side of the vocal 
process and adjoining outer surface of the arytenoid cartilage. 



The portion of the muscle which is inserted into the cord is some- 
times spoken of as the aryvocalis muscle. 

The Action of the Muscles of the larynx is concerned both with the 
movement of the vocal cords and the closure of the upper Jaryngeal 

The cricothyroid acts as a tensor of the vocal cords by tilting the 
thyroid cartilage downward and forward (oblique fibres) and by pull- 
ing the cartilage as a whole slightly forward (transverse fibres). As 
the arytenoids are prevented from riding forward on the to].) of the 
cricoid lamina, this forward tilting of the thyroid cartilage must put 
tension on the vocal cords. In opposition to this action of the crico- 
thyroid, the thyroarytenoid relaxes the vocal cords by approximating 
the angle of the thyroid cartilage with the arytenoid cartilage. While 

Fig. 66. 
Diagrams illustrating closed and open glottis. 

1, Thyroid cartilage; 2, Thyroarytenoideus interims; r>, Crieoarytenoi- 
dens lateralis; 4, Arytenoid cartilage: , r >. Cricoarytenoideus posticus; *>, 
Arytenoidens transversus; 7, Cricoid cartilage; 8, Thyroid cartilage; 
9, Thyroarytenoideus interims; 10, Cricoarytenoideus lateralis; 11, Aryte- 
noid cartilage; 12, Cricoarytenoideus posticus; V.\, Arytenoideus trans- 
versus; 14, Cricoid cartilage. 

the tliyroarytonoic] as a whole, relaxes the whole vocal cord, it is prob- 
able that the falsetto voice results from a partial contraction of the in- 
ternal thyroarytenoid by relaxing only a portion of the cord while the 
crirothyroid makes the remaining part of the cord tense, the tense 
portion only being capable of vibration. The posterior erieoarytenoid 
muscle by rotating the arytenoid cartilage so that the vocal process 
turns outward, is the abductor of the cords while the lateral cricoaryte- 
noid muscle by rotating it in the opposite direction becomes the ad- 
< luct or of the cords. 

The transverse arytenoid muscles bring the central sides of the 
arytenoid cartilages together and thus complete the closure of tlm 

glottic- chink after the vocal cords proper have boon approximated by 
tlio inward rotation of the arytonoid cartilage. 

The closure of the superior laryngoal aperture during swallow- 
ing is accomplished chiefly by the oblique portion of the arytonoid act- 
ing in concert with the arytenoepiglottic muscles. r riio transverse 
arytenoid with the thyroarytenoid muscles probably aid in the closure 
by approximating 1 the arytenoid cartilages and compressing the sides 
of the larynx at about the position of the false vocal cords. The su- 
perior aperture when closed presents a tk T" shaped fissure with the 
top of the "T" approximately parallel with the transverse axis of the 
epiglottis and the stem running between the two arytonoid bodies. 
The muscles therefore which affect this closure must bo looked upon 
in effect as true sphincters. 

The Nerve Supply of the Larynx. 

The nerves supplying the larynx are two in number, and both are 
branches of the pueumogastric or vagus. 

The Superior Laryngeal Nerve leaves the vagus high up in the 
neck, and passes obliquely downward and forward on the inner side of 
the internal and external carotid arteries. On approaching the larynx. 
it divides into two unequal parts, a larger internal, and a smaller ex- 
ternal branch. 

The Internal Laryngeal Nerve passes between the middle and in- 
ferior pharyngeal constrictors and roaches the interior of the larynx 
by penetrating the thyrohyoid membrane. Sensation is supplied by 
this nerve to the mucous membrane of the larynx from the epiglottis 
down to the upper part of the trachea. This nerve probably also con- 
tains vasomotor and secretory fibres, which it supplies to the whole of 
the laryngeal mucous membrane. 

The External Laryngeal Nerve runs downward on the external 
surface of the inferior constrictor, ending at the cricothyroid muscle 
which it supplies. Branches arc sent to the inferior constrictor muscle 
and probably, a few motor twigs pass to the arytonoid. 

The Recurrent or Inferior Laryngeal Nerve leaves the pnounio- 
gastrie in the lower part of the neck, and turns upward to supply all 
of the intrinsic muscles of the larynx except the cricothyroid. and 
part of the arytenoid. 


The cervical lymphatic nodes are divided into two main groups, 
the superficial or collecting nodes and the dee]) or terminal nodes. The 


superficial group is arranged as a sort of a collar around the upper 
part of the neck with a few irregular extensions. This pericervical 
circle is composed of the following subgroups: 

1. Suboceipital group and aberrant glands of the nape of the neck. 

Mastoid group. 

.'!. Parotid and subparoticl group. 

4. Snhniaxillary group with the facial glands as an off-shoot. 

f>. Suhmental group. 

(i. Retropharyngeal group. 

The Suboceipital Group of glands are rather inconstant struc- 
tures varying from one to three in number and usually are placed on 
the occipital insertion of the complexus muscle just external to the ex- 
ternal border of the trape/ius. They receive the lymph vessels from the 
back of the head and their efferent vessels terminate in the highest 
nodes of the substernomastoid group. 

The Mastoid Group or retroauricular glands, generally two in num- 
ber, lie on the mastoid insertion of the sternomastoid. These glands 
receive their afferent vessels from the temporal portion of the hairy 
seal)), from the internal surface of the auricle except the lobule and 
from the posterior surface of the external auditory meatus. They 
empty into the highest glands of the dee]) lateral chain. 

The Parotid Group consists of glands in the parotid space either 
external to the gland, the superficial nodes, or in the actual substance 
of the parotid, the deep nodes. The deeper parotid nodes are scat- 
tered throughout the substance of the parotid but for the most part 
are grouped around the external carotid artery. They are quite nu- 
merous though some are very small and can be seen only by the micro- 
scope. These glands receive afferent vessels from the external surface 
of the auricle, from the external auditory meatus, from the tympanum, 
from the skin of the temporal and frontal regions and possibly also 
from the eyelids and base of the nose. It is possible that at times 
they drain the nasal fossa 1 also and the posterior part of the alveolar 
border of the superior maxilla. The elTerents run into the upper sub- 
sternomastoid glands near the exit of the external jugular vein from 
the parotid. 

The Subparotid Glands belong in reality to the parotid group but 
are placed beneath the parotid, between it and the plmryiigeal wall in 
the lateropharyngeal space. Suppurative inflammation of these glands 
ii'ivcs rise to lateral pharyngeal abscesses. Their afferents come from 
the nasal fossa-, from the nasopharynx and from the Kiistachian, while 
their elTerents pass to the upper glands of the deep cervical chain. 


The Submaxillary Group consists of fVotn three to six nodes situ 
ated along the length of, and immediately beneath, the lower border 
of the mandible. The largest of the group is generally found neat' the 
facial artery. These glands are jnst beneath the fascia and are more 
or less intimately associated with the upper border of the submaxil- 
lary salivary inland. Their afferent vessels come from the external 
nose, the cheek, from the upper and the external part of the lower lip, 
from practically the whole of the gums and from the anterior third of 
the sides of the tongue. The efferent vessels running over the surface 
of the submaxillary salivary glands empty generally into the glands 
of the deep cervical chain near the bifurcation of the common carotid. 
They may at times pass to glands further down the chain. 

The Facial Glands are small inconstant structures found in the 
course of the afferent vessels leading to the submaxillary nodes. They 
generally form three groups. The inferior or supramaxillary rest on 
the jaw just in front of the masseter muscle. Occasionally there is a 
gland immediately on the edge of the jaw at this position called the 
inframaxillary gland. A less frequent group of glands is the middle 
or buccinator group on the external surface of the buccinator mus- 
cle, All of these buccinator glands lie outside of the bnccal fascia. 
There may, however, be a subfascial gland or a submucous gland. The 
third group is still less constant and is situated jnst to one side of th." 

The Submental Group consisting of from one to four glands are 
found in the triangle bounded by the anterior bellies of the two di- 
gastric muscles and the hyoid bone. The afferent vessels of this group 
are from the skin of the chin from the centre portion of the lower lip 
and from the mucous membrane covering the external portion of the 
alveolus, from the floor of the mouth and from the tip of the tongue. 
The efferent vessels run either to the submaxillary gland or directly 
downward to a node of the deep cervical chain situated on the internal 
jugular vein just above where it is crossed by the omohyoid. 

The Retropharyngeal Group consisting generally of two glands is 
placed back of the posterior pharyngeal wall near its outer edge being 
almost '2 cm. from the median line. These glands are separated from the 
atlas by the rectus capitis anticus major muscle and are in rather close 
relation externally with the sheath of the great vessels of the neck. 
Suppurative inflammation of these nodes leads to retropharyngeal ab- 
scess. In this case the abscess starts laterally but being limited ex- 
ternally by the fascia covering the vessels enlarges medianward. Oc- 
casionally there are small inconstant nodes back of the pharyngeal 
wall almost in the median line. The retropharyngeal glands receive- 


their afferents from the mucous membrane of the nasal fosstv and ac- 
cessory sinuses, from the nasopharynx including tlie pharyngeal ton- 
sil, from the region of the Eustachian tube and possibly from a part 
of the tympanic cavity. It must be said, however, that the retrophar- 
yngeal lymphatic glands are only interrupting nodes placed on the col- 
lecting lymphatics as they pass from the upper part of the back of the 
throat to the posterior group of the deep cervical chain. The afferent 
lymph vessels of the retropharyngeal lymph glands follow the same 
general course as those efferent*, which come directly from the poste- 
rior pharyngeal wall and pass behind the great vessels of the neck to 
reach the posterior edge of the sternomastoid muscle, and empty into 
the upper nodes of the posterior group of the deep cervical chain. 






Fig. J7. 
Dissection showing the upper deep cervical lymph ludes. 

1, Masseter muscle; "2, Facial artery; I',, Submaxillary gland; 4. llypoglos- 
sal nerve; ">, Digastric (posterior belly) and stylohyoid muscles; t'. 
Anterior group of the deep cervical lymph nodes; 7, Facial nerve; 8, 
Hxternal jugular lymph node; !, Sternomastoid muscle; 10, Posterior group 
of the deep cervical lymph nodes; 11, Spinal accessory nerve; 11'. Sterno- 
mastoid artery; 1.'',, Internal jugular vein. 

The Descending Cervical chain of lymph nodes consists of two sets 
of u'lands, the deep cervical chain and several more or less important 
secondary and more superficial chains. The deep glands situated on 
each side of the neck comprise from fifteen to thirty nodes on an aver- 
age, although these fiu'iires do not represent the extremes of variation. 
This u'roiip of u'lands is variously termed the carotid chain, the sub- 


sternomastoid group, or the deep lateral glands of the neck, and may 
theoretically and clinically be divided into two groups, although ana- 
tomically they are closely associated. They extend from just beneath 
the ear downward under the sternocleidomastoid muscle, generally 
only as far as the point where the omohyoid crosses the vessels and 
nerves, but occasionally reaching as far as the junction of the internal 
jugular and subclavian vein. The more superficial division of the deep 
lateral chain lies posteriorly and is called the external group. The 
external glands are generally small, and placed in part beneath the 
posterior border of the sternocleidomastoid, and occasionally extend so 
far down the anterior border of the trape/ius muscle as to come into 
rather close relation with the supraclavicular glands. They rest rather 
irregularly distributed, on the external surface of the splenius, levator 
anguli scapuhv, cervical plexus and the spinal accessory nerve. 

The anterior or deep division of the main group is placed directly 
over the great vessels of the neck, and is termed the internal jugular 
group. These nodes are situated beneath the anterior border of the 
sternocleidomastoid muscle, and when enlarged may be forced anteri- 
orly until some of them appear immediately below the angle of the jaw. 
One or two large glands are constantly found below the posterior belly 
of the digastric, just above the spot where the thyrolingual-facial vein 
opens into the internal jugular. These nodes receive lymphatics from 
the tongue while immediately above the digastric is a large node which 
drains the tonsil and surrounding region. A few glands are sometimes, 
found between the internal jugular and the prevertebral muscles. 

The Accessory or Superficial Descending Cervical chain consists 
of four groups, the external jugular chain, the superficial anterior cer- 
vical chain, the deep anterior cervical chain, and the recurrent chain. 

The EXTERNAL JrtiULAR CHAIN consists usually of two or three 
nodes resting on the external surface of the sternomastoid just below 
the parotid gland. Occasionally one or two nodes are found further 
down along the course of the veins. Their afferent vessels come from 
the auricle and parotid region and their efferent vessels terminate in 
the upper nodes of the deep cervical chain. It is claimed that some- 
times an efferent vessel from these glands may follow along the course 
of the external jugular vein and empty into the supraclavicular glands. 

inconstant nodes on the anterior jugular vein. 

The DEEP ANTERIOR CKRYICAL CHAIN may be divided into three dis- 
tinct groups: the prelaryngeal, the prethyroid and pretracheal. 

The prelaryngeal group consists of one. two or three inconstant 
glands most frequently found in the triangular space bounded by the 


two cricothyroid muscles. When present their afferent* come from 
the middle lymphatic pedicle of the larynx. Their efferent* may run 
either to the pretracheal nodes or to the lower nodes of the deep lateral 

The prethyroid glands are usually absent. 

The pretracheal group is usually present and consists of one or 
more very small nodes. Their afferent* come from the thyroid body 
and the prelaryngeal nodes and their efferent* terminate in the lower 
node* of the deep lateral chain. 

The RECURRENT OHAIX consists of from three to six minute nodes 
along 1 the course of the recurrent laryngeal nerves. Their afferent ves- 
sels come from the inferior pedicle of the larynx, from the neighbor- 
ing region of the trachea and esophagus and a part of the thyroid body. 
It is important to remember that the efferent vessels of this chain 
terminate in the inferior node* of the deep lateral chain instead of pro- 
ceeding downward to the mediastinal glands. It i*, however, possible 
that occasionally an efferent from these nodes passes directly to the 
superclavicular glands. 

The Supraclavicular Group of lymph glands occupies the supra- 
clavicular or subclavian triangle. These glands are generally very 
numerous and are imbedded in the adipose tissue found in this triangle 
the so-called "fettpolster" of Merkle. In the upper part of the triangle 
they are just beneath the superficial cervical fascia and rest on the 
splenins, levator anguli scapuhr and scalenus muscles. Also they 
hold important surgical relations with some of the lower 
branches of the cervical plexus which supply the trapezius and with 
the ascending cervical artery. The more inferior glands of this group 
are in greater part placed in front of the middle layer of cervical fascia 
lying very close to the terminal subfascial portion of the external jug- 
ular and descending branches of the cervical plexus. Some nodes 
more deeply placed are found behind the oniohyoid and the middle 
layer of cervical fascia being just in front of the brachial plexus and 
the third portion of the subclavian. 

The majority of authors place this chain of glands as an auxiliary 
group of the deep cervical chain, but my own researches have led me 
to believe that the supraclavicular nodes rarely show any anastomosis 
with any of the cervical lymph nodes. This is a most important ana- 
tomic feature because a direct connection between these nodes and the 
cervical lymph glands would establish the necessary link in the lym- 
phatic chain from the tonsils to the apex of the lung. 

The alferents of the su pracla vicular glands come, first from the 
posterior part of the scalp and from the muscles of the neck, second 


from the skin of the pectoral region, third from tho skin of the arm 
over the cephalic vein, fourth from the humeral chain of the axillary 
group of glands, and fifth (doubted by some authors) from the parietal 
pleura covering the apex of each lung. The efferent vessel of the 
supraclavicular glands generally empties into the jugular trunk. 

The jugular lymphatic trunk, the terminal vessel of the deep 
lateral chain, usually terminates on the right side in the angle of junc- 
tion of the internal jugular and subclavian veins. On the left side it 
most frequently terminates in the thoracic duct. 



Viewed from the side, the neck is divided by the sternocleido- 
mastoid muscle into two triangles, an anterior, and a posterior triangle. 
The anterior cervical triangle is subdivided into a digastric (submaxil- 
lary), a carotid (superior carotid) and a muscular (inferior carotid) 
triangle by the digastric and omohyoid muscles, while the posterior 
triangle is divided by the posterior belly of the omohyoid into the 
occipital and supraclavicular triangles. 

The skin of the neck is loosely attached and the creases and folds 
formed by the flexion of the head as a rule run from above and behind 
obliquely forward and downward. It is important to remember the 
direction of these folds as incisions heal with less deformity when 
made either in the fold itself or parallel with its course. In the lower 
part of the neck the folds run more transverse, and the incision should 
then be less oblique following the direction of the skin fissures. 

Beneath the skin is the superficial fascia. This fascia is continu- 
ous with that of the head and chest, and contains the superficial nerves 
and blood vessels, none of which, however, have any great surgical 

Between the superficial fascia and the deep fascia is placed the 
Pilatysma myoides muscle. This muscle is a thin sheet covering the 
anterior part of the side of the neck, arising from the deep fascia of 
the pectoral region and from the clavicle. Its fibres extend upward and 
slightly forward. The greater part of the muscle is inserted into the 
lower border of the jaw but some of the fibres are continuous with 
the depressor labii inferioris, the depressor anguli oris, and the 
risorius. The anterior fibres meet across the middle line just below the 

Just beneath the posterior part of the platysma is the external 
jugular vein. The line of this vein is from the angle of the jaw to the 


middle of the clavicle. It is formed by the junction of the posterior 
auricular vein with the posterior branch of the temporomaxillary vein. 
It passes downward external to the deep fascia, crossing obliquely over 
the sternomastoicl muscle, and pierces the deep fascia in the anterior 
part of the suhclavian triangle. It crosses in front of the third part 
of the suhclavian artery and empties into the subclavian vein. 

Almost immediately posterior to the vein running parallel with its 
upper part will be found the ii'reat auricular nerve. This nerve is the 





Fig. 68. 
Superficial dissection of the carotid triangle. 

1, Masseter muscle; 2, Facial artery; ?,, Submaxillary gland; 4, Jlypoglos- 
sal nerve; 5, Anterior group of the deep cervical lymph nodes; ti, Superior 
thyroid artery; 7, Facial nerve; 8, Posterior auricular artery; !), External 
jugular lymph node; 10, Posterior belly of the digastric muscle; 11, 
Stcrnomastoid muscle; 12, Posterior group of the deep cervical lymph nodes; 
13, Spinal accessory nerve. 

largest of the superficial, or cutaneous branches of the cervical plexus, 
ll pierces the deep cervical Fascia just above the middle of the posterior 
border of the stcrnomastoid muscle and ascends in close relation with 
the external jugular vein. Immediately beneath the ear it divides 
into three branches; the anterior or facial branch which supplies the 
skin over the parotid inland and anastomoses in the substance of this 
inland with the facial nerve; the auricular branch, which supplies both 


sides of the lower part of the pinna; an<l the mastoid branch, which 
supplies the skin of the scalp behind the ear. Above the anricularis 
maxims, the small occipital nerve, a branch of the cervical plexus passes 
upward along the posterior border of the sternomastoid. .lust below 
the great auricular nerve the superficial cervical nerve pierces tin- 
dee]) fascia and passes forward and transversely over the sternomas- 
toid and beneath the external jugular vein. 

The deep fascia of the neck invests all the muscles and forms 
aponeurotic coverings for the esophagus, pharynx and trachea, cap- 
sules for the salivary glands, and sheaths for the larger blood vessels. 
This fascia is attached behind to the ligamentmn undue and the spinal 
process of the seventh cervical vertebra. A superficial layer passes 
forward,, enveloping the trapczius muscle and uniting in front of the 
muscle, it crosses over the posterior triangle of the neck to envelope 
the sternomastoid muscle. Above it is attached to the mastoid process 
and the superior curved line of the occipital bone and below to the clav- 
icle. From the anterior edge of the sternomastoid muscle it continues 
forward to the median line of the neck in a single layer. In the front 
part of the neck the upper attachment is to the lower border of the 
jaw, the styloid process, and the hyoid bone. 

Below, near the sternum, it divides into two layers, an anterior and 
a posterior which are attached respectively to the anterior and pos- 
terior edges of the upper portion of the sternum. The interval thus 
formed (the space of (Jruber) contains fat, the sternal head of the 
sternomastoid and the anterior jugular veins. 

Just below the mastoid process a superficial layer of the deep 
fascia is continued over the parotid gland and the masseter muscle as 
the parotid and masseteric fascia, and is attached to the lower border 
of the zygoma. 

From the deep fascia processes extend between the various struc- 
tures of the neck. At the angle of the jaw it becomes thickened and 
forms the stylomandibular ligament, which extends from the tip of the 
styloid process to the posterior border of the angle of the mandible. 
Other thickenings of this fascia form the pterygospinous ligament 
and the stylohyoid ligament. This latter ligament runs from the tip 
of the styloid process to the lesser cornu of the hyoid bone. 

Two main processes are given off from the deep fascia, a posterior 
and an anterior. The posterior process, or prevertehral fascia, arises 
at the anterior border of the trapezius muscle, and covers the numer- 
ous muscles of the back of the neck, the brachial plexus, the phrenic 
and cervical sympathetic nerves and passes inward behind the large 
vessels, the pharynx and the esophagus to meet its fellow of the other 


side. It is attached above to the base of the skull and below to the first 
rib as far forward as the anterior border of the anterior scalenus muscle. 
It also passes down into the chest over the longus colli muscle and the 
bodies of the vertebra*. It forms the sheath of the subclavian and axil- 
lary vessels by a process beginning just outside of the anterior scalenus 
muscle. In conjunction with the anterior process it forms the sheath 
of the carotid artery and internal jugular vein. 

The anterior process, or pretracheal fascia, passes inward and for- 
ward from the anterior border of the sternomastoid just in front of 
the trachea, and envelopes the thyroid gland. It is attached below to 
the first rib. 

The dee]) cervical fascia surrounding the trachea and the great 
vessels follows these structures down into the chest where it is con- 
tinuous with the fibrous layer of the pericardium. The prevertebral 
and the pretracheal fascia* divide the neck into three compartments. 
The anterior compartment contains the anterior belly of the omohyoid, 
the sternothyroid and the sternohyoid muscles. The middle contains 
the pharynx, esophagus, trachea and the thyroid gland; while the pos- 
terior contains the vertebral column, the upper vertebral muscles, the 
scalene muscles, the levator anguli scapula*, and the whole musculature 
of the back of the neck with the exception of the trapezius. 

The most important compartment formed by the dee]) cervical 
fascia is the visceral compartment. This compartment is bounded an- 
teriorly by the pretracheal fascia, posteriorly by the pervertebral 
fascia and laterally by the fascia forming the sheath of the dee]) blood 
vessels. It extends from the base of the skull downward into the pos- 
terior mediastinum. In front it runs from the hyoid bone into the 
anterior part of the superior mediastinum. 

The Sternocleidomastoid Muscle is the most prominent muscular 
landmark of the neck. It forms a distinct ridge of swelling, running 
from the mastoid process downward and forward across the side of 
the neck to the region of the steriioclavicular articulation. It has two 
heads, one, the sternal head, a narrow tendinous structure which arises 
from the anterior surface of the nianubriuni of the sternum, and a cla- 
vicular head, broader and only (tartly tendinous, which arises from the 
upper surface- of the inner third of the clavicle. It is inserted by a 
rather broad attachment into the outer surface of the mastoid process, 
and into the adjoining portion of the superior curved line of the occip- 
ital bone. Its anatomic relations are very important. Its anterior 
border, beginning above, is the superficial landmark for the location 
of the facial and spinal accessory nerves and of all t he st met i ires which 
occupy the carotid triangle, such as the juirnlar and adjoining lymph 


nodes of the upper (loop cervical chain, the internal jugular vein, the 
carotid arteries and the various branches of the external carotid, and, 
it' they are desired to be approached near their origin, the hypoglossal 
the pneumogastric, the sympathetic, and the glossopharyngeal nerves. 
Lower down, its anterior border is the landmark for the common car- 
otid and internal jugular veins, the descendens hypoglossi, and tlie su- 
perior and recurrent laryngeal nerves. Tlie anterioi 1 part of the upper 
extremity of the muscle is covered by the parotid inland. About one- 
fourth of the way down its anterior border, the sternocleidomastoid 
muscle covers the posterior belly of the digastric muscle as it passes 
upward and backward to its insertion into the mastoid process. 

The Submaxillary Salivary Gland is situated just beneath the hori- 
zontal ramus of the mandible near the angle and is partially covered 
by it. It occupies a triangular space which is bounded externally and 
above by the inner surface of the mandible, externally and below by 
the skin and fascia as they pass from the edge of the jaw to the neck, 
and internally by the mylohyoid muscle. The posterior part of the 
inland also rests internally on the hyoglosstis, the posterior belly of the 
digastric and the stylohyoid muscles. It is crossed externally by the 
facial vein, while the facial artery passes through a groove on its ex 
ternal inferior surface. The posterior end of the gland which is really 
the most bulky portion very often reaches to the anterior edge of the 
sternomastoid muscle. Along its upper border just beneath the lower 
edge of the jaw, the submaxillary lymph nodes are sometimes very 
closely associated with its capsule, so that in malignant disease with 
metastasis to the submaxillary lymph nodes it is probably best to re- 
move the salivary gland, as well as the lymph nodes in order to be sure 
that tlie disease is eradicated. The submaxillary or Wharton's due*: 
leaves the gland from the anterior end and is often accompanied by a 
tongue-like prolongation of the glandular tissue. 

The Digastric Muscle consists of two bellies, a posterior and an 
anterior. The posterior belly arises from the digastric groove on the 
internal surface of the mastoid process. It runs forward and down- 
ward, passing through the stylohyoid muscle, where it becomes ten- 
dinous. This tendon is attached to the upper surface of the hyoid bone 
by a pulley-like band from the cervical fascia. The tendon passes on 
through this pulley and becoming lleshy, forms tin- anterior belly, which 
is inserted into the lower border of the lower jaw close to the symphysis. 

The Stylohyoid Muscle arises from the base of the styloid process 
of the temporal bone, and after enclosing the digastric, is inserted into 
the body of the hyoid bone. Its course is almost parallel with that of 
the digastric. These two muscles form the posterior inferior boundary 



of the submaxillary triangle, and are important landmarks for the 
deeper structures. Superficial to them will be found the anterior 
division of the temporomaxillary vein, the facial vein, and their com- 
mon trunk as it passes downward and inward to join the internal jug- 

Facial Nerve. In this position, it is well to bear in mind the rela- 
tion of the supramandibular and inframandibular branches of the facial 




Dissection of the pes anserinus of the facial nerve. The dotted line 
represents the normal outline of the parotid gland. 

1, Parotid gland; 2, Temporofacial division; '.",, Cervicofacial division; 
4, Stylohyoid and digastric hranches; 5, Lymph nodes of the upper deep 
cervical group; 6, Temporal branch; 7, Malar branch; 8, Infraorbital 
branch; 9, Branches to parotid gland; 10, Huccal branch; 11, Supramandib- 
ular branch; 12, Facial artery; !.'{, Inframandibular branch. 

nerve. These nerves generally come from a common stem, the cervieo- 
facial. The inframandibular branch passes down from beneath the in- 
ferior edge of the parotid gland to supply the platysma myoides, and to 
form a communication with the superficial cervical nerve of the cervical 
plexus. From its superficial position, this nerve is almost bound to 


be cut in the operations on this region. Fortunately, the results are of 
little consequence. The supramandibular branch, emerging from be- 
neath the parotid gland, slightly in front of the inframandibular 
branch, sweeps forward and downward to the inferior edge of the 
mandible, follows this to the anterior border of the masseter muscle, 
and turning slightly upward supplies the depressor anguli oris, the 
depressor labii inferioris, and the orbicularis oris. The position of 






7 ' 

8 -- 

Fig. 70. 
Deep dissection of the carotid triangle. 

1, Parotid gland; 2, Inframandibular branch of facial nerve; 3, Sterno- 
mastoid muscle reflected; 4, Spinal accessory nerve; 5, Hypoglossal nerve: 
6, Internal carotid artery; 7, External carotid artery; 8, Descendens hypo- 
glossi; 9, Common carotid artery; 10, Internal jugular vein; 11, Supraniandib- 
ular branch of facial nerve; 12, Posterior belly of digastric muscle; 13, Sty- 
lohyoid muscle; 14, Facial vein; 15, Facial artery; 16, Anterior division of 
temporomaxillary vein; 17, Submaxillary salivary gland; 18. Anterior belly 
of digastric muscle; 19, Lingual vein; 20, Temporofacial vein; 21, Internal 
laryngeal nerve; 22, Superior thyroid artery. 

this branch of the nerve is somewhat variable, and occasionally, just 
after it emerges from the parotid gland, its course is so far down as to 
make it very open to injury in removing the lymph nodes at the angle 
of the jaw. Cutting of this nerve is deplorable as it paralyzes one-half 
of the lower lip. 


Internal Jugular Vein. At about this depth it is important to re- 
member the position and relation of the large veins of the neck. The 
internal jugular vein which is~a continuation of the lateral sinns, begins 
above by a dilation called the bulb which occupies the posterior com- 
partment of the jugular foramen. It runs obliquely downward and 
forward, terminating behind the clavicle near the sternum where it 
unites with the subclavian vein to form the innominate. At first it is 
behind the internal carotid artery, but gradually passes around as it 
descends until finally it is on the outer side of the carotid artery. In the 
lower part of the neck it sometimes overlaps it in front. The right 
vein is not very closely associated with the artery at the base of the 
neck, whilst the left vein is almost in front of the carotid artery on 
that side. An imporant tributary to this vein is the common facial 
vein. This latter vein is formed by the union of the facial vein and 
the anterior division of the temporomaxillary vein. The common 
facial vein crosses over the external carotid artery generally a little 
below the posterior belly of the digastric muscle and frequently has 
to be Heated and cut to expose the external carotid near its base. 
Sometimes the common facial vein gives off at the anterior edge of 
the sternomastoid a branch which may be quite large and which runs 
along the anterior border of the sternomastoid to the suprasternal 
fossa where it joins the anterior jugular vein. The internal jugular 
vein occupies the connective tissue sheath in common with the carotid 
arteries and the pneumogastric nerve. 

The Hypoglossal Nerve leaves the skull through the anterior con- 
dyloid foramen. It arches downward and forward passing to the outer 
side of both the internal and external carotid arteries and internal to 
the posterior belly of the digastric and the stylohyoid muscles. As it 
crosses the internal carotid artery it passes below and around the oc- 
cipital artery. In its course this nerve communicates with the pharyn- 
U'eal branch of the vagus, and sends a small branch k> the thyrohyoid 
muscle. It passes forward beneath the stylohyoid muscle and external 
to the hvoglossus muscle just above the hyoid hone. In this position 
it is an important landmark for an approach to the lingual artery. 'I" 1 he 
lingual branches of this nerve are distributed to the liyou'lossus. the 
geniohyoid and the geniohyoglossus muscles and practically to all the 
intrinsic muscles of the tongue. 'The descendens hypoglossi, a rather 
laru'e branch of the hypoglossal, descends along the external surface 
of the carotid .-heath, though sometimes it occupies the interior of the 
sheath and forms with a branch from the second and third cervical 
nerves the aiisa hypoglossi. Branches from this plexus run to the omo- 
hyoid. the sternothyroid and the stcrnohyoid, but it is probable that the 


iniiervation of these muscles comes through the cervical nerves ami not 
1 lirough the liypoglossal. 

The Common Carotid Artery arises on the right side of the neck 
from the innominate artery, and on the left side from the arch of the 
aorta. In the neck, however, the two arteries have practically the same 
relations. It is important to remember, however, that the thoracic 
duct passes immediately behind the left carotid artery just before 
archill,** 1 downward to enter the innominate vein, and the recurrent lar- 
yngeal nerve has already passed to the inner side of the artery before 
the artery enters the neck proper. On the right side the recurrent laryn- 
geal nerve lies behind the carotid artery in the lower part of the neck. 
At about the level of the tirst ring of the trachea the inferior thyroid 
artery, a branch of the thyroid axis, passes immediately behind the 
common carotid. The sternomastoid branch of the superior thyroid 
artery crosses over the common carotid along the anterior edge of the 
omohyoid at about the level of the sixtli cervical vertebra. A line for 
the common cartoid is from the upper part of the sternoclavicular ar- 
ticulation to a point midway between the angle of the jaw and the tip 
of the mastoid process. The point of bifurcation into the two termi- 
nal branches, the external and internal carotid arteries, is usually on 
a level with the upper border of the thyroid cartilage. It is, however, 
not uncommon for the external carotid to be given off considerably 
higher up, and this anomalous condition sometimes makes it difficult 
to quickly reach the external carotid for ligation. 

The Omohyoid Muscle which crosses the common carotid externally 
consists of two bellies, the anterior and the posterior. It arises from 
the upper border of the scapula and the snprascapular ligament and, 
passing forward and slightly upward, becomes tendinous beneath the 
sternomastoid muscle. This part of the muscle is called the posterior 
belly. The anterior belly begins from this intermediary tendon and 
passes obliquely upward and forward to be inserted into the outer edge 
of the lower border of the body of the hyoid bone. The intermediary 
tendon is held in place to the first rib by a process of the dee]) cervical 
fascia. The anterior belly of the muscle forms the upper boundary of 
the inferior carotid triangle and crosses the common carotid artery at 
about the level of the cricoid cartilage. 

The External Carotid Artery is usually about two and a half inches 
long and supplies blood to the upper part of the neck and nearly the 
whole of the head and face, outside of the cranium. Its course is gen- 
erally at first slightly forward, then backward, upward and inward, be- 
hind the posterior belly of the digastric and the stylohyoid muscles to 
the under surface of the parotid gland. It terminates near the upper 


part of the gland, generally beneath it but sometimes in its substance 
by dividing into the internal maxillary and the superficial temporal 

The Superior Thyroid Artery, the first branch of the external 
carotid, arises from the front of the carotid just below the tip of 
the great cornu of the liyoid bone. The artery runs at first forward, 
but soon turns downward, sending 1 brandies to the larynx, sternomas- 
toid muscle and the thyroid gland. In the beginning 1 of its course it 
lies on the inferior constrictor muscle, and is in very close relation 
with the external laryngeal branch of the superior laryngeal nerve. 
For a short distance after leaving 1 the cover of the sternomastoid the 
artery is directly under the deep cervical fascia, but lower down it is 
covered by the omohyoid, sternohyoid and sternothyroid muscles and 
is generally overlapped by its accompanying vein. 

The Ascending Pharyngeal Artery, the second branch, arises from 
the inner surface 1 of the external carotid, almost opposite the superior 
thyroid and runs upwards on the constrictor muscles of the pharynx 
to supply the wall of the pharynx and the soft palate. A palatine branch 
from this artery is not a constant structure, but when present takes 
the place of the ascending palatine branch of the facial, and supplies 
the upper part of the tonsil. 

The Lingual Artery, the third branch, springs from the front of 
the external carotid just above the superior thyroid and about opposite 
the tip of the great cornu of the hyoid bone. The artery forms a loop 
upwards in the first part of its course, and here, except that it is crossed 
superficially by the hypoglossal nerve, it is covered only by the skin, 
fascia and platysma. Reaching the posterior border of the hyoglos- 
sus muscle it passes beneath this structure just above the great cornu 
of the hyoid hone. It terminates as the rauine artery, and is the chief 
blood supply to the tongue. 

The Facial Artery, the fourth branch, arises from the carotid im- 
mediately above the lingual, but passes upward to the inner side of the 
posterior belly of the digastric and runs forward and downward 
through a special groove in the submaxillary gland to the margin of 
the jaw, just in front of the masseter muscle. Sometimes, however, 
after reaching the upper border of the digastric muscle, it loops up- 
wards until it comes into close proximity with the inferior pole of the 
tonsil, though always separated by the middle const rictor muscle. 
After reaching the edge of the jaw, the facial artery passes just be- 
neath the fjiscia and skin to supply the various structures of the face, 
terminating in the angular artery on the side of the nose. 

The Occipital Artery, the fifth branch, arises from the back of the 


external carotid just below the posterior belly of the digastric and run- 
ning upward and backward under the posterior belly of the digastric, 
it crosses, first the internal carotid artery, then the hypoglossal nerve, 
the pneumogastric nerve, the internal jugular vein and lastly the spinal 
accessory nerve. The hypoglossal nerve hooks around the artery just 
as it branches from the carotid. By passing between the transverse 
process of the atlas and the base of the skull, the occipital artery 
reaches the digastric groove of the niastoid process. In this part of 
its course it is separated from the vertebral artery by the rectus capitis 
lateralis muscle. 

The Posterior Auricular Artery, the sixth branch, leaves the back 
of the external carotid just above the digastric muscle and passing 
under the posterior part of the parotid gland runs between the mastoid 
process and external auditory meatus, where it is in close relation 
with the posterior auricular branch of the facial nerve. 

The Internal Maxillary Artery, the seventh branch, one of the ter- 
minal branches of the external carotid, begins behind the neck of the 
lower jaw and passes forward to supply practically all of the internal 
structures of the face. The first part of the artery is closely associ- 
ated with the auriculotemporal nerve and internal maxillary vein, and 
it lies between the sphenomandibular ligament and the neck of the 
jaw. Its second part, occupying the 1 zygomatic fossa, may run either 
over or under the lower head of the external pterygoid muscle. AY hen 
it passes between the heads of the external pterygoid muscle it comes 
into close relationship with the third division of the fifth nerve. The 
third part of the artery runs between the lower heads of the external 
pterygoid, thence through the pterygomaxillary fissure into the 
sphenomaxillary fossa. This artery gives off numerous branches, one 
of which, the posterior or descending palatine, runs downward through 
the posterior palatine canal to the roof of the mouth, where it crosses 
forward beneath the mucous membrane just inside the alveolar proc- 
ess. It gives off small branches which supply the soft palate and anas- 
tomose with the ascending palatine and tonsillar branches of the 
facial and probably with the ascending pharyngeal artery. Another 
branch, the vidian, supplies branches to the upper part of the pharynx 
and to the Eustachian tube. Another branch, the pterygopalatine sup- 
plies the upper and back part of the nose, the pharyngeal vault and 
surrounding structures. 

The Superficial Temporal Artery, the eighth branch, the second of 
the terminal branches of the external carotid, begins in the upper part 
of the parotid gland behind the neck of the mandibular, and, dividing 


into an anterior and posterior branch, supplies the anterior half of the 

The Internal Carotid Artery, beginning- at the level of the upper 
border of the thyroid cartilage, runs upward and inward posterior and 
external to the external carotid. It passes into the skull through the 
carotid canal of the temporal bone. Posterior to the artery and slightly 
internal are the rectns capitis anticus major muscle, the prevertebral 
fascia and the sympathetic cord. The internal jugular vein and vagus 


Fig. 71. 

The relation of the palatal tonsil to the vessels and nerves of the caro- 
tid triangle. Portion of the mandible has been resected and the tongue 

1, Palatal tonsil reflected backward and upward from its bed; 2, Uvula; 
'.',, External carotid artery; 4, Palatopharyngeal muscle; f>, Internal carotid 
artery; 6, Ascending pharyngeal artery; 7, Lateral pharyngeal wall drawn 
inward and backward; 8, Anterior palatal pillar drawn upward: !), Facial 
artery; 10, Lingual nerve; 11, Cut surface of tongue; 12, Glossopharyngeal 
nerve; 1M, Hypoglossal nerve; 14, Lingual artery; in, Styloglossus muscle; 
I*!, Superior thyroid artery; 17, Superior laryugeal nerve; 18, Common 
carotid artery. 

nerve, while on a plain posterior to the artery, are generally somewhat 
external to it. The spinal accessory and glossopharyngeal nerves for 
a short distance in the upper part of the neck arc found behind and 
slightly to the outer side passing between it and the internal jugular 
vein. Internally it is closely associated with the wall of the pharynx 


hut separated by the ascending pharyngeal artery, Ili<- pharyn.u'eal 
plexus of veins and the superior laryugeal nerve. Just hefore Ihe 
artery enters the temporal hone the levator palati muscle is found 
on its inner side. It is crossed externally hy the hypou'lossa! 
nerve and the occipital and posterior auricular arteries, and 
it is separated from the external carotid hy the stylopharyngens and 
styloglossus muscles, the stylohyoid ligament, the glossopharyn- 
geal nerve, the pharyugeal branch of the vagus, and some fine sympa- 
thetic twigs. r riie digastric and stylohyoid muscles run external hotli 
to it and to the external carotid. The upper part of the internal carotid 
in the neck is covered hy the parotid gland. As a rule no tranches arc 
given off from the internal carotid artery, while in the neck. 

The Pneumogastric or Vagus Nerve occupies the carotid sheath be- 
inii' placed behind and between first the internal, then the common car- 
otid artery and the internal jugular vein. Two gaiiiiTia are found on 
the pneumogastric nerve as it leaves the skull through the jugular 
foramen. The upper and smaller one, the ganglion of the root, gives 
off a meningeal branch and an auricular (Arnold's nerve) branch. 
The latter generally communicates with the tympanic branch of the 
glossopharyngeal, also with the facial nerve. The lower ganglion of 
the trunk gives off the pliaryngeal branch and the superior laryngeal 
nerve 1 . The pliaryngeal branch which really derives its fibres from the 
spinal accessory nerve, runs between the internal and external carotid 
arteries and helps in the formation of the pharyngeal plexus. 

The Superior Laryngeal Nerve runs downward and inward behind 
the external and internal carotid arteries to the thyroid cartilage. In 
its course it divides into the internal and external laryngeal nerves. 
The internal laryngeal nerve gains access to the larynx by running be- 
tween the middle and inferior constrictor muscle of the pharynx and 
through the thyrohyoid membrane. The external laryngeal nerve 
passes downward upon the inferior constrictor muscle ending in the 
cricothyroid in the lower part of the neck. 

The Recurrent or Inferior Laryngeal Nerve is a branch of the vagus. 
On the right side of the neck it leaves the vagus as it passes over the 
subclavian artery. It then runs upward behind the subclaviau, the 
common carotid and the inferior thyroid arteries, and behind the thy- 
roid body. It enters the larynx by passing beneath the lower border of 
the inferior constrictor muscle. The left recurrent laryngeal nerve 
leaves the vagus as it crosses the aortic arch. Passing around 
and behind the arch it runs upward in the interval between the trachea 
and esophagus. In the neck its course is similar to that on the right 


The Spinal Accessory Nerve divides in the jugular foramen, the 
accessory portion of the nerve joining the vagus. The spinal portion 
of the nerve then runs downward into the neck, occupying at first the 
interval between the external carotid artery and the internal jugular 
vein. It runs downward, outward, and then crosses obliquely back- 
ward over the vein to reach the internal surface of the sternomastoid 
muscle. It then pierces this muscle, sending fibres to it, and enters 
the posterior triangle of the neck near the exit of the cervical plexus. 
Crossing the posterior triangle it supplies the trapezius muscle enter- 
ing on its inner surface. 

The Glossopharyngeal Nerve leaves the skull through the jugular 
foramen and arching downward and forward passes between the in- 
ternal carotid artery and the internal jugular vein, and below the ex- 
ternal carotid. It passes around the outside of the stylopharyngeus 
muscle and the stylohyoid ligament and below the hyoglossus muscle, 
terminating in the tongue. It innervates the stylopharyngeus muscle 
and sends important branches to the pharyngeal plexus. It also sends 
a few direct fibres to the mucous membrane of the pharynx and another 
branch to form the tonsillar plexus which supplies the mucous mem- 
brane covering the tonsil and the immediate surrounding region. 

The Pharyngeal Plexus of nerves is made up of branches from the 
glossopharyngeal and the pneumogastric nerves and the superior cer- 
vical ganglion of the sympathetic. 


I>Y (iKORiiK I"]. Sll.\.MMAf(;||. M. I). 


Xowhere is surgery more dependent on a knowledge of anatomic 
details than in the operations upon the ear. In the temporal hone al- 
located a number of important anatomic structures a slight injury 
of which may be followed by serious results. The fact that these 
structures encroach on the field of operation which lies deep in the 
temporal bone makes the danger from injury much greater than when 
the operating is done in soft structures. 

The perfecting of aural surgery is the direct result of the modern 
tendency to specialization which has made it possible for the otologist 
to master the complicated anatomy of this region. The iirst problem 
for the surgeon who would undertake the operations on the ear is to 
master the details of the anatomy of this region. This cannot he ac- 
quired from text-books nor is this knowledge readily gained by 
attempts to do these operations on the cadaver. A thorough grasp of 
the complicated anatomy of the temporal bone is best acquired by a 
study of preparations made especially to show this or that relation. 
The knowledge comes through the actual making and handling of such 
preparations. The most that can be hoped from a chapter on the sur- 
gical anatomy of the ear is to point out the various relations which 
must be kept in mind when undertaking the surgery of this region and 
to emphasize these relations by drawings from actual preparations. 
The study of such a chapter can in no sense serve as an adequate sub- 
stitute for the actual handling of anatomic preparations, which after 
all is the only way of acquiring real anatomic knowledge. It is hoped 
that this chapter may serve to call the attention of the beginner to the 
more important surgical relations of the temporal bone so that with 
this as a guide he may work out for himself these relations from prep- 
arations of his own. 

The Development of the Temporal Bone. 

The temporal bone is formed from three parts, the pars petrosa, the 
pars squamosa and the pars tympanica, which in the new-born are 



sharply separated by well marked sutures. Of these the petrous is the 
most important as it contains the labyrinth and it is from the petrous 
bone that the mastoid process develops. The tympanic bone in the 
newborn is but a shallow curved rim containing a groove, the sulcus 
tympanicus, for the attachment of the membrana tympani. The rim is 
incomplete at the upper pole, the cleft forming the incisura tympanica 
in which the membrane of Shrapnell is attached. The squamous bone 
in the new born forms the outer covering 1 for the recessus epitympa- 
nicus (the attic and aditus) as well as the outer covering for the antrum 
tympanicum. The roof of these chambers, the teamen tympani et 
antri, is formed in part from the squamous bone and in part from the 
petrous. The suture passing directly through the tollmen is quite 
patulent in the new-born. This explains the ready occurrence in the 
young' of meningeal symptoms in cases of acute suppuration of the 
middle ear. 

The outer surface of the temporal bone in the new born presents 
an appearance quite unlike that seen in the adult. The most con- 
spicuous difference is the complete absence of an osseous external 
meatus. The membranous meatus is connected to the shallow rim ot 
bone, the pars tympanica, in which the membrana tympani is attached. 
This close relation between the membrana tympani and the mem- 
branous external meatus accounts for the occurrence of pain in a 
young child whenever in cases of acute otitis media the auricle is ma- 
nipulated. In older children this symptom disappears because the 
cartilage of the meatus is separated by a well developed bony meatus 
from the area of infiltration about the attachment of the membrana 
tympani. Another peculiarity in the new-born is the complete absence 
of a mastoid process. Thai part of 1he pelrous bone from which Ihe 
proccssus masloideiis develops presents a flat surface with scarcely a 
suggestion of a prominence from which the process develops. A con- 
spicuous suture beginning opposite the middle of the posterior wall of 
the tympanum and coursing upward and backward to a notch on the 
posterior margin of the temporal bone marks the union between the 
petrous and sqiiamous bones. (Fig. 7'2.) This suture, the petrosqiia- 
mosal, opens directly into the antrum tympanicum and often persists 
in the adult as a depression into which the periosteum penetrates. The 
persistence of the petrosquamosal suture in children has an important 
practical bearing on the course of antrum infection at this age as it 
permits of the rapid development of a suhperiosteal abscess. It ex- 
plains also why a simple Wild's incision in an infant is so much more 
effective than in the adult. A Wild's incision in an infant for the 
relief of a subperiosteal abscess formed by an extension from the 



antrnm through the petrosquamosal suture amounts often lo the same 
as a Schwartze operation in the adult as it ^ives a free opening into 
the antrnni, the only pneumatic space developed at this a.u'e. 

On the outer surface of the temporal hone, just hack of the pars 
tympanica, at about the junction of the middle with the lower thirds of 
the posterior wall of the tympanic cavity, is a round opening for tin- 
exit of the facial nerve. It is important that this position of the stylo- 
mastoid opening in the infant he kept in mind when making the incision 

Fig. 72. 


Fig. 72. Temporal bone from ne\v-born, showing distinctly the three 
parts which go to make up this bone: the pars squamosa, pars tympanica, 
pars petrosa. Note the absence of bony external meatus and the absence 
of a mastoid process. The opening of the facial canal is on the exposed 
outer surface of the temporal bone. (Dr. G. W. Boot's preparation. I 

Fig. 7;'.. Temporal bone from child one year old. showing the per- 
sistence of the petrosquamosal suture, also the beginning of a mastoid 
process which is still to small to cover the opening of the facial canal. 
The bony external auditory canal is beginning to form. The lower ante- 
rior part is still entirely wanting. ( Ur. G. AY. Boot's preparation.) 

for the relief of a subperiosteal abscess, for this incision mi.u'ht sever 
the facial nerve. 

In the development of the temporal bone after birth the two con- 
spicuous changes brought about are the formation of a mastoid proc- 
ess and of a bony external meatus. The processus mastoideus develops 
largely from the petrous bone. It is first recognized as a small tubercle 
at about the ai>'e of one year. (Fii* 1 . "'>.) Its development takes place 
in two directions, outward, that is external to the cavity of the tym- 
panum, and downward below the cavity of the tympanum. It is the 
development of the processus mastoideus that causes the stylomas- 


toid foramen to recede from the surface of the temporal bone until in 
the adult it lies fully iT) mm. from the outer surface of the mastoid. At 
the age of three years the mastoid has already assumed the shape 
found in the adult and the digastric groove is easily recognized. (Fig. 
74.) The pet rosquamosal suture has usually been obliterated with only 
occasionally a depression marking its site. The external bony cover- 
ing of the antrum is still usually quite porous. 

The development externally of the processus mastoideus is shared 
by both the squamous and the tympanic bones. All three enter into 
the formation of the bony external nieatus. In its development the 
tympanic bone forms a trough with an opening above the posterior. 
This trough in the adult forms the anterior, the lower, and part of the 
posterior bony nieatus auditorius externus. The upper wall of the bony 
nieatus is formed by a horizontal plate from the squamous bone. The 
upper posterior margin of the external meatus is formed by the pro- 
cessus mastoideus and is developed in part from the petrous and in 
part from the squamous bones. It is this upper posterior part of the 
external bony nieatus that is occupied frequently in the adult by pneu- 
matic spaces, mastoid cells. 

Meatus Auditorius Externus. 

In the new-born, as already pointed out, the external auditory 
nieatus consists only of the cartilaginous membranous portion, there 
being no bony meatus. In the adult this cartilaginous portion forms 
scarcely the outer third of the canal. In the development of the bony 
canal the part formed by the squamous and petrous bones pushes out 
beyond that formed from the tympanic bone, so that the anterior lower 
wall of the bony meatus is shorter than the upper and posterior wall. 
This deficiency is pieced out by an extension from the cartilage form- 
in ^ the auricle. In this cartilage which forms the outer part of the 
anterior lower wall of the external meatus are several clefts called the 
inc'isiinc Satitorini which relieve the rigidity of this part of the canal 
and permit greater mobility of the auricle. Through these clefts in 
the cartilage a parotid abscess occasionally discharges into the ex- 
ternal meatus and through them a furuncle in the meatus may dis- 
charge into the region of the parotid. 

The anterior lower wall of the bony meatus is formed by a thin 
plate of bone which x-parates the meatus from the glenoid fossa. A 
severe blow on the chin may fracture this bone and drive the head of 
1h (1 mandible into the external nieatus. 'The floor of the external 
nieatus make> a decided curve downward at its inner third fori 

THK SUK<;i('AL AX ATOMY ()!' T 1 1 K K.M! 


Temporal bone from child three years old, showing the mastoid proc- 
ess, the bony external auditory meatus, and obliteration of the petrosquu- 
mosal suture. (Dr. G. W. Boot's preparation.) 

Temporal bone from child ten years old. The adult characters of the 
temporal bone are developed. Persistence of depression over the niastoid 
showing the line of the petrosquamosal suture. (Dr. G. \V. Boot's prepa- 



the snlcus of the external ineatus. ( Fi.u 1 . <(>.) The narrowest part of 
the external ineatus is at the entrance of this sulciis. The sulcus itself 

Fig-. Ttj. 

Frontal section through the adult temporal bone: the anterior part 
viewed from behind. Section passes through external meatus, cavum tym- 
pani. and labyrinth. 

is at times so deep that insects and small foreign bodies lod.u'in.u 1 in it 
may lie completely out of the line of direct ins], ction. 

The upper posterior wall of the external meatus is formed from 
the mastoid process and this is the only part of the meatus Avail en- 


Aduli temporal hour showing the position of the anlriini tympanicnin 
and masioid ci-lls along the upper posterior wall of the external canal. 

eroached on I iy ma.-loid cells. Tlioe cells may he found external to 
the suprameatal spine ( l-'iv.'. 77) which is located often somewhat \vi 



the outer margin of the meatus. The ant rum tyinpanicuin lies above 
the upper posterior wall of Hie meatus just external to Ilie membrana 
tympaui. (Fig. 77, 7S, 7!'.) lu cases of acute iuasloi<l disease when the 

Fig. 78. 

Horizontal section through the temporal bone 1 viewed from above. Sec- 
tion through the external canal, cavuni tympani, labyrinth and internal 

temporal bone is being involved, a ])eriostitis over this portion of the 
canal frequently results in a bulging or sinking of this part of the pos- 

Fig. 79. 

Section through mastoid process and external canal, showing pneumatic 
type of mastoid with the larger colls on the poriphora. also the position of 
the antrum above and posterior to the external canal. 

terior wall. A mastoid abscess frequently discharges into the external 
canal at this point. In cases of chronic suppuration with cholesteatoma 
formation in the antrum the cholesteatoma frequently breaks through 



into the external meatus at this point. On the other hand it should be 
remembered that a furuncle located along the posterior wall of the 
meatus may be confused with a mastoid abscess, since in addition to 
producing 1 a bulging of this wall of the canal it is often associated with 
an infiltration and edema over the mastoid process with displacement 
forward of the auricle, such as a mastoid abscess produces. The rela- 
tion of the facial canal to the upper and posterior walls of the external 
meatus is of great surgical importance especially in doing the radical 
mastoid operation. The inner rim of the upper wall of the external 
nieatus lies directly over the facial canal from the point where the 
nerve enters the tympanum in front of the oval window until it begins 
to curve downward toward the stylomastoid opening. (Figs. 7(i and 

Section through temporal bone, showing the relation of the facial 
canal to the fenestra vost.ibuli and of the horizontal canal to the antrum. 

M). ) In this part of its course the facial nerve is covered by an ex- 
tremely thin shell of bone in which dehiscence frequently occurs. From 
the point where t he facial canal turns downward until it emerges from 
the stylomastoid foramen it lies in the hone which forms the posterior 
wall of the bony meatus. At the point where this canal enters tho 
posterior wall of the bony nieatus just posterior to the oval win- 
dow it lies on a level with the inner wall of the tympanum. As it 
passes downward it lies out further and further along the external 
meatus so that at the level of the floor of the tympanum the canal lies 
several millimeters external to the inner wall of the tympanum. (Fig. 
s 'i.) Again the relation of the facial canal to the external meatus is 
such that where it enters the posterior wall of the nieatus near the up- 
per part of the tympanum it lies close to the meatus wall but as the 



canal passes downward it recedes further and further from the meatus 
until at the level of the floor of the tympanum it lies several millimeters 
posterior to the external meatiis. ( Kiii's. SO and Si.) These relations 

Fig. 81. 
Section through temporal bone, exposing the facial canal. 

of the facial canal to the posterior wall of the external ineatus make it 
necessary, when performing the radical mastoid operation, to leave- 

Fig. 8'2. 

Adult temporal bone, showing anatomic relations after a complete 
tympanomastoid exenteration. 

standing a part of the posterior wall of the canal. ( Fii>\ 82.) On the 
other hand it is possible to remove the ledge of hone lying in front of 
the facial canal which separates the canal from the meatus. 



The Processus Mastoideus. 

The mastoid process is surgically the most important part of the 
temporal bone. Most of the serious complications arising in the course 
of suppurativo middle ear disease develop from disease of this proc- 
ess and the operations undertaken for the relief of these complications 
begin with an exenteration of the mastoid. 

The outlines of the mastoid process present a cone-shaped appear- 
ance, the apex of the cone pointing downward, the bast 1 of the cone 
uppermost. The size in the adult is not constant. The outer surface 
is more or less rounded or flattened depending largely on the size. In 

Adult temporal bone, showing the typical relation of the linea tcin- 
oralis extending in a horizontal direction back from the external canal. 

tin- well developed process the outer surface is more rounded while ii: 
the >ma!l process the surface is more flattened. 

The markings on the outer surface of the mastoid process are of 
importance. They serve as a guide in making an opening into the 
antruin. The base of the mastoid is marked off by a horizontal ridu'e, 
a continual ion of the root of the zygoma. This is known as the linea 
temporal]* and i> constant although not developed as prominently in 
some cases as in others. The linea temporalis usually extends directly 
hack from and on the same plane with the root of the zygoma. (Fig. 
) It lie-, therefore, a little above the external meatiis. In some 
cases, however, it curves down around the upper posterior margin of 

Tin-: sri;ic.\i, ANATOMY OK TIIK KAI;. 

the external meatus and lakes its horizontal course I'roni about the 
middle of the opening of the external incatus. (Fig. S-k ) In other 
cases the linea temporalis takes a sharp curve upward immediately 
back of the upper posterior margin of the external ineatus. (Fig. 80.) 
It is important to understand these variations since this ridge often 
serves as a guide in opening the antruin and as a landmark indicating 
the line of separation between the mastoid and the middle brain fossa. 
In keeping below the linea temporalis when opening the mastoid proc- 
ess there should lie no danger of entering the middle fossa. The cases 
in which the linea teinporalis takes a sharp curve upward just back 
of the external ineatus are exceptions. Here the middle fossa can 

Fig. 84. 

Adult temporal bone showing the linea temporalis making a marked 
curve down along the posterior border of the external meat us before turn- 
ing backward. (Anatomic variation.) 

be readily entered by chiseling directly inward from beneath this 
ridge. As a guide for finding the antrum the linea temporalis can 
usually be relied on. The opening is made immediately below the 
ridge quite close to the meatus, and the direction of the external 
meatns followed until the antrum is reached. There is but one type 
of process in which this method could fail to lead to the antrum. 
This is when the linea temporalis curves down along the pos- 
terior margin of the external meatus before coursing backward. (Fig. 
84.) In these cases the opening made into the mastoid as indicated 
could readily miss the antrum and might lead to an injury of the facial 



Another constant landmark on the outer surface of the temporal 
bone is the spina supranieatuni located at the upper posterior margin 
of the external meatus. (Figs. 74 and 77.) This is a small roughened 
area for the attachment of the superior ligament of the auricle. The 
size of the spine varies. It is usually quite conspicuous but, especially 
in children, it may be so small as to escape detection. As a guide in 
opening the antrum it can always be relied upon as its position at the 
upper posterior margin of the external meatus is constant. The 
antrum. which lies some distance out along the upper posterior wall 
of the external meatus, is readily reached by making an opening in the 
mastoid just back of the suprameatal spine and following the direction 
of the external meatus. To lay off an imaginary triangle in this local- 



Fig. 85. 

Adult temporal bone showing the linea temporally making a curve "up- 
ward at the posterior margin of the external meatus. (Anatomic variation.) 

ity before making the opening into the antrum would only complicate 
the situation and lead to confusion in the mind of the beginner. The 
simplest method of finding the antrum when the suprameatal spine 
can be recognized is the direction given above. In all cases in which 
the spine cannot be made out no difficulty will be experienced in locat- 
ing t he ant rum if it be kept in mind that t his cavity lies above the upper 
posterior wall of the external meatus a short distance external to the 
drum membrane. 'The opening in the mastoid should be made close to 
the external meatus just below an imaginary line passing through the 
upper margin of the external meatus and the occipital protuberance. 
II 1h<' opening follows closely the direction of the external meatus one 
cannot fail to find the aiilriini if that cavity has not been completely 



obliterated, as it may bo in rare eases of chronic suppuration of the 
middle ear. 

Other markings on the outer surface of the niastoid are the open- 
ing for the emissary niastoid vein, the tympanomastoid, and the potro- 
squamosal sutures. The opening of the emissary niastoid vein is along 
the posterior margin of the niastoid. (Fig. 84.) it frequently repre- 
sents a point of increased tenderness in cases of thrombosis of tin- 
lateral sinus. The location of the opening should be kept in mind when 
operating on niastoid cells located along the posterior margin of the 
process. The tympanomastoid suture is seen along the posterior mar- 
gin of the external meatus. It marks the separation between the part 
of the posterior wall of the meatus formed from the tympanic bone and 

Section through niastoid process, antrum tympanicum, and external 
oanal. (Pneumatic type.) 

that formed from the niastoid process. The petrosquamosal suture is 
well marked in the young child but is usually quite obliterated in the 

The niastoid process in the adult usually contains pneumatic 
spaces which communicate with the antrum and are known as niastoid 
cells. In the new-born there is an absence of a niastoid process and of 
niastoid cells. The antrum, which is in reality part of the tympanum 
and is known as the antrum tympanicum, exists in the new-born. As 
the niastoid process develops pneumatic spaces develop and as a rule 
completely fill the process. (Figs. 79, 86, 87.) These cells often extend 
beyond the confines of the niastoid process forward into the root of 
the zygoma and posterior into the occipital bone. The cells lying near 
the antrum are as a rule small in size. The cells occupying the tip of 

11 J 


the mastoid and those lying along the posterior margin are usually 
much larger. (Fig. 7!', S(>, 87.) lu Figs. 88 and 81) is shown an unusu- 


Pig. 87. 
Pneumatic type of mastoid. Larger cells arranged along the periphery. 

ally large mastoid cell outside the mastoid process lying internal to 
the diagastric groove. Such a mastoid cell is especially dangerous be- 
cause in the first place a suppuration .here could produce no symptoms 

Fig. SS. 

Fij^s. XX and S'.t. Section through teni])oral bone. Section passes 
through nntruiii, vestibule and internal meatus. Large pneumatic cell de- 
ve|o|)i. ( | internal to the digastric groove. (Anatomic variation.) 

over the outer sui-face of the mastoid and in the second place such a 
cell might readily escape detection when operating on the mastoid 


process. The mastoid cells ;ill communicate with the autrum and al- 
though the walls separating adjoining cells usually show dehiscences 
cells may retain their own openings leading to the aiitrum. In this 
way it is possible for a large cell at the tip of the mastoid to communi- 
cate with the autrum through its own channel and without communi- 
cating with adjoining 1 cells. 'Fhis condition may explain the occurrence 
of an isolated abscess in t he tip of 1 he mastoid process. 

The process of pneumati/ation of the mastoid is often incomplete 
so that mastoid cells are formed in but a part of the mastoid. In such 
cases the cells are located close to the antrum while the tip of the proc- 
ess and the posterior margin are free from air cells. (Figs. *<>, 90, 1)1.) 

Fig. 90. 

Section through temporal bone, showing relation of the horizontal 
canal and facial canal to the middle ear chambers: also relation of the 
carotid and bulbar jugnlaris to the cavuni tympani. 

In other cases no mastoid cells whatever exist. ( Figs. 9'J and 9 .'>.) Here 
the process is Hatter and smaller than normal and the size of the an- 
trum also is quite small. In other words the whole impression one gets 
from an examination of this type of mastoid is that of an undeveloped 
infantile condition. It is this type of mastoid process that is found in 
cases of chronic suppurativc otitis media dating from early childhood. 
Mr. Cheatle interprets these facts as indicating that cases of acute 
purulent otitis media are more inclined to become chronic when occur- 
ring in the non-pneumatic type of mastoid. Others are inclined to be- 
lieve that the lack of pnemnatization in such cases is itself the direct 
result and not the cause of the chronic suppuration. The suppuration 
beginning in early childhood before the development of the mastoid 


has progressed vci-y far hinders its further development; the result 
beini>' these cases of complete absence of mastoid cells. This condition 


Fig. 111. 

Section through the mastoid process, showing but partial pneumati- 
zation. A few small mastoid cells near the antrum are all that have 

l)ipl<Hic type of mastoid. Complete absi nee of pneumatic spaces. An- 
trum tympanicum contracted. 

should not he confused with the process of osteosclerosis or hardening 
of the honi- -iirroiindiim' as a rule a cholesteatoma formation in the an- 


rum. Tlie 1'oof of the mastoid is a thin shell of bone which separates 
the antrum and the inastoid cells from the middle brain fossa. Over 
the antrum it is called the teginen antri. Dehiscence in the bone fre- 
quently exists so that only the lining of the mastoid cells and the dura 
separates the cells from the brain cavity. (Figs. 77, 90, 94, !).").) 

A number of important structures come into close relation with 
the mastoid process. The sigmoid curve of the lateral sinus lies in- 
ternal to this process and encroaches more or less on spaces of th" 
mastoid. (Fig. S ) The distance separating this sinus from the pos 
terior wall of the external nieatus varies in different individuals. I'su- 
ally there is ample space between the sinus and the posterior wall of 
the nieatus to permit of a wide opening into the antrum. In other 
cases the sinus lies so close to the nieatus wall that the opening into 

Section through adult temporal bone, showing persistence of infantile 
type with absence of pneumatic spaces in the mastoid. The relations of the 
horizontal and facial canals to the middle ear spaces. 

the antruin lias to he made by working along 1 the upper posterior wall 
of the nieatus instead of posterior to the suprametal spine. The 
location of the sigrnoid curve is usually the same on hoth sides. The 
important relation of the facial canal to the inastoid has already been 
discussed. It is important to remember that mastoid cells may develop 
in close proximity to the facial canal and that these cells may lie deeper 
than the facial, that is internal to it. The facial nerve is most readily 
injured in its course through the tympanum or at the point where it 
makes the heud downward toward the stylomastoid opening. (Figs. 
77, 80, 81, 90, 92, 94.) 

The horizontal semicircular canal forms a prominence in the floor 
of the antrum where its hard ivory-like capsule can readily he recog- 
nized, when opening the antrum, by its smooth glistening appearance. 
Its position is such that should the cavity of the antrum be mistaken 



for a mastoid cell a single stroke of the chisel in an attempt to pene- 
trate further might readily open the canal. Its position in a measure 
protects the facial nerves from injury when operating on the mastoid, 
for its hard capsule forms a partial covering for the facial canal just 
back of the oval window. (Figs. SO, 90, 94, Of).) The superior semi- 
circular canal encroaches at times on the anterior inner wall of the 
antrum. (Fig. 9(5.) In antrum disease it is possible for an erosion 
into the superior canal to occur. This canal is not exposed to injury 
in operating on the mastoid as is the horizontal. 

Fig. f4. 

Soft ion through adult temporal bone, showing the relations of the 
carotid to the cavuni tyinpani and the structures in the floor of the reces- 
sus opitympanicus. 

Cavum Tympani. 

Anatomically the tympanic cavity forms but a part of a larger 
cavity which includes the aiilrum tympanicum and the passage between 
I hoc two. the recessus epitympanicus. (Figs. S0-9f). ) Pathologically 
also these chambers should be considered together as they are usually 
involved in the same process. The division of the passage way from 
tin- t vmpaiiimi to the antrum into two parts, an attic and aditus, is not 
feasible anatomically. ( Fig. 95.) 

The inner wall of the tympanic cavity is formed largely by the 
capsule of the labyrinth. The first turn of the cochlea produces a 



prominence just posterior to the renter to which the term promontory 
is given. Just above the promontory is an oval opening into the vesti- 
bule of the labyrinth railed the I'enestra vestibuli. This is the oval 
window in which the foot plate of the stapes is attached. The win- 
dow itself is at the bottom of a depression out of which only the head 
of the stapes and a small part of the crura 1 project, .lust posterior to 
the promontory, lying but a couple of millimeters from the oval win- 
dow, is the opening into the tirst turn of the cochlea called the fenestra 
cochlea 1 . This is the round window covered over by a membrane which 
separates the tympanum from the srala tympani. Directly posterior 
to that part of the promontory which separates the oval from the round 
window is a depression often extending under the canal for the facial 

Section through mastoid, eavum tympani, tuba auditiva. showing a 
large tubal cell. 

nerve. This depression is known as the sinus tympanicus. It is dii'li- 
cult to smooth out this pocket when performing the radical mastoid 
operation. A conspicuous marking on the inner wall of the tympanum 
is the canal for the tensor tympani muscle. This lies just above the 
tympanic orifice of the Eustachian tube. The processus eochleari- 
formis which forms the posterior end of this canal projects out a short 
distance over the anterior margin of the oval window. (Fig. !)4.) The 
relation of the facial canal to the inner wall of the tympanum is of 
great surgical importance as the facial nerve in its course through the 
tympanum is covered by an extremely thin delicate covering of hour 
which can readily be fractured by the use of a curette. The nerve en- 
ters the tympanum in front of and just above the oval window. Its 
course is more or less horizontal until just posterior to the oval win- 



dow it curves downward toward the stylomastoid opening. (Figs. 80, 
si, 90, 9.'!, 94, 9(>.) The prominence formed by the horizontal semicir- 
cular canal in the floor of the passage from the antrimi into the tym- 
panum projects out beyond tin. 1 facial canal and in this way serves 
often to protect the nerve from injury when operating in this region. 
The root' of the tympanum is formed by a plate of bone separating 
this cavity from the middle fossa. This is called the teamen and is 
often extremely delicate. ( Figs. 77, SO, 90, 94, 95, 98.) In the new-born 
it is crossed by the suture between the squamous and petrous bones 
through which blood vessel communications extend between the dura 
and the membrane lining the tympanum. Through this tegmen sup- 

Fig. J6. 

Section through the mastoid and tympanic cavity, showing the relation 
of the horizontal and superior canals to the antrum. 

purative disease in the tympanum frequently penetrates into the brain 

The floor of the tympanum contains a number of depressions 
called tympanic cells. These cells arc occasionally quite extensive in 
which case it becomes difficult if not quite impossible to clean them out 
entirely in operating on the tympanum. (Fig. 97.) The floor of the 
tympanum extends somewhat deeper than the floor of the external 
meatii.-. This depression is called the recessus hypotympanicus. The 
relation of the bulb of the jugular to the floor of the tympanum is such 
that infection occasionallv extends from the tympanum directly to the 


hull). The hull) is frequently exposed to injury when r.u retting the 
floor of the tympanum. In most eases the hull) is separated from the 
tympanum hy a thick wall of hone. ( Fig. 90.) In other cases the hull) 
forms a prominence in the floor of this cavity. 11 is then covered hy 
an extremely thin shell of hone readily hrokeu hy the curette. ( Fig. 

In the anterior wall of the tympanum is located the tympanic ori- 
fice of the Eustachian tuhe. ( Figs. 82 and !).">.) The internal carotid 
lies directly in front of the tympanum from which it is separated hy 
a thin plate of hone. (Figs. SO, Si', DO, 94.) In performing the radical 
mastoid it is important to rememher that the carotid lies helow, that 
is internal to the Eustachian tuhe. In order to avoid injuring this ves- 
sel the pressure of the curette in the month of the tuhe must he directed 
upward, that is outward. The mesial wall of the tuhe should not he 

Horizontal section through the temporal bone seen from below. A laruc 
tympanic cell developed near the floor of the tympanum. 

curetted. Pneumatic cells are frequently found opening into the Fu 
stachian tuhe near the tympanum. These are the tuhal cells and at 
times they are quite extensive. (Fig. 9f).) On account of the relation 
of the internal carotid it is often not feasihle to eradicate these tuhal 
cells when performing the radical mastoid operation. 

Tn the posterior wall of the tympanum is located the opening into 
the antrum. (Figs. 94 and 9f>.) This opening occupies ahout the up- 
per third of the posterior wall. The canal for the facial nerve forms 
a slight prominence along the mesial wall of this opening. (Figs. DO and 
94.) At the lower margin of the opening 1 the facial canal enters the 
posterior wall of the tympanum. Toward the Moor of the tympanum 
this canal recedes more and more from the posterior wall of the cavum 
tympani. (Figs. 80 and 81.) A small houy prominence just hack of the 
oval window contains an opening for the transmission of the tendon of 



the stapedius muscle. This prominence is called the eminentia pyra- 
midalis. (Fig. J)4.) The depression in the posterior wall of the tym- 
panum, called the sinus tympanicus, lies directly under the eminentia 
pyramidal is. 

The external or outer wall of the tympanum is formed chiefly by 
the membrana tympani. At the floor of the tympanum is a depression, 
the recessus hypotympanieus, the external Avail of which is formed by 
the floor of the bony meatus. (Fig. 7(5.) At the upper part of the tym- 
panum is the recessus epitympanicus, the outer wall of which is 
formed bv the bone forming 1 the roof of the external meatus. (Fig. 

Fig. 98. 

Section through temporal bone, showing relation of the bulbus jugu- 
laris to cavum tympani and relations of the cochlea and facial canal to the 
cavum tympani. 

7<i. ) hi removing the external wall of 1 he so-called attic, there is danger 
of injuring the facial nerve as this structure in its course through the 
tympanum lies directly internal to the lower margin of the external 
wall of 1 his chamber. 

When curetting out the tympanic cavity great care must he taken 
on account of the danger of injuring important structures. Jn 
the floor of the tympanum is tin- recessus hypotympanieus and the 
tympanic cells which frequently require cleaning out when perform- 
ing the radical operation. Here the danger of injuring the hull) of the 
jugular must lie kept in mind. Along the posterior wall of the tym- 
panum are several depressions, the largest of which, the sinus tym- 
panicu>. extends often under the canal for the facial. These cells are 


exposed only by removing the ledge of hone in t'ronl of the facial canal 
in the lower half of the posterior wall of t lie meat us. ( Figs, so and si.) 
In the floor of the Kustachian tnhe near its tympanic orifice are the 
tnbal cells, which must he opened with great caution on account of the 
location of the internal carotid just anterior and internal to the tym- 
panum and internal to the Eustacliian tnhe. The roof of the tym- 
panum, the teamen tympani, separates this cavity from the middle 
fossa. It is a fragile shelf of hone easily perforated by a curette. In 
curetting the inner wall of the tympanum the region just below and in 
front of the prominence for the horizontal canal should be avoided be- 
cause the facial canal crosses the tympanum here and in this region is 
the oval window with the stapes. A dislocation of the latter may lead 
to an infection of the labyrinth. 

The relations of the lateral sinus are important to keep in mind 
not only when operating on the sinus itself but whenever an opening 
into the mastoid is made. The variations in the location of the sigmoid 
curve of this sinus are such that unless they are understood there is 
often great danger of opening the sinus when performing the simple 
mastoid operation. The sigmoid usually lies far enough posterior to 
the external meatus to permit of a free opening into the antrum. (Fig. 
82.) It frequently projects forward, however, so close to the posterior 
wall of the external meatus that a free opening from the surface of 
the mastoid into the antrum is obstructed. It usually lies at a consid- 
erable distance from the surface of the mastoid but in those cases in 
which the sinus is pushed forward it approaches closer and closer to 
the surface of the mastoid. It can be seen in some cases after the 
periosteum has been removed, as a bluish discoloration from the sur- 
face of the mastoid. In all cases the cortex of the mastoid should be 
removed with caution until the location of the sinus has been deter- 
mined. In rare cases there is a congenital absence of the lateral sinus 
on one side. The author has one such preparation in his collection. 
Xear the upper posterior margin of the mastoid process the sinus 
takes a horizontal direction backward. At about the level of the floor 
of the tympanum the sinus turns inward and somewhat forward in a 
horizontal direction towards the bulb. 

The position of the bulb of the jugular and its relation to the sur- 
rounding structures must be understood by the surgeon who under- 
takes to operate on the mastoid. In cases of infection it becomes neces- 
nary to expose the bulb and to lay it freely open. The relation of the 
bulb to the cavum tympani has already been described. When the bulb 
occupies that relation to the lloor of the tympanum which is shown in 



Fig. 1'S or in Fig. !M an exposure of the bulb by operating through the 
tynipaiiuin is feasible. 

The location of the bulb varies, however, even more than does that 
of the lateral sinus. In most cases the bulb makes but a shallow inden- 
tation in the lower surface of the temporal bone, so that a curette 
passed forward along the lateral sinus will remove clots located in it. 
In these cases it is separated from the floor of the tympanum by a 
thick layer of bone. In other cases the dome of the jugular bulb is 
pushed upward higher and higher along the posterior wall of the 
petrous bone. In these cases the appearance is not unlike an erosion 
produced by an eddy in a stream. The extent to which the bulb is 
pushed upward in these cases is often surprising. Occasionally the 
bulb extends 1o the highest margin of the petrous bone. In Fig. 100 is 


Fig. !)!. 

Horizontal section through the temporal bone seen from above, showing 
the relations of the bulbus jugularis to the lateral sinus. 

shown a case in which the bulb extends through the superior margin of 
the petrous bone and in its course ((Illiterates part of the posterior wall 
of the internal nieatus as well as the bony covering of the aqua'ductus 
vest ibiili. 

The surest route for the exposure of the jugular bulb is to fol- 
low along the course of the lateral sinus until the bulb is reached. By 
chiseling along in front of the sinus a layer of bone can be removed 
posterior to the facial canal which will usually permit of a more or less 
free exposure of the bulb, depending, of course, on whether the bulb 
is shallow or deep. The thickness of the bone thai can be removed in this 
way along the anterior wall of the sinus without an injury to the facial 
nerve is often as much as ()..") cm. ( Fig. !>!).) Care must be taken in mak- 
ing Ihi- opening into the bulb not to extend the chiseling too far up 
alonu' the posterior surface of the petrous bone for here there is danger 
ot opening into the posterior semicircular canal. 

'I' I IK Sl'ltCIC A I, ANA 

III connection with the surgical relation of the lateral sinus it 
should he mentioned that this structure serves as the best guide for 
the opening of a cerebellar abscess. r rhese abscesses lie usually some- 
where along the posterior surface of the petrous bone in front of the 
lateral sinus. To attempt to drain such an abscess by an opening back 
of the sinus is more difficult because of the great distance from the sur- 
face. The best route by which to reach these abscesses is by making 
an opening in front of the lateral sinus. If the anterior wall of the 
lateral sinus is followed and the chiseling is not carried too far for- 
ward it is possible to expose the cerebellum without an injury of the 

Fig. 100. 

View of the posterior aspect of the temporal bone, showing bulbus jug- 
ularis extending to the upper margin of the petrous bone. (Anatomical 

posterior semicircular canal provided that the abscess is not secondary 
to a labyrinth suppuration. 

The surgical anatomy of the labyrinth is best explained in con- 
nection with the operation on the labyrinth. In this connection atten- 
tion may be called to the relations of the labyrinth to the middle 
ear chambers. In the cavum tympani the capsule of the labyrinth is 
freely exposed. The promontory on the inner wall is formed by the 
large turn made by the beginning of the basal coil. By chiseling from 
the lower edge of the fenestra vestibuli a free opening into the vesti- 
bule is made and in removing the promontory free drainage of the coch- 
lea is accomplished. In removing the promontory the relation of 
the bull) of the jugular shown in Fig. i>8 should be kept in mind. In 
just such a case the author has opened the bulb while removing the 


promontory. The apex of the cochlea can bo exposed by chiseling for- 
ward from the anterior margin of the oval window. The apex of the 
cochlea lies internal to the tympanic orifice of the Eustachian tube. 
Its relation to the internal carotid lying 1 just posterior or external to 
this structure makes it necessary to exercise great care when working 
in this region. 

Two of the semicircular canals come into more or less close rela- 
tion to the middle ear cavities, the horizontal and the superior. The 
capsule of the horizontal canal forms a white glistening prominence 
readily seen in opening the antrum. It lies in the floor of the recessus 
epitympanicus at the point where this opens into the antrum. The re- 
lation of the superior canal to the middle ear is not nearly so intimate. 
It lies just above the anterior end of the exposed part of the horizontal 
canal. In this way its anterior cms is readily exposed by chiseling 
above the prominence of the horizontal canal and directly over the oval 
window. Tn opening this canal the position of the facial nerve along 
the upper margin of the oval window must not be forgotten. The pos- 
terior semicircular canal does not come into close relation to the mid- 
dle ear. It can be reached by removing the triangular piece of bone 
between the superior and the horizontal canals. 




Special Difficulties and Dangers. 

The teclmic of external operations upon the upper air passages and 
the esophagus would be simple enough were it not for certain special 
difficulties and dangers peculiar to these operations. It is well there- 
fore to first consider these, that the full significance of the various steps 
:,:-i the operations to be described later may be more fully appreciated. 

Pneumonia. Pneumonia following operation on the upper air 
passages is due in most instances to one of two causes: (a) the 
inhalation of blood or mucus, and (b) the inhalation of infected wound 
discharges. These injurious inhalations occur usually in the course of 
the operation, although occasionally the postoperative oo/ing is in- 
haled. These dangers may be prevented in part by scrupulously main- 
taining a dry field during the entire course of the dissection. This is ac- 
complished by picking up every vessel large enough to be considered at 
all, either before dividing it or immediately after it lias been divided. 
In this manner the field will be kept so clear of blood that all an- 
atomic structures may be easily seen and identified. During the 
later stages of the dissection the vessels which have been picked up 
may be ligated with either light catgut or light silk. While this man- 
ner of dissection may at first seem to be tedious, it will in the end 
prove the quickest method, and is the method of choice in dissections 
for the exposure of the larynx, pharynx, trachea, or esophagus. When 
the field of operation has been reached, however, the prevention of 
blood inhalation becomes quite a different problem, because the blood 
supply of the mucous membrane is maintained principally by terminal 
arterioles which cannot be effectively controlled by ligation. At this 
point in the operation one of two courses may be adopted. The 
patient may be placed in a head-down, inclined posture at such an 
angle that the blood will gravitate away from the lung: or by the 
hypodermic use of novocain and adrenalin the trachea, the larynx. 


and the pharynx may be entered without resultant coughing or ma- 
terial oozing. If the mucous membrane has been locally anesthetized 
the bleeding may usually be controlled by the local application of 
pledgets of cotton saturated with adrenalin pressed firmly against the 
bleeding points by hemostatic forceps. The further control of hemor- 
vhage depends upon the circumstances of the individual operation. If 
conditions permit, a rubber tube which snugly Mils the trachea or even 
distends it will entirely control the dangerous factor of blood inha- 

There are both advantages and disadvantages to the control of 
hemorrhage by posture, for the amount of hemorrhage, especially of 
venous hemorrhage, is increased by gravity. Then too, the head-down 
position is less favorable for the operator. The direct control method 
has the advantage of light, accessible position and the minimum bleed 
ing. The author has rarely found it necessary to resort to the head- 
down posture, although it lias sometimes been temporarily used during 
some phase of an operation. Occasionally, of course, a great emer- 
gency may exist in which the head-down posture is urgently demanded. 

Local Infection. The next great danger associated with opera- 
tions on the upper respiratory tract is that of local infection, for it 
may happen that after the air passages have been opened a serious 
local infection will spread over the contiguous territory and along the 
deep ] ilanes of the neck. 'Fhe occurrence of some infection must be 
taken for granted, but it is for us to consider by what means the 
amount and the virulence of the infection may be diminished and how 
it can be localized. In the first place, the danger may be minimized 
in advance by canvassing all of the contiguous territories and mak- 
ing sure that there are not present any active foci of infection, such 
as decayed teeth, pyorrhea, alveolar abscesses, discharging sinuses. 
peritonsillar abscess, pharyngitis, or purulent rhinitis. At the time 
of the operation itself we may control the local severity of the infec- 
tion by using only sharp dissections and by minimizing to the utmost 
the trauma of surrounding tissues; hv leaving no oozing of blood; by 
making careful decisions as to the immediate closure of the soft parts 
overlying the wound; and by using iodoform packing if there must 
be any wound in the soft parts of the throat and neck. When infection 
has been inaugurated there are no better therapeutic measures than 
the hot pack- and the inhalation of medicated or plain steam. 

Mediastinal Abscess. After pneumonia, mediastinitis and 
niediastinal abscess have been the most fatal after-results of the 
operations \ve are considering. The onset of infection is usually a 
week- or ioi days after the operation, and is characterized by a 

LARYNX, PHARYNX, ri'l'KH KSOl'J I A< ; I'S, AM) TI!A< ' 1 1 KA . 

steeplechase temperature, not high, and always re 
ing. There is usually but little pain, and the course of the 
toward slow, but certain death. In many respects it resembles the 
retroperitoneal abscesses which also come late, are almost painless, 
progress slowly, show a steeplechase, but low tempi-rat lire curve, and 
(Mid usually in death. The explanation of the characteristic, painless, 
tedious and fatal course of mediastinal abscess is probably found 
in the fact that this region of the body has always been protected from 
wounds by the bony chest wall. P>eiug closed to wounds through the 
vast periods of man's evolution, it has been closed likewise to infec- 
tion. The tissue of this protected region, therefore, has not been 
(Midowed with the elements required to efficiently meet and overcome 
infection as have been, for example, the peritoneum and the external 
parts of the body. In view of this fact, we must guard this helpless 
territory with special care. 

As we have shown that preoperative measures may in large de.irree 
prevent the extensive course of local infection, so the danger of 
mediastinitis may be guarded against by preoperative protection. If 
in the course of a laryngectomy, for instance, the divided trachea is 
stitched to the skin, there is great danger that subsequent coughing 
will cause it to become detached. Its moorings having been lost, it 
will be thrust back and forth, in and out of the thoracic box, like 
the piston of an engine. Mediastinal infection will be the almost 
inevitable result. If, on the other hand, the free (Mid of the trachea 
is not fixed by sutures, but is held by gauze packing about it, then 
the trachea will retract within the thoracic cage like the head of a 
turtle, and again infection must result. It is obvious, then, that the 
trachea should be so fixed by preliminary operation that there may 
be produced an invincible barrier of granulations extending across 
the base of the neck and the entrance to the thoracic cage. There 
are two methods by which this may be done: The ordinary simple 
tracheotomy will fix the trachea and will stimulate the formation of 
efficient granulation tissue; or exposing the trachea and the lower 
larynx and packing the lateral planes of the neck with iodoform gauze 
will result in the production of granulations and in fixing the trachea 
so firmly that coughing cannot break its moorings. Each of these 
methods of itself alone has certain advantages and disadvantages. The 
simple tracheotomy is not so certain a safeguard against infection of the 
mediastinum as is the latter method, and it does not result in so firm a 
fixation of the trachea in the deeper part of the neck: but it has the 
advantage 1 of establishing a strong defense mechanism in the 1 mucous 
membrane of the trachea itself. On the other hand, tin 1 packing of 


the (loop planes with iodoform, while otherwise an ideal protection, 
<loes not snp])ly the jtrotective defenses in the mucous membrane of 
the trachea. An ideal defense, then, is found in a combination of the 
two operations, that is, in opening and packing the deep planes of the 
base of the neck, and at the same seance making a low tracheotomy. 
By this means the mediastinum is put under strong guard, and at the 
same time the later teclmic of the operation is measurably reduced. 

Vagitis. Though a less frequent risk than those we have 
described, vagitis represents a formidable and special danger. Tn the 
course of the convalescence following laryngectomy, usually after the 
fourth day, a group of new symptoms is occasionally introduced; the 
pulse becomes very rapid and irregular in rate and rhythm it may 
jump from 90 to 140 in a few minutes; the heart's action becomes 
tumultuous at times; the patient is quiet or perhaps a little appre- 
hensive. Death from vagitis has been reported, though in the author's 
oases the symptoms passed after a rather boisterous course of a few 
days. It is probable that the trunks of the vagi have become involved 
in the wound infection and as a result these nerves have been ren- 
dered unfit to properly conduct stimuli. Hence there arises the 
striking conflict between the vagus and the accelerator control, the 
picture being very similar to the immediate effect of crushing or 
dividing both vagi simultaneously. As a protection against this, one 
might utilize the well-known physiologic fact that the division of one 
vagus causes no notable change in the heart's action. In the course 
of extensive dissections for the wide excision of cancer of the neck, the 
author lias eight times excised a portion of the trunk of one vagus. 
('lose observation of the pulse and respiration detected no change nor 
was any later alteration observed. Following this indication, then, 
at the preliminary operation one should carry the dissection on one 
side of the larynx all the way to the upper margin of the field of final 
operation, and should pack this territory with iodoform gauze just 
as the deep pianos of the nook are packed. P>y this procedure one 
vagus must take the brunt of exposure and adjustment before the 
larynx is removed. I>y the time the laryngectomy is done this vagus 
would be readjusted and ready to resume its function in case it was 
affected at all, and so the heavy onslaught of the vagi upon the heart 
would not be made by both vagi simultaneously. In the case in which 
the author tried this plan it seemed to be completely effective. When 
va iritis has become established there is little that can be done to 
alleviate it, although hot applications are apparently of some service. 

Reflex Inhibition of the Heart and Respiration Through Me- 
chanical Stimulation of the Superior Laryngeal Nerves. This is a 


minor phenomenon peculiar to the surgery of this region, but it is 
reported to have resulted in several deaths and has caused much 
anxiety and trouble to those who have never known of its existence 
and who have not known how to interpret and obviate it. In a 
laryngectomy the terminals of the superior laryngeal nerves in the 
larynx and on the surface of the rima glottidis are of necessity dis- 
turbed, and the trunks of these nerves are divided in the course of 
operation. The function of the laryngeal nerves is the protection of 
the pulmonary tract from the entrance of foreign bodies. The slight- 
est touch of their endings, therefore, causes a cough reflex, and a 
strong contact will cause an inhibition of respiration and of the heart. 
The nerve supply of the trachea has no such function, but the area of 
distribution of the inhibitory nerve endings extends over a part of the 
pharynx and a part of the posterior nares even. Fortunately, we have 
an absolute protection against this dramatic and sometimes dangerous 
phenomenon, in the hypodermic administration of 1 100 grain atropin 
(adult dose) before the operation. In addition a spray, a local appli- 
cation, or the local hypodermic injection of novocain will control 
absolutely the inhibitory reflexes. 

Selection and Care of Tracheal Cannula. The last special diffi- 
culty which we shall consider relates to the after-care of the patient, 
and refers to the selection and care of the trachea! cannula. After 
trying many kinds of cannula 1 , the author has found that the common 
male or female curved cannula, or plain rubber tubing even, will 
answer all purposes. The greatest care should be exercised in adjust- 
ing the metal tubes so as to prevent pressure necrosis. Rubber tubing 
is preferred by some patients, but the metal tubes usually are best. 
A rubber tube drawn over a metal tube is perhaps the easiest to wear, 
but the author has found that patients become careless by their 
familiarity with danger and will wear loose-fitting tubes. This point 
was strongly impressed on the author by the difficulty once encount- 
ered in extracting a rubber tube that had slipped off the metal tube 
and had been carried deep into the trachea. After a stormy session 
in which the patient almost suffocated, the tube was caught by groping 
deep within the trachea with a curved hemostat forceps and it was 
extracted while the patient was unconscious from asphyxia. In time 
all laryngectomy cases get along without tubes. In fact, in recent 
eases the author has been able to dispense altogether with tracheal 
tubes, both at the time of the operation and ever afterward, and the 
author's patients have all preferred to get along without phonating 


Operations on the Trachea. 

Tracheotomy. A tracheotomy may bo high or low, an emergency 
or a planned operation. There is but little difference between the 
technic of the high and the low tracheotomy, but there is a vast differ- 
ence between planned and emergency operations. The latter will 
therefore be described separately. 

Emergency Tracheotomy. Foreign bodies in the larynx or 
trachea, the pressure of tumors, the closure of the trachea by the swell- 
ing of previous strictures, the pressure of an abscess, the encroachment 
of malignant tumors of the thyroid or other tissues, the closure of the 
larynx by intralaryngeal tumors, at first gradual but finally sudden, 
and many other causes of obstruction may demand an emergency 
tracheotomy. Then, too, the trachea may collapse during the re- 
moval of a large obstructing goitre especially if the operation is 
being performed under ether anesthesia. Whatever the cause, this 
emergency presents one of the most dramatic of surgical crises. 
I nder the urgent necessity, it is usually a laryngotomy and not a 
tracheotomy that is performed. But in the presence of an emergency 
when a life is dickering fine distinctions are lost. 

In emergencies which occur in the course of operations upon 
natients who are laboring against respiratory obstruction there are 
several very important points to be considered in the effort to -prevent 
respiratory collapse. First, the patient must be kept free from 
excitement, by morphin and atropin if personal influence be insuf- 
ficient. I'tider excitement respiration is accelerated. The resultant 
increase in the exchange of air at once accentuates the diminished 
space at the constriction and makes the patient feel acute symptoms 
of suffocation, whereas quiet breathing can be accomplished easily 
through a smaller aperture. Second, a little mucus may precipitate 
respiratory obstruction. Happily, the secretion of mucus may be 
wholly controlled by the use of atropin. Third, a general anesthetic 
is absolutely contraindicatod when a patient is exerting more than 
the normal muscular action in effecting an exchange of air, especially 
when he is iisinu' the extraordinary muscles of respiration. The author 
ha> >een instances of the fatal error of giving a general anesthetic to 
>ueh a patient. Inhalation anesthesia paraly/os the extraordinary 
mu>e|e> of respiration. These muscles are used only when enough 
oxyiren to sustain life cannot be secured by the action of the ordinary 
muscles of respiration. I ndcr these circumstances therefore the 
extraordinary mu>e|es become vital. 

Therefore, in cases of respiratory obstruction in which the extra- 


ordinary muscles of respiration arc used, the operation musl he per- 
formed under local anesthesia ami it' by chance there is no local 
anesthetic available it must be done without anesthesia of any kind. 

The ideal state for operation in the presence of partial obstruction 
is the general quiescence produced by morphin, local anesthesia beinu: 
secured by the use of novocain. When an emergency tracheotomy is 
to be performed, it is best to put the patient quickly in the Trendelen- 
berg posture so that the bleeding, which under the influence of 
asphyxia is sure to be increased, may not be inhaled and cause a septic 
bronchitis or pneumonia. In emergencies the probability of blood 
inhalation is so great that the patient should at once be placed in the 
Trendelenberg position. The trachea should not be opened by a 
plunging incision, a procedure which has brought many a promising 
attempt to grief. An orderly but accelerated dissection whereby the 
operator may distinctly see the tracheal rings yields the quickest 
relief even in the hands of master surgeons indeed it is by performing 
controlled operations that one becomes a master surgeon. As soon 
as the trachea has been perforated nothing but bad technic can cause 
the patient to suffocate. If the soft parts are sufficiently retracted 
by instruments or fingers or both so that the blood is kepi out, the 
patient will do all the better. As for the tracheotomy tube any piece 
of rubber tubing will answer. In the absence of rubber tubing or 
tubing of any sort the tracheal lings may be stitched to the skin on 
each side. After an emergency opening of the trachea which has been 
performed under the partial anesthesia of asphyxia, the patient will 
rapidly revive under a normal supply of oxygen though his suffering 
will be great. Morpllin should therefore be given as quickly as possi- 
ble. In the management of the excited patient upon whom an 
emergency tracheotomy is performed it is important to take extra- 
ordinary care to prevent further excitement or further pain. Such 
a patient needs rest and quiet to regain normal composure. 

Planned Tracheotomy. The selection of the position for a trache- 
otomy depends entirely upon the condition for the relief of which the 
operation is to be performed. Technically, indeed, two considera- 
tions might seem to influence the choice of the position of the opening. 
The upper portion of the trachea is the most accessible, but at this 
point the thyroid renders the dissection difficult: in the lower portion 
of the trachea the thyroid does not interfere with the dissection but 
here the trachea is much more deeply situated in the neck. In a con- 
trolled operation, however, neither the thyroid above nor the dee}) 
position of the trachea below need interfere with the selection of that 
point which will best serve the purpose of the tracheotomy. A trans- 



verse incision through the skin leaves the best ultimate scar, an 
important consideration. It is an interesting fact that, since folds and 
creases are normally transverse or oblique, a vertical scar at once 
fixes the attention, while a greater scar even is unnoticed if it be 
placed obliquely or transversely. A transverse skin incision presents 
but little more technical difficulty than an ample vertical one. A con- 

FiK. HU. 
Tracheotomy under local anesthesia; novocainixiiiK the skin, 

trolled technic so easily surmounts this obstacle that the patient should 
whenever possible he triveii the advantage of the transverse incision. 
The patient is first placed in a quiet and apathetic condition by 
means of a moderate dose of niorphin or of niorphin and scopolamin. 
Xo inhalation anesthetic is used. 

LAKYXX, 1'IIAHYNX, ri'l' KSOl'l I A< ; TS, AND TKACIIKA. 1 -i.5 

The skin and subcutaneous tissues are infiltrated with 1 400 solu- 
tion of novocain. (Fig. 101.) The area of infiltration is put under 
immediate pressure to extend the anesthetic field. In dividing tin- 
tissues sharp dissection only is used and the field is kept clear and 
translucent by dividing the vessels between forceps or, when this 
is impossible, by clamping them immediately after their division. 

The wound should be retracted as lightly as possible. If the line 
of incision necessitates the division of the thyroid the same bloodless 
dissection should be made. If the lateral lobes of the thyroid are 
fused in the median line the gland may be grasped in forceps on each 
side of the proposed line of incision and divided. (Fig. 10:!.) After com- 
plete division of the thyroid the cut margins may be secured against 

Fig. 1D2. 
Tracheotomy. Incision through thyroid gland and trachea. 

bleeding by the insertion of button hole stitches with a curved needle. 
When the trachea is freely exposed it is carefully infiltrated with 
novocain first, the superficial layers, then gradually and slowly the 
deeper parts of the tracheal wall, care being taken not to allow the 
needle (which should be a fine one) to penetrate beyond the advanc- 
ing zone of infiltration. The needle point should always be in 
anesthetized tissue so that the tracheal wall, including the keenly sen- 
sitive mucous membrane, may be anesthetized without causing a single 
cough. The addition of adrenalin to the novocain solution makes 
possible the opening of the trachea without pain and with little or no 
oozing. The prevention of oozing is an important point, first, 
because blood should be scrupulously excluded from the trachea 


as a protection against subsequent infection; and second, because the 
trickling 1 of even a drop of blood down into the trachea will incite 
violent coughing and the strain of the coughing will in turn increase 
the oozing because of the increased blood pressure caused thereby. 
This increased oozing again causes still more coughing and so a 
vicious circle is established. Such a vicious circle cannot well be 
immediately broken by sponging the blood because of the violent 
motion of the coughing, and the sponge by touching the anesthetized 
tissue of the trachea will set up more coughing and hence defeat its 
purpose. If in spite of precautions oozing into the trachea does occur 

Fig. 103. 
Tracheotomy. Novocainizing the trachea from within. 

one can only wait until an adjustment takes place and the patient be- 
comes quiet. 

In dividing the trachea the operator may choose between a trans- 
verse division between the tracheal rings, or a vertical division passing 
through the rings. The transverse incision closes more readily than 
the vertical but it does not offer quite so free an opening. Trache- 
otomies performed for temporary purposes, therefore, should be 
transverse; but for the long continued use of a tracheal tube 
especially it' the tube is to be handled by inexpert hands, the vertical 
Incision is better. 

As soon as the trachea is opened the mucosa should be anesthe- 
tized with a two per cent solution of novocain. Meanwhile the trachea 
is held open with such an instrument as a small single hooked 
ienaciilum to provide for an abundance of air. (Fig. 10.').) 

The teclmic of the low tracheotomy is the same as that for the 



high traclieotomy. It may he well to mention two rather surprising 
facts, however, the extraordinary depth of the trachea low in a thick 
neck, a depth which apparently increases in a restless patient, and 
the astonishingly extensive excursion of the trachea in the act. of 

In this connection one sees a remarkably beautiful dynamic 
adaptation in the contraction of the various muscles of the neck to 
prevent rupture of the pleura. Were it not for the strong protection 
offered by the neck muscles the pleura at the apices would surely be 

Tracheal Tube. Among the many types of t radical tubes the 
standard curved metal cannula consisting of an inner and an outer 
tube gives the best service. (Fig. 104.) 

An albolene or other oil spray applied to the trachea! mucosa is 
an added protection against secretions and against too much drying 

Fig. 104. 
Tracheotomy. After the operation. 

of the air which is now deprived of the moisture and perhaps warmth 
that it gains in passing through the upper air passages in normal 
breathing. At all events the liberal use of an oil spray not only adds 
to the comfort of the patient but also reduces the tendency to desicca- 
tion of small masses of mucus in the neighborhood of the trachea 1 

After-care of the Patient. The highly efficient after-care of 
tracheotomy patients is indeed a difficult achievement. There is an 
enormous difference between the efficiency of a nurse after experience 
in the care of tracheotomy cases and in her first case. It is well to 
specialize such work. For the proper care of her patient the nurse 


requires a supply of feathers trimmed down in such a manner that the 
inner tube may be promptly cleared of mucus as soon as the peculiar 
mucus noise is heard. At first the patient tends to become panicky 
v>:henever any mucus obstruction exists, and the inexperienced nurse 
may share the patient's apprehension, surely an unhappy atmos- 
phere. The experienced nurse learns to manage the mucus so that 
there is only an occasional necessity to remove and cleanse the tube. 

The first removals of the tube should be done by the surgeon 
since the excitement and the coughing may cause a certain amount of 
obstruction which may throw the patient into a panic, ruder these 
conditions the effort to replace the tube may increase the obstruction, 
cause bleeding, disturb the local field and so do much harm. Tntil 
the granulations produce a living mould of the tube and thus guide it 
to its place it is best in replacing the tube to use a pair of slender 
retractors by means of which the opening in the trachea may be 
brought into view. The tracheotomy tube will then readily drop into 

The air of the patient's room should be kept evenly warm and 
moist and may be medicated by vaporizing pine needle oil. The moist 
air and a piece of gau/e moistened with salt solution placed over the 
"radical tube will decrease the desiccation of the secretions about the 
tube and will maintain a higher temperature in the trachea. The 
inhalation of cold air JUT sc is not harmful as the ordinary cold air 
breathing shows; cold air may produce a different effect, however, 
when one part of the respiratory tract is cool and the remainder re- 
mains warm just as one usually catches no cold when entirely naked 
hut readily takes cold if there is only a partial exposure of protected 

The t radical tube and the entire wound should be protected by gau/e 
which should be changed frequently. 'Flic patient may sit or lie in 
any desired posture, though sitting is usually preferable. The entire 
chest and neck should at all times be well covered with oil over which 
a pneumonia jacket is placed, ('old drafts in the room are especially 
to be avoided. Nourishment should be well maintained. It is most 
important to keep the wound free from pus accumulation because the 
inhalation of wound discharges is a distinct danger. If there is no 
contraindication, such as an existing obstruction, it is well occasionally 
to n-niove the tube for a time, especially if the patient is fretting 
about the irritation. If the general precautions are scrupulously 
olerved the iiTcat danger of tracheotomy, tracheobronehopiilmonary 
i n feet ion may be a von led. 

It lia- been an agreeable surprise to observe the facility \vith 

LAKYXX, IMIAUYNX, ri'l'KK KSol'l I A< : TS, AM) THAI ' 1 1 KA. l.'JT 

which patients care for their 1 radical tubes at'lci- they ha\'c become 
adjusted. It is done as a matter of routine and with the precision 
accompanying any other detail of the daily toilet. The author has 
held patients retain tracheotomy tubes for as lon^ as twelve years 
het'ore the opening was closed. 

Closure of a Tracheotomy. The ultimate closure of a tracheotomy 
is easily accomplished. The entire scar is bloodlessly separated from 
the normal tissues surrounding it just as the scar is dissected out in 
a case of hernia following abdominal drainage. When the dissection 
has reached the trachea! wall, the infiltration with novocain and 
adrenalin is most carefully extended throughout the basal attachment 
of the scai' before the separation of the scar is attempted. After the 
excision of the scar the soft parts can very readily be brought together 
into their normal relation in the median line. It is unnecessary to 
suture the trachea directly because on the release of the scar the parts 
will show a surprising tendency to fall together even after many 
years of separation. The author has found that the wound heals by 
first intention and that afterward there does not remain a dimple or 
a depression even. If the original skin incision was transverse there 
will soon be no noticeable scar to mark the place. 

The cases in which the trachea I tubes were worn longest were 
those in which there were larynx-filling papillomata in little children. 
In three such cases a successful issue was finally reached in one 
after twelve years, in another after nine years and in the third after 
fourteen. The patients were inspected at various intervals. .Par- 
ticularly noteworthy was a case of Dr. \Y. K. Lincoln in which after 
fourteen years the larynx was found to be free. The tracheal tract 
was then closed. During this time the larynx grew normally though 
it had been but slightly used. 

Cicatricial Stenosis of the Trachea. Cicatricial stenosis of the 
trachea usually follows syphilitic liberations, decubitus from wearing 
intubation tubes, and ulceration from other causes. 

This condition presents a very difficult problem. If the trachea 
be opened merely, the scar dissected out as neatly as possible, and 
the trachea then closed, recurrence is quite sure to occur. Dissection 
followed by the insertion of a tube gives no better results. The 
presence of the tube apparently increases the reaction which is 
marked by the formation of even more scar tissue. In the author's 
opinion there is but little hope in any method except in resection of 
the trachea. This operation offers at least one formidable difficulty 
the surprisingly great elastic retraction of the trachea toward the 
lung, which exists even in the quiescent state, is greatly increased bv 


coughing. This retraction of course throws a heavy strain on the 
stitches and on the line of healing. This difficulty can be met by the 
use of mattress stitches of silver wire which include in their grasp a 
ring of the trachea above the stenosis and one below it. A good 
closure is secured by inserting three such silver wire mattress stitches, 
one on each lateral side of the esophagus and one in front, leaving the 
free end long so that it emerges freely from the wound. By twisting 
these wire sutures the apposition of the trachea is readily secured. 
This, of course, can succeed only when the trachea is quite normal. 
If the rings are soft or the tracheal wall edematous, the method can- 
not succeed. 

In one of the author's cases the tracheal wall was in such poor con- 
dition that the sutures could not hold and it was necessary in the end 
to resort to a permanent tracheal tube. Fortunately there are not 
many of these cases. 

Surgery of the Larynx. 

Laryngectomy for Intrinsic Cancer. The legitimacy of opera- 
tion upon any part of the body, especially those parts the damage of 
which may cause immediate danger to life, depends upon the answers 
which can be given to three vital questions: Will the operation result 
in the cure of the disease? Can the risks be overcome? What will he 
the extent of permanent disability? So uncertain until very recent 
years have been the answers to these questions as applied to laryn- 
gectomy for cancer, that it is not strange that the operation is one 
of the most recent developments in surgical history, having been first 
performed by Bill roth in 1S74. 

Even after surgeons had become convinced of the possibility of 
the cure of intrinsic laryngeai cancer by this means it was, and is still, 
most difficult to persuade patients to submit to it the instinctive objec- 
tion to deep throat operations being the natural outcome of the expe- 
riences of the far distant past when the throat was the point of attack 
in oiii 1 carnivorous evolutionary ancestors, and it being still the part 
most liable to danger in hand-to-hand conflict. 

Does laryngectomy for cancer result in a cure of the disease? 
I pon our answer to this depends the need for considering the other 
two questions. We still accept Krishaber's classification of laryngeai 
cancer as intrinsic and extrinsic. As the term implies, intrinsic laryn- 
geal cancer starts within the larynx itself in the vocal cords, the ven- 
tricular bands or the parts below; while the extrinsic form starts in 
the epiglottis, the arytcnoids or other parts outside the larynx proper. 
Intrinsic cancer, then, is contained within a hyaline cartilage box, and 


is in large measure cut off from Hie possibility of lymphatic involve- 
ments; while the extrinsic form grows rapidly and can easily and early 
extend through the lymph channels. 

Early diagnosis and removal is the keynote of safety in cancer- 
ous growths anywhere, and laryngcal cancer makes itself known almost 
at once, since from its very beginning the probability of its presence 
becomes evident in the persistent hoarse voice of the patient. We may 
say, then, that intrinsic laryngeal cancer exists, as it were, in a safe 
deposit box. It early announces its presence and has but feble power 
of extensive invasion or of metastasis. We conclude, therefore, that 
this form of cancer of the larynx is curable by excision. Kxtrinsic 
cancel 1 , on the other hand, is rapidly fatal, and operation for its relief 
is at best but a desperate remedy. 

What is the surgical risk:' The author has performed twenty- 
seven laryngectomies for cancer with two operative fatalities; one 
deatli resulting from mediastinal abscess, the other from necrosis of 
the trachea with a consequent septic pneumonia. This makes a mor- 
tality rate of seven plus per cent, a rate which compares favorably witli 
that of excisions for cancer of the tongue, of the stomach, and of the 

What is the permanent disability of the patient? Those princi- 
pally feared are impairment of speech, disfigurement, and a predispo- 
sition to pulmonary diseases and accidents. As to speech impairment, 
all patients acquire a Imccal whisper which serves the purpose of 
speech remarkably well. One of the author's patients is at the head 
of a large industrial corporation; another is a judge; another is fore- 
man in a public works department; another became a popular barber: 
still another is managing a small coal sales agency; one housewife ap- 
parently gets on well enough; and a farmer has managed his Hocks and 
his teams in silence. The speech defect, to be sure, is great, but it can 
be compensated for to a remarkable degree by the development of the 
buccal whisper, the use of gestures and other forms of primitive lan- 
guage, and by the adaptation of those individuals who come into daily 
contact with the patient. 

The disfigurement may be well covered by wearing various kinds 
of cravats or neckwear arranged in such a manner as to allow free 
breathing, and at the same time to diminish the sibilant sounds of the 
changing air currents. 

As to the predisposition to accident and disease, to the author's 
knowledge there has been no instance of a foreign body in the respira- 
tory tract of any of his laryngectomized patients, nor has there been a 
single case of pneumonia. Not only have his patients shown no ten- 


clency to pneumonia and bronchitis, but they have boon remarkably 
free from nasal colds. 

We may conclude, then, in answer to onr third question, that 
though the disability resulting from laryngectomy is great yet it is 
fairly well compensated for. 

Some years ago the author made an interesting study of the laryn- 
gectomies reported in the medical press from 1874 to 1901. A summary 
of the statistics gives significant results. From 1874 to 1876, 1:2 lar 
yngectomies for carcinoma were reported with one ultimate cure, mak- 
ing the percentage of ultimate cures 8.88. From 1876 to 1886, 108 lar- 
yngectomies, '21 ultimate cures, percentage of ultimate cures 19.44. 
From 1886 to 1896, 15(5 laryngectomies, 49 cures, percentage of cures 
211. 81'. From 1896 to 1901, :!() laryngectomies, '20 cures, percentage of 
cures 66.67. The causes of death as reported are those with which we 
still are contending, but which improved technic lias helped us in large 
measure to meet. Indeed, the figures just given show the increasinLi; 
confidence of surgeons and patients in operative relief for this distress- 
ing disease, a confidence well supported by the rapidly decreasing 
mortality rate. 

Anesthetic in Laryngectomy. Before proceeding to the detailed 
technic of laryngectomy, some special statement should be made 
regarding the manner of administering the anesthetic. It should be 
borne in mind that the administration of the anesthetic should be so 
planned that the operator may be unhampered in his technic. that the 
anesthetist may give an even and safe anesthetic, and that there may 
be no inhalation of blood, while the choice of the anesthetic itself is a 
most important factor. Our general anesthetic of choice is nitrous 
oxid-oxygen. The patient already it is presumed in fear of the 
possible suffocating results of a laryngeal operation, takes this anes- 
thetic without the terrifying suffocating symptoms caused by ether, 
and is quickly under its influence without a struggle. \Ve have proved 
also by laboratory investigations that whil<> nitrous oxid does not 
alter the immunity of the patient, other on the other hand tends to 
impair the immunity. Since nitrous oxid-oxygen, however, should be 
U'iven by the trained anesthetist only, the following technic is equally 
applicable to the administration of ether. In our discussion of niedi- 
astinitis wo have described the preliminary tracheotomy by means of 
which the trachea has become firmly fixed in its position. (Fig. 10.").) 
At the time of operation the tracheotomy lube is removed and a well- 
lubricated snug-fitting rubber tubing a foot or more long is slowly and 
carefully .-lipped into the trachea. The rubber tubing being slightly 
larger than the trachea, the latter is dilated and the rubber 'tube com 



pressed, so that a fluid-tight fit results. By this moans, the entrance of 
any blood into the respiratory tract is prevented. (Fig. 10(i.) The 
long piece of rubber tubing may then be attached to the nit rous- oxid- 
oxgyen apparatus, or it may be joined to a special apparatus consist- 
in i>' of a funnel covered with gau/e upon which ether may be dropped. 
By this arrangement the anesthetist is at a distance from the field of 
operation and is unhampered by the operator, while the operator on 

Fig-, in."",. 
Laryngectomy. Preliminary tracheotomy with iodot'orm gauze packing. 

his side is unhampered by the anesthetist. There results an even anes- 
thesia and the best opportunity for a well controlled operation. 

To prevent nocuous impulses from the field of operation from 
reaching- the brain, and as a protection against the excitation of special 
reflexes through the mechanical stimulation of the trunk or terminals 
of the superior laryngeal nerves, novocain is used as a local anesthetic. 
The manner of its administration will be given in the description of 
the operative technic. 

Technic of Laryngectomy. First the skin is thoroughly infiltrated 



with novocain along the median line from a point ahove tlie hyoid l>one 
to the traclieotomy opening. The tissues are divided down to the box 
of the larynx, the divisions of the platysma and of the other soft parts 
being 1 preceded also by novocain infiltration. The dissection is then 

Cut surface covered 
\vith granulations. 

Fig. 10G. 

Laryngectoniy. Five days after preliminary traclieotomy. Arrange- 
ment, of tul)e for anesthesia. 

carried down along- the lateral aspects of the larynx until the larynx is 
completely freed. If there is hick of free working space at the upper 
end a lateral incision is made parallel with the hyoid. The thyrohyoid 
muscles ahove and the sternotliyroid muscles below are severed. So 
far as its muscular attachments are concerned, the larynx is now com- 
pletely mobilized. If the laryngoKcopic examination has fixed accu- 



ratoly the limits of the neoplasm, the level of the division of the larynx 
may bo predetermined, and the next step will he the division of the 
trachea or the cricoid at a level free from disease. Before this last 
division is made, however, iiovocain is infiltrated into the nmcosa 
throughout the entire length of the proposed division. By this means 
the terminals of the superior laryngeal nerves are completely blocked 
and the mucosa may be divided and the larynx opened without causing 
a change in the respiration or the circulation. If the patient is old 
and the cartilage is ossified it is necessary to exert the greatest pn-- 

Fig. 107. 
Laryngectomy. Separation of the larynx from the esophagus. 

caution in dividing the larynx in order that the esophagus may not 
be injured. The divided end of the larynx is next raised up and the 
attachment between the larynx and the esophagus is divided with 
knife or scissors. (Fig. 107.) In a short, thick neck the wings of the 
larynx which extend down laterally to protect each side of the 
esophagus, are divided with scissors. The dissection is then carried 
upward until the upper end of the larynx is reached, where its pos- 
terior wall becomes fused with the anterior wall of the pharynx. The 
upper end of the larynx is then cut free, the larger arteries being 
severed at the verv last. I lemostasis must be most tliorouu'hlv ob- 



served throughout the operation. If the cancer is intrinsic the 
lymphatic glands which drain the diseased zone should be carefully 
removed with the larynx itself. 

Two important questions now arise regarding the manner of deal- 
ing with the wound: (1) What shall be done with the end of the 
trachea.' and ('2) Shall the entire wound of the neck be closed? As 
to the trachea, there are two alternatives: It may be freed sufficiently 
to bring it forward and stitch it to the skin, or it may be left where 
it lies, excepting at its very upper end, which may be bent forward 

Fig. 108. 
Laryngortoiny. Closure of pliaryngral opening. 

and sewed to (laps of skin brought down from each side. The advan- 
tage of the first method is that by this means the trachea is protected 
from the inhalation of wound secretion. The disadvantage is the very 
definite- possibility that the loss of blood supply may result in 
gan.uTcnc of the trachea. This did occur in one of the author's cases. 
The objection to leaving the trachea in its natural bed and transplant- 



ing to it the skin flaps is the fact that wound secretion will almost 
certainly enter it. By giving the wound adequate care, however, this 
danger may he avoided. 

As to the care of the rest of the wound, the author's best pro- 
cedure has been to suture the opening in tin; pharynx and (Fig. 10*), 
if possible, to roonforee this suture by drawing other soft parts togct her 
over it. The rest of the field is left open, being packed lightly with 
iodoform gauze. (Fig. 10!).) With such a wide open wound the 
secretions may bo easily controlled and prevented from entering the 
trachea. The patient should be sustained by the fullest diet he can 

Fig. Id!). 
Laryngectomy. Closure of wound with iodoform gauze packing. 

be made to take, and by most careful nursing. The sutures in the 
pharynx may not hold, but the formidable-looking wound will close 
very readily by granulation and contraction. 

Laryngectomy is followed usually by a brisk local reaction: but 
since the mediastinum has been protected by the previous gauze pack- 
ing, and the bronchopulnionary tract has been given a special defense 
by the preliminary tracheotomy, the patient is well equipped to meet 
the new condition. 

In the author's twenty-seven laryngectomies there were two 
deaths, and these two were apparently the most promising cases of 
all. The prognosis in these cases seemed so favorable that the author 


ventured to discard the full preliminary preparations. In one case 
no preliminary protective operation of any kind was made and the 
patient died at the end of five weeks with mediastinal abscess. In the 
other case a preliminary gauze packing was placed in the neck around 
the trachea, but no preliminary tracheotomy was performed. In this 
case the isolated upper end of the trachea was brought forward to the 
skin and anchored. The entire isolated portion necrosed, as did also 
a portion of the trachea beyond the isolated part. As a result pus was 
inhaled into the respiratory tract below the level of the sternum. An 
autopsy showed no pneumonia and no mediastinitis, but a septic 
tracheitis and bronchitis. Death was the result of local absorption, 
and of absorption from the trachea and from the bronchial mucosa. 
This case demonstrated most conclusively the efficiency of the granu- 
lation barrier which is created by a preliminary iodoform packing. 
Had a preliminary tracheotomy been made, or had the trachea been 
allowed to remain in its bed, the patient would surely have recovered. 

In sixteen of these twenty-seven laryngectomies for cancer the 
laryngeal box was so choked with the growth that tracheotomy was 
required to prevent suffocation. Most of the author's patients gave 
a long history of hoarseness followed by gradual, though intermittent 
obstruction to respiration. In two cases, there was associated lues. 
One of these last two cases illustrated well the clinical difficulty of 
diagnosis. The lesion was first diagnosed correctly as luetic, and 
under a course of treatment the greater part of the growth disappeared. 
The residual growth, however, showed a progressive tendency, and 
was later diagnosed as cancer. Laryngectomy was performed and the 
patient is now alive and well, more than three years since his opera- 
tion. The special lesson from this case is that cancer of the larynx, 
like cancer of the tongue, may follow local luetic lesions. There is 
danger, therefore, that the hope of a luetic cure may defer too long 
the laryngectomy which is the only chance for the cure of the cancer. 

Extrinsic Cancer of the Larynx. As already stated extrinsic 
cancer of the larynx presents a different and a more desperate problem 
than does intrinsic cancel'. Extrinsic cancer is more difficult to attack 
on account of its position; it is disseminated earlier and more widely 
on account of the greater muscular activity of the parts involved. 
Extrinsic cancer of the larynx is however more accessible than cancer 
of the tonsil or cancer of the pharynx. The same considerations apply 
to eMiicer of the base of the tongue. 

In attacking cancel 1 here a preliminary tracheotomy is essential, 
wide neck incisions are made, the cancel 1 is exposed most cautiously 
and is thoroughly thermocaiiteri/ed. In the further dissection great 


care must bo exorcised not to disturb tlio osoliar. After complete and 
wide excision of tlie cancel' the wound should be left wide open for 
the free use of the X-ray. 

In one instance the author excised the base of the tongue, the 
pillars of the pharynx, the pharynx itself, the entire larynx, the hyoid, 
in short all of the tissues lying between the juncture of the posterior 
and the middle third of the tongue, the upper ring of the trachea and 
the upper end of the esophagus, leaving but a slight covering of the 
vertebra 4 . This enormous wound looked hopeless for a long time 
during which the X-ray was used freely but finally closed completely. 

About four years later metastasis developed in one of the sub- 
maxillary lymphatic glands. When the author saw it, this inland was 
quite largo, was inHamed, hugged the jaw closely and involved the 
swollen reddened skin covering it. Again a wide excision was inado, 
so extensive that the wound could not have been closed had the author 
so desired. The X-ray was used freely during the process of healing. 
The lower jaw was so closely linked by the cancel 1 that about one- 
third of the jaw was sawed off longitudinally the sawed fragment of 
bone coming 1 off with the rest of the cancer. In due time the wound 
was skin grafted and closed. It has been over five years since this 
last operation and nine years since the first. The patient is now at 
work. He speaks with a sort of buccal whisper, is able to swallow, 
to drink and to smoke with ease and comfort. 

This case taught the author that no one can tell when a case is 
hopeless for surely this patient seemed to be in a hopeless condition. 
The repair of the mutilations produced by this operation in which so 
many important structures were removed and the consequent recovery 
have been a source of encouragement and inspiration ever since. 

In another case of extrinsic cancer the operation in a local field 
was not so extensive but the lymphatic involvement was much greater. 
In this case the growth had so filled the larynx that the obstruction 
had caused asphyxia, as a result of which the patient had fallen upon 
the street. An emergency tracheotomy was performed, at which time 
one of the lymphatic glands was removed for diagnosis. At the later 
operation the excision was carried laterally so as to include the 
lymphatic gland-bearing tissue on both sides, all of which was removed 
en bloc with the larynx and the base of the tongue. The patient is 
well and hale seventeen years after the operation. 

Stenosis of the Larynx. Stenosis of the larynx may be due to 
intubations now infrequently done or to ulcerations which are 
usually syphilitic. Like stenosis of the trachea already described 
stenosis of the larvnx is an exceedingly formidable condition. 


The author has attempted to open the larynx by splitting it 
vertically, dissecting out the scar and then resuturing the incision, 
but the stenosis recurred so promptly that the patient \vas denied the 
comfort of a goodly respite even. 

In another instance the author did a hemilaryngectomy in the 
hope that the larynx might adapt itself as it may do in hemilaryngec- 
tomy for cancer but this did not afford a permanent air space. 

In another case the larynx was opened wide, the scar was com- 
pletely dissected out and an attempt was made to cover the raw area 
immediately with large and accurately placed skin grafts. The 
respiratory tract and the grafts as well were 1 protected by a trache- 
otomy. .Despite the utmost care the grafts did not grow. For a time 
they did well, but the patient was a child only four years old and hard 
to control. The author gained the impression however that were it 
an adult case and the skin grafts autodermic they might have held. 
Even then, however, one could not be certain that the scar might not 
again contract. In a child with stenosis of the ericoid referred to the 
author by Dr. W. B. Chamberlain, an attempt was made to remedy the 
stricture by resecting the lower end of the ericoid and suturing the 
trachea and the divided ericoid together by means of silver wire. 
The resection of the strictured ericoid was easily accomplished but as 
the trachea was so much smaller it was difficult to bring it into 
precise tubular apposition. Although a union was secured the 
stenosis was not relieved and the author was obliged to resort to a 
permanent trachea! tube. With our present means the author is 
unable to see much hope in operations for strictures of the larynx 
resulting from massive scar tissue firmly fixed to the box of the larynx. 
In one case the use of thiosinamin was added to the operative pro- 
cedure hut apparently its influence was nil. 

Surgery of the Pharynx and Esophagus. 

Cancer of the Pharynx and Esophagus. Hitherto cancel- of the 
esophagus and of the pharynx has not been attacked as successfully 
as cancer in many other parts of the body. When dealing surgically 
with cancel 1 in these regions it is important to bear in mind that if 
cancer cells become lodged iii the fresh wound they are not only likely 
to grow, but to grow with oven greater vigor than in the original 
lesion. There is not an abundance of experimental evidence to support 
this statement but ample clinical proof is not lacking. The experi- 
mental evidence that is especially pertinent is the following: It a 
piece of cancer tissue from a dog is rubbed on an abraded surface of 
the skin of another dog a cancer is likely to develop from the cells 
which became detached and lodged on the denuded surface. 

LARVNX, riiAin.xx, ri'i'Ki; KSOIMI AIM'S, AND TUACIIKA. 141* 

In operations for cancer anywhere if the field is not protected the 
entire raw surface area will be sown with cancer cells and a rich 
growth of cancer will spring up over the entire wound surface-, will 
grow furiously and usually will cause the death of the patient in less 
time than would the original growth had it been left unmolested. 
This is perhaps the most important point to be considered in the 
treatment of cancer of the pharynx, the tonsil, tin- pillars or the rima 
glottidis. The operation is technically beset with difficulties but no 
instrument, no finger, no sponge, that has touched the cancer surface, 
should be used again, nor should they touch anything else that may 
be used in the operation. The operation should not be undertaken 
if its result is to he no more than the implantation of a new cancel- 
that may extend even farther than the original growth. The only 
means by which the reimplantat ion of cancer cells may be prevented 
is hy the immediate and complete destruction of the original growth 
by thermo-cauterization. Tare must then he taken to prevent the 
dislodgment of the eschar and even after these precautions have 
been taken it is hest to follow the operation by the use of the X-ray if 
the field is accessible. It is wise also to make a very wide excision 
of the growth, and to remove all the lymphatic nodes which drain the 
involved area. In serious risks it is best to perform the operation in 
two stages, first excising the local field, and then after ten days or more 
removing the lymphatic bearing tissue of the neck by a block excision. 
If the growth is located in the tonsil or the pillars it is possible to give 
the anesthetic and to prevent the inhalation of blood either by passing 
tubes through the pharynx and packing them with gauze, or by the 
intratracheal insufflation method of Aleltzer and Auer. If the cancer 
is still lower down, it is hest to make a preliminary tracheotomy and 
introduce as large a rubber tube as the trachea will hold, thus prevent- 
ing the inhalation of blood. In operations on the tonsil the application 
of a CYile clamp on the external carotid artery will minimize the 

Excision of the Tonsil for Cancer. Bearing in mind the general 
precautions stated above, the excision of the tonsils for cancer is per- 
formed in the following manner: 

1. A tube for the administration of the anesthetic is passed 
through the pharynx and held by gauze packing. 

2. All of the visible growth is completely destroyed by thermo- 

:>. The lymphatic glands which drain the tonsil are excised 
en bloc through a wide neck incision. 

4. The external carotid is closed by means of the Crile clamp. 


5. If more room is needed the ramus of the jaw is divided. 

6. With the fingers of one hand inside the throat a wide dissec- 
tion is made of the base of the growth, extreme care being taken to 
leave undisturbed the eschar surface. Internal as well as external 
dissection should be used if necessary. 

7. The vessels are closed carefully. A curved needle and catgut 
being used if necessary to control oozing in the mouth. 

S. The clamp is removed from the external carotid. 

9. A Lane plate is applied to the divided ramus. The plate may 
cause suppuration, but it will hold the bone in place until union has 
been secured. 

10. The wound is immediately exposed to X-rays if the patient's 
condition warrants it. 

11. The wound is packed with iodoform gauze the external 
wound being partially closed. 

Cancer of the Pillars. Tn operations below the tonsil the best 
procedure is to perform a tracheotomy and then to open the pharynx 
freely by means of an ample incision just above the hyoid. The same 
procedures as those described in the operation for cancer of the tonsil 
are applicable here except that the wound in the neck, by means of 
which the exposure is made, is closed at once, and it is not necessary 
to apply temporary clamps upon the carotid. It is well to allow the 
tracheotomy tube to remain until the pharyngeal wound is well healed. 

Stenosis of the Pharynx. The discouraging results of operative 
procedures for the relief of stenosis of the pharynx are well illustrated 
by the following history of one of the author's cases. This patient 
has already undergone twenty-four operations of various kinds in- 
cluding all the intrapharyngeal methods. The author resolved to 
make a wide excision of every vestige of the stricture. A preliminary 
tracheotomy was made, ten days after which the principal operation 
was pel-formed. An incision was made around the anterior half of 
the neck through the skin, platysma and fascia. The pharynx was 
then opened. With one hand inside the pharynx the dissection above 
and below the stricture could be accurately guided so easily that the 
author was able to make an annular resection including the entire area 
of the scar. By means of a long needle with an eye near the point 
mattress stitches were inserted into the opposing pharyngeal walls, 
thus bringing together this enormous opening in the throat. The 
wound healed splendidly, but after some months the stricture recurred. 

The author then planned another type of operation. A long 
perineal needle with an eye near the point, threaded with heavy silver 
wire, was passed through the skin of the side of the neck and through 


all the soft parts down to the base of the stricture-. Tin; base of the 
stricture was then pierced, the needle passing into the month. The 
silver wire was then detached from the eye and the needle was with- 
drawn until the point was once more external to the base of the 
stricture, and was then passed through the small opening in the 
center of the pharynx. The free end of the silver was again threaded 
into the eye of the needle and the needle was withdrawn. In this 
manner one side of the scar was grasped by the loop of heavy silver 
wire. Another wire was similarly inserted into the opposite side and 
both wires were tightly twisted. The purpose of this procedure was 
to form a mucous-membranc-covered fistula analogous to the skin 
fistula one makes when operating for web finder. This was faithfully 
tried but unfortunately the wake of the wires filled as fast as they cut 
their way out. The author then abandoned further efforts and made 
an esophagostomy, which appeared to be the only possible means of 

Esophagostomy. Like tracheotomy and enterostomy, esophagos- 
tomy may be permanent, or it may be used for temporary purposes 
only. The author has many times made use of esophagostomy for a 
temporary purpose, closing it after it has served its purpose. The 
most striking case of this nature was the case of extrinsic laryngeal 
cancer already described in which the larynx, the hyoid, a large por- 
tion of the pharynx, the tonsils, the base of the tongue and all of the 
intervening tissue were excised. At the end of the operation no 
pharyngeal mucosa was left. The esophagus was stitched up into tin- 
skin at the side of the neck and was securely fastened with silk 
sutures. The trachea was stitched to the opposite side. After a time 
new mucous membrane spread over the pharynx. The author then in 
several stages freed the esophagus from its attachment to the skin at 
the side of the neck and brought it to the median line. In two more 
seances he sutured the large hiatus in the anterior pharynx. After 
a good union was secured the esophagostomy opening was finally 
closed. The patient made an excellent recovery. 

In performing an esophagostomy the important point is to make 
the incision so ample that all the field may be seen clearly. (Fig. 110.) 
The dissection should bo so controlled that the recurrent laryngeal 
nerve, the big blood vessels, the vagus and the other important 
structures may all be so clearly soon that they cannot be mistaken nor 
injured. (Fig. 111.) If each step in the operation however minute- 
is controlled not the slightest mishap need occur. After the esophagus 
has been reached, however, it is important to avoid extending the 
dissection in the neck the least bit more than is required; for. in the 


first place, a wide dissection is not needed; and, in the second place, 
the dee]) planes of tissue in the neck have hut little power of resisting 

If no emergency exists, it is even safer to hring the esophagus 
well u] into the wound; to pass a small strip of iodofonn gauze around 

Esophagostomy. Ample incision of skin alont; the anterior bonier of 
sternomastoid muscle. 

it; and to pack the wound gently for several days hefore the esophagiu 
is opened. 'This point is not of sufficient importance however to justi- 
fy any lo of time. The fixation of the esophagus to the skin is most 
-afcly made hy means of silk interrupted sutures. (Tig. 111'.) 

The author has heen happily surprised to observe the ease will 
\vhicli patients swallow even \vhen the esophagus is hroughl to tin 
edu'e of the -kin \voi 

LAKYNX, IMIAKYNX, ri'l'KIt KSOI'I I A< I TS, AND Tl!.\< ' 1 1 KA. 

Cancer of the Esophagus. Cancel- of the esophagus is rarely 
cured for usually the condition is not recognized until symptoms of 
obstruction appeal', by which time the disease has almost certainly 
spread into inaccessible territory. 

The technic of resection of the esophagus for cancel' is essen- 
tially the same as that already described for esopliaii'ostoiny. The 
incision should be ample enouii'li to expose the cancer for a consider- 
able distance above and belo\v the limits of the cancerous tissue. It 
is rarely possible to unite the ends of the divided esophagus. 

Diverticula of the Esophagus. Operations for divert iciila of the 

Fig. 111. 
Esophagostomy. Exposure of esophagus. 

esophagus present a sharp contrast to those for pliarynuval stricture, 
for the former are usually successful. The author has operated on 
five cases and found them readily curable. 

Before operation X-ray bismuth pictures should be made to de- 
termine the exact location, the extent and the nature of the sac which 
is most commonly situated at the upper lateral aspect of the esophainis. 
often extending downward below the clavicle even. 

The operation is performed in the following manner: 

1. A lon.u 1 vertical incision is made over the middle of the sac. 

'2. By sharp knife dissection the sac is exposed, the Held beinu' 
kept bloodless and translucent by picking up and clamping each 
vessel either before or at the moment of its division. 

:>. The entire pouch or sac is isolated up to its esopha.ii'eal or 
pharyiii>'eal point of origin. 



4. The sac is cut off exactly as one cuts off a hernial sac. The 
opening of the diverticulum is closed by a silk suture preferably with 
a cobbler stitch. The first row of stitches is reenforced by a second row, 
and a small drain is inserted at the lower end of the wound after clos- 
ing the overlying tissues. 

If the diverticulum be high up on the esophagus, especially if it 
involve the pharynx, the patient should not be allowed to swallow 
until the line of union is well established. As the victims of esophageal 
diverticula have usually had much experience with throat and 

Fig. 111'. 
Esophagostomy. Esophagus stitched to skin. 

esophageal instrumentation, the insertion of a small flexible tube 
through which nourishment may be given will lie no hardship. 

One of the author's patients had had another diverticulum re- 
moved twelve years previously. In this case the pharyngeal wall 
was strikingly thin, and in addition to two diverticula the pharynx 
was greatly dilated on the same side. The site of the first operation 
was clearly visible, the scar being sound. Kot.h diverticula were; re- 
moved and in addition a large elliptical portion of the dilated pharynx 
was excised. The result has been excellent. 

Diverticula with narrow necks are of course the easiest to remove. 




By Harris P. Mosher, M. 1). 


Historical. Kirstein in 1S94 introduced the direct method of ex- 
amining" the larynx. The instrument with which he accomplished the 
exposure of the larynx was an elongated tong'ue depressor with hoods 
of various sizes. Killian took up the procedure, and changed the flat 
speculum of Kirstein into one of tubular form, systematized the steps 
of the examination and won from the medical profession the recogni- 
tion of its great value. The foresight and enthusiasm of Killian have 
been supplemented by the great inventive ability of Briinings. The 
result of the labors of these men has been that a number of instruments 
are available today for the direct examination of the larynx. 

The advantages of the direct examination of the larynx arc self- 
evident. It is the natural method. The physician works upon the 
larynx in the same fashion that a surgeon works upon any other part 
of the body. Manipulations in the larynx carried out under the guid- 
ance of a mirror, are executed round a right angle corner with the ante- 
rior and posterior positions of the various parts of the larynx reversed. 
The indirect method of examining and operating upon the larynx must 
be credited with very great accomplishments, and it will always be 
employed, but the special workers of the coming generation will turn 
instinctively to direct manipulations upon the larynx rather than to 
the older procedure. 

Contraindications. Absolute contraindications to the employ- 
ment of direct inspection of the larynx are seldom found. Chief among 
these is a high grade of dyspnea. The direct examination should not 
be attempted in severe cases of uncompensated heart lesions, or in a 

*This article is based upon the writings of Brunings, Kahler and Jackson. The author's own ex- 
perience furnishes a certain small part. Kpitomes of new work, and such in great measure is this article, 
must go to the original sources for the facts. This the author has done. He wishes here to make full and 
grateful acknowledgment of his indebtedness. 



case of advanced aneurism. Intractable gagging in spite of thorough 
cocainization is not so much a contraindication, although the result 
is the same, as it is an insurmountable obstacle. Where the direct ex- 
amination proves to be impossible, it is generally due to uncontrollable 
reflexes. However, unless there is some disease of the cervical verte- 
bra 1 oi 1 some unusual malposition ov deformity of the larynx the direct 
examination is almost always possible under general anesthesia. 
Where the patient is suffering from marked dyspnea the performance 
of tracheotomy usually makes the direct examination possible. 

rncontrollable gagging, the chief difficulty in carrying out direct 
examination, interferes fully as much in the indirect method as it does 
in the direct. In either case it must be successfully combatted before 
the examination can proceed. 

The Choice of the Anesthetic. In examining the larynx directly 
the operator has the choice of local or general anesthesia. Some form 
of anesthesia is necessary on account of the gagging and coughing far 
more than on account of the pain, since the manipulations employed in 
the direct examination of the larynx and trachea give rise to but 
little pain. It is essential, therefore, to do away -with the sensitiveness 
only of the mucous membrane. This can be brought about either by 
the use of cocain locally or by the production of general anesthesia in 
addition to local anesthesia, because even with the general anesthesia, 
the use of cocain is necessary. "Die operator ought not be a partisan in 
this mattei'. lie should employ either form of anesthesia at will. Infants 
and children are best examined under general anesthesia. In many 
adults a satisfactory examination is possible only under ether. Certain 
systemic diseases like multiple sclerosis, bulbar paralysis, tabes, and 
hysteria, increase the sensitiveness of the mucous membranes. In old 
subjects the mucous membrane of the larynx and trachea is often very 
tolerant. In robust males with chronic catarrh, twice or three times the 
amount of cocain as is required for women is often needed to produce 
anest hesia. 

Cocainization. liriinings with his customary thoroughness has 
studied the methods of cocaini/at ion exhaustively. He has demon- 
strated that cocain applied bv a brush or swab is three times as et't'ec 

I I t 

live as it is when introduced by a spray. If adrenalin is added to the 
coca'm solution the anesthesia is noticeably prolonged. l-Jriimngs uses 
a syringe which he converts into a swab syringe by winding cotton on 
the lip of the camila. The barrel of the syringe is graduated so that 
the operator can control the dosage of cocain. This author finds that 
on the average five drops of a twenty pel' cent solution is sufficient to 
produce anesthesia in an adult. In children the strength of the solu- 

LAHYXCOSCOI'Y, UliONCIIOSCOl'Y, KS( ) I' 1 1 A< ;< )S( '( )\'\ . 

tion is reduced to ten pet' cent, because they do not tolerate the drug 
as well as adults. 

With a swab or the swab syringe, a drop of a twenty per cent solu- 
tion of cocain is applied to the base of the tongue, and another to tin- 
posterior pharyngeal wall. After an interval of three or four minutes 
the cocain is applied to the tip of the epiglottis. Finally a drop or two 
is placed in the larynx. This calls for accurate dosage. The writer of 
this article has not had any experience with the brush or swab syringe, 
but has used the simple swab and with it a ten per cent solution of 
cocain for the first of the anesthesia, and a twenty per cent solution 
in the larynx. The weaker solution allows the cocain to be employed 
more freely. Fntil the beginner perfects his technic he will do well to 
use the weaker solution for the most part. If cocain is mixed with 
adrenalin chloride much stronger solutions can be used in the larynx. 
Some operators employ as high as fifty per cent. 

The Difficulties of the Examination. The greatest difficulty in the 
way of a successful examination is incomplete anesthesia. Time is lost 
and the examination is rendered incomplete or made impossible unless 
the anesthesia is profound. From its nature the procedure of direct 
examination is disconcerting if not alarming to an inexperienced pa- 
tient. Therefore, the patient should be calmed by the assurance, 
repeated if necessary, that he will not strangle. lie is encour- 
aged to hold the head as loosely as he can and to breathe quietly and 
regularly. From time to time the examination is interrupted in order 
that the patient may spit out the accumulated saliva. He is cautioned 
to do this quietly and not to hawk. During the examination the pa- 
tient is liable not only to bend the head too far back but to allow 
the whole body from the knees up to swing backward. The assistant 
should see to it that the patient keeps straight and erect. These 
are the principal and natural faults into which the patient falls. 
The faults of technic to which the examiner is liable are also natural 
ones. The first, incomplete cocainization, is due to haste. For the 
patient's sake he wishes to get the examination over quickly. The sec- 
ond mistake on the part of the physician is to insert the speculum too 
deeply at first and in consequence to miss and to pass the epiglottis and 
to strike the point of the instrument against the posterior pharyn- 
geal wall. This produces uncontrollable gauging and often, for the 
day at least, makes further manipulation impossible. In pressing tin- 
epiglottis and the base of the tongue forward the speculum should be 
held firmly and the procedure executed in a deliberate and unhesitat- 
ing fashion. Otherwise the tongue is tickled and rebels. Tuder firm 
pressure it yields and submits. When the tip of the speculum has en- 


terecl the larynx there is danger of the shaft striking against the teeth 
or the unprotected gums, thus causing pain. The examiner's finger 
should be so placed as to prevent this. The success of the examination 
depends most of all upon the character of the patient's neck. If he has 
a thin neck, and if he is fortunate enough to have no teeth the pros- 
pects of a successful examination are good. If, on the contrary, the 
patient has a short, thick neck, and a protruding upper jaw and 
retains all his teeth, the outlook for the examination is not so hopeful. 
The amount of force required to bring the larynx into view varies 
with the individual neck. Briinings has made the observation that a 
force of 10 kg. is bearable, 15 kg. painful, and 20 kg. unbear- 
able. He has found also that the ease of seeing the anterior commis- 
sure varies greatly; in fact it may be thirty times as difficult in one 
patient as in another. The harder it is to obtain a view of the anterior 1 
commissure the smaller must be the diameter of the speculum. With 
a speculum of 9 mm. diameter a pressure of 9 kg. will expose the 
anterior commissure. With a speculum of 14 mm. diameter the same 
amount of force will expose only the posterior part of the larynx. 

The Method of Making the Direct Examination. 

The patient should be examined if possible when the stomach is 
empty. If the physician feels that his patient will be unruly a dose 
of bromid or morphin some little time before is of benefit. The patient 
is seated upon a low stool (30 cm. in height), and the assistant stands 
behind and supports the head. The patient's head is bent slightly 

The patient protrudes his tongue and holds it with his left hand. 
The examiner guards the upper teeth of the patient with the forefinger 
of his left hand at the same time pushing the upper lip out of the 
way. The thumb of the left hand is held against the left forefinger and 
the angle between the two fingers is made to serve as a guide for the 
shaft of the speculum. Two forms of specula are used for direct exam- 
ination, the tubular speculum of Jackson (Figs. 11.'! and 114) and the 
speculum of Briinings. Suppose that the instrument of Jackson is the 
one which the examiner is using. It is manipulated ;is follows: The blade 
of the speculum is carried into the mouth along the central line of the 
tongue until the tip of the epiglottis appears. As soon as this is rec- 
ognized the end of the speculum is carried over it. This is the first 
stage of the examination, if for purposes of clearness the examination 
is described in stages. It is vital for the success of the examination 
not to have this first manipulation miscarry. When the epiglottis has 
been passed by the tip of the speculum, the handle of the instrument 

LARYXGOSCOL'Y, JJKOXCHOSCOl'Y, KSOI'H A< i( >S( '( M'Y , K I ( . 15!) 

is gently raised and at the same lime the patient's head is allowed to 
swing backward slightly and by degrees. As the head of the patient 
goes back the end of the speculum is pushed downward along the 
posterior surface of the epiglottis into the vestibule of the larynx. 
From the moment that the tip of the epiglottis has been passed until 
a satisfactory view of the larynx is obtained, firm pressure is kept upon 
the base of the tongue by lifting up the handle of the speculum and 
thus forcing its shaft and tip forward. The discovery and the passing 
of the tip of the epiglottis constitute the first stage of the examination, 
the sinking of the speculum into the vestibule of the larynx the second, 
and the pushing of the epiglottis and the base of the tongue forward, 

Fig. 113. 

Jackson's tubular speculum. The instrument is made in two sizes, for 
children and aduHs. Johnson has modified this speculum by making the 
horizontal part of the handle detachable. 

the third stage 1 . If at any time the examiner loses his way, that is, 
misses the epiglottis, or strikes the posterior pharyngeal wall or finds 
himself in the pyriform sinus, the speculum should be withdrawn and 
the examination started again from the beginning. It is a help, after the 
tip of the epiglottis has been passed and the speculum is about to enter 
the vestibule of the larynx, to ask the patient to speak, in order that 
the movement of the arytenoid cartilages may give the proper direction 
for the deeper introduction. A successful examination should be a 
matter of only a few minutes. 

Passing the Speculum from the Corner of the Mouth. If there 
happens to be a sufficient u'ap between the teeth on either side of the 
upper jaw advantage may be taken of this space to pass the speculum 



at this place. If no <i'ap exists and the incisor tooth arc prominent, the 
speculum may be passed between the bicuspid teeth or from the corner 
of the mouth. The distances are shorter and the muscles more relaxed. 
For this purpose the head of the patient is rotated a little and bent 
slightly to the opposite side. Tarried out with a small .Jackson spec- 
ulum this method of making the direct examination is very successful 
in children and infants. This procedure has been especially developed 
by Johnston. 

The Direct Examination With Counter Pressure. In the direct 
examination it is the forward pressure of the speculum which enables 
the operator to see the larynx, but this at the same time limits his view 
because the larvnx as a whole is dislocated considerablv forward. In 

Fig. 114. 

Diagrammatic representation of direct laryngoscopy and schema, show- 
ing direction of force applied in using the tubular speculum. (After Jack- 
son. ) 

order to counteract this the operator almost instinct ively puts his 
finder on the larynx from the outside and pushes it backward. Briin- 
in,u's has .u'iven this common manipulation a special name, direct exam- 
ination with counter-pressure, and has devised an instrument to do 
the work of the physician's hand, and so free it for other uses. With 
this instrument the inventor states that the anterior commissure can 
be seen in all cases. 

The Direct Examination Under Ether. The patient is prepared 
for li'cneral anesthesia in the usual way. Before he comes to the exam- 
ining table he is u'iven, if an adult, a sixth of a irraiu of morphin and 
one one-hundred and fiftieth of a .u'rain of atropin. The patient is 
placed on his back' on a table hiii'h enoii.u'h to briu.u' the head to the 
same level as the face of the examiner if he prefers to work sitting. If 
he prefers to work standing the table is put upon a platform. The 


author has found it less tiring and less awkward to make tin- examina- 
tion standing. (Figs. 115 and ll(i.) The head and shoulders of UK- pa- 
tient are brought over the end of the table while an assistant supports 
the head with his left hand upon his left knee. The knee of the assist- 
ant is supported at the proper height by an adjustable foot rest. When 
the ether has been well started the physician cocainizes the deep phar- 
ynx of the patient and the region of the pyriform sinuses with a swat) 

Fig. 115. 

Position of second assistant and patient for endoscopy per os. (Jo\vns. 
caps and covers are omitted to show the position better. (After Jackson, i 

saturated with a ten per cent cocain solution. Often it is a help to 
have a suture through the tongue. The introduction of the spec- 
ulum is the same as under local anesthesia except, of course, that in 
the majority of cases it is easier. The ether examination is resorted 
to when the patient is intractable under local anesthesia. It is used 
in the case of children, or when, besides making an examination, oper- 
ations of considerable extent are to be carried out. The assistant 
should so hold the head of the patient that he can at any moment 


transfer it to the hand of the physician. Often the physician can obtain 
a better view by manipulating the position of the head for himself. 
In a hard examination the head passes many times from the hand of 
the assistant to the hand of the examiner. The assistant's free hand 
is ready at any moment to push the larynx back and to manipulate the 

Fix. 116. 

Bronchoscopy room at Massachusetts General Hospital. The elevated 
platform is shown, with the operating table and the assistant who holds the 
patient's head. The rheostat and dry cell battery are seen on the wall at the 
left. Behind the assistant is a Coakley lamp. On the left also, but not 
shown in the photograph, are the electric suction pump and the ground 
glass box for holding X-ray plates. 

anterior commissure into view, or to close the cords in order to show 
the presence of a new .u'rowth. 

In examining children under ether it is not always necessary to 
brinir the head over the end of the table. If the occiput is allowed to 
rest on the table and the chin is brought up, in very many instances a 
perfect view can be obtained. It is well to 1 ry this posit ion first. ( M'ten 


this position is successful also with adults. If i' 
does not succeed the head may be turned to tin- 
side and the speculum carried down between 
the bicuspid teeth or from the corner of tin- 
mouth. This manipulation is especially useful 
for introducing the bronchoscope between tin- 
cords because it is easier to get in line with the 
trachea in this way than it is from the middl" 

For operating purposes Briinings employs an 
open speculum. Some years ago the author de- 
vised practically the same kind of a speculum, 
and used it for some time but soon replaced it 
by an open adjustable speculum of the pattern 
shown in Figs. 117 and 118. An open speculum 
increases the operating field. Such a spec 

Fia. 117. 

Mosher's adjustable speculum for direct and suspension laryngoscopy 
( Side view.) 




Mosher's adjustable specu- 
lum, showing the mechanism 
by which the speculum can be 
adjtisted to any width. 

is tlie only pattern through which direct in- 
tubation with the larger tubes can be per- 
formed. The eye strain in using the open 
speculum is lessened. All the landmarks of 
the pharynx and larynx are visible at once 
and in their natural perspective. The writer 
is very partial to the open speculum when it 
can be employed. In children it is especially 
successful. In appropriate necks of adults 
it is also successful. The author always tries 
this form of speculum first because when it 
succeeds no other speculum gives as good a 
view. The open speculum may be used with 
or without general anesthesia. However, 
with infants and young children for obtain- 
ing a diagnostic view of the larynx, for in- 
tubation, for extubation, or for removing 
coins from the upper part of the esophagus 
it can be employed without ether. 

The Instruments for Direct Examina- 
tion and Direct Operating. The examining 
instruments are the tubular speculum of 
Jackson, the speculum of Briinings lighted by 
the electroscope, and fitted with the attach- 
ment for counter-pressure, and some form of 
open speculum. The light for the open spec- 
ulum may be obtained by Jackson's melhod, 
or by reflection from a head mirror. The in- 
struments used through Hie various specula 
in direct operating upon the larynx are made 
with the shaft of the proper length and at an 
appropriate angle with the handle. Tli< i first 
instrument is the laryngeal knife. The other 
instruments come under the head of punches 
or grasping forceps. (Fig. 119.) The shaft 
of the instruments should be as thin as pos- 
sible and retain its rigidity. The instruments 
of Briinings are most excellent. In using in- 
struments which work with a scissor motion 
it is hard to judge when they are placed at 
the proper depth. They either fall short or 
overreach the growth to be seized. It is 

LAKYNtiOSOOI'Y, Illio N< ' 1 1 osrol'Y , l-'.Si il'l I .M ;os< '( l'\", I. '!''. I').) 

easier to adjust accurately an instrument 1 lie blades of \\ hidi are placed 
at, riu'ht angles to the end of Hie shaft and which close upon each oilier 
from above downward. The lower blade ean be carried below the 
UTowth and then brought upward until the movement of the in'owlh 
shows that the blade is touching it from below. If the blade- are then 
shut the bite is usually successful. 

In hard examinations where neither the position of the head nor 
counter-pressure will cause the speculum to brinu' about a sufficient 
view of the larynx, and the writer must confess that he has had such 
cases a small, short bronchoscopo introduced from the an.u'le of the 
mouth will at times brin.u 1 into view the desired part of the larynx. 
The writer well remembers a youn.u 1 sailor of splendid physique who 
had a small fibroma situated well forward on the left vocal cord. I nder 
ether a most trying and humiliatiu.u 1 examination followed. Success 
however followed when a small brouchoscope was introduced from the 
anu'ie of the mouth on the ri.u'ht and carried into and across the larynx 
until the growth was pinned inside the tube and against the lateral 
wall of the larynx. An assistant meanwhile pressed the larynx back- 
ward and made counter-pressure on the left. 

A working set of instruments for bronchoseopv is as follows: 

1. Jackson's tubuh-r speculum (j'dult ;;;:<! child size). 

-. Jackson's bronchoscom x (7, 8.5. ]n. ;:ml li' mm. in diameter). 

:!. 13r;inings' universal electroscope. 

4. Hriinings' extension double tubes (7. 8.5. in. u>. and 11 mm. in diameter). 

5. Briinings' autoscope or split spatula speculum (11 and i:'> mm. in diameti-n. 
I!. nriinings' extension forceps with five different tips: or Jackson forceps with 

tips; or Coolidgo forceps with shaft of three lengths and Tips. 
7. Suction apparatus (hand buib. hand or electric aspirator, witli tline tube.; 

25, 35. and 50 cm. in hngth). 
S. Foreign body hook. 
!i. Casst-lbcrry's pin cutter; or Moshor's pin brndi r. 

10. Brunings' or Mosher's safety pin closer. 

11. Jackson's dilator for the bronchi. 
1L'. Mosher's adjustable speculum. 

i: 1 ,. Two angular locking forceps, for us- with the npni sjieculum (Mosherl. 

14. Twelve Coolidge's cot ion carriers. 

15. Kirstein's head light. 
K). Angular laryngeal knife. 

17. Ring punch, for work about the mouth of the i sopluuvus (Moshtr). 

fourth. The latter is an eas; 
larynx and the mouth of the esophagus. It is economy to have all four 
in the operating room. The writer has his examining table in a special 
which is u'iven up to bronchoscopy and esophau'oscopy. The table 


(Fig. 116) stands on a platform the left corner of which is cut out to 
allow standing room for the operator. On this platform beside the 
examining table there is room for the etherizer and the assistant who 
holds the head of the patient. On the right on a wall bracket 
is a Coakley rheostat. Below this is another shelf for the Jackson 
double dry cell battery, and on the platform is an electric light on an 
upright stand. On the right also is placed an electric aspirating pump. 
Each piece of apparatus is connected with its own socket. .V Kirstein 
head light is kept at hand. In the complete operating room there 
should be an illuminated box with a ground glass face for holding and 
demonstrating X-ray plates. 

The table for instruments is placed behind and to the right of the 
operator. Beside the table and behind and on the right stands the 
first assistant. Opposite the first assistant but on the other side of the 

Fore-ops for direct work upon the larynx. (Pt'an.) Various tips 
(natural size) arc shown bolow the forceps. 

fable is the nurse. It is the duly of the nurse to load the cotton car- 
riers. She should see to it that a good number of these are always 
ready so that the operator may never have to wait. The swabs are 
loaded either with cotton or better with small pieces of selvedged 
gau/e cut and folded to the proper size. It is of the utmost importance 
that the nurse and the first assistant should know how to fasten the 
swabs securely to the carriers. When the operator is looking down a 
tube he should not be required to turn his head in order to receive an 
instrument. When he asks for one the first assistant not only 
pas>cs it to him over his shoulder but places the end of the instru- 
ment in 1 he m out h of t he tube and its handle in t he hand of t he operator. 
I'eforc beirinnin.u' the examination all instruments should be tested 
ami proved to be in working order. Ivxtra lights should be on hand; 
or what is belter, if the Jackson bronclmscopc is used, an extra light 

LAKYMiOSCOI'N , Illio X < ' 1 1 Osroi'Y . KSOI' 1 1 A< ;< )S( 'o|'\ . KTC. l(i~ 

carrier with a tested light should he in readiness. The assistant- 
should know how to change the lights and how to adjust the instru- 

Every detail should he provided for het'ore the examination is be- 
gun. The operator must he willing to supervise the smallest details- 
it' he wishes the examination to go <|iiiekly and smoothly. The suc- 
cess of the operation often depends upon the thoroughness of the prep- 

On an accessory tahle the instruments for tracheotomy should he 
sterilized and ready for use. There should he enough assistant- for 
carrying out this procedure and they should he surgically trained. 

The Inhalation of Oxygen. A cylinder of oxygen gas should he 
in every operating room for use in cases calling for bronchoscopy. The 
administration of the gas may make it possihle to avoid a trache- 
otomy if severe dyspnea is present, while the use of the gas to combat 
shock and respiratory arrest is important. If a bronehosoopc is in 
place when the emergency arises the gas may he administered through 
this directly, or through the suction tube if the .Jackson type of bron- 
choscope is employed. Daeger has devised an apparatus by which the 
amount of oxygen administered can be accurately measured and eon- 

Suspension Laryngoscopy. 

About three years ago Killian introduced suspension laryngos- 
copy. Within the last twelve months his perfected instruments have 
begun to be used extensively. The underlying principle of the pro- 
cedure is the transference of the weight of the patient's head from the 
hand of the examiner to the handle of the speculum. This u'ives the 
physician a new hand, his left, with which to work. The suspension is 
accomplished by elongating the handle of the speculum, and eiidinir 
it in a hook. To this handle is attached a skeleton mouth-gag. A nut 
and a screw in the handle of the speculum control the width of this. 
A second nut and screw elevate the tip of the speculum. Spatula 1 of 
different sizes are fitted upon the handle. Kach of these has incorpor- 
ated in it a narrow secondary spatula. The position of the tip of this 
is again regulated by a nut and screw. The apparatus is efficient and 
beautiful, but complicated. The claim is made for it that besides hold- 
ing the patient's head it will always bring the anterior commissure 
of the larynx into view. The writer's experience with the apparatus 
as yet is too limited to pass on such a statement, but from what he 
saw at Killian's demonstration in London in li'i:>. and from what he 
has learned from the men in this country who have employed the 
method and Killian's instruments exteusivelv. he considers this state- 



ment much too broad. This is relatively a small matter, of course, be- 
cause there will always be a percentage of cases in which neither a 
speculum nor the human hand can force the anterior commissure hack 
into the field of vision. The gist of the matter is that an advance has 
been made, how great time alone can settle, by the introduction of 
suspension. The tired laryngologist eagerly grasps the relief which it 
affords. (Fig. 120.) 

The way having been shown by Killian, the rest of the world of 

Fit;. 120. 
Killian's susp< nsioii apparatus. 

laryngologists will rush in with possible improvements of the ap- 
paratus, aiming especially to simplify it. The writer admits that lie is 
one of those who have made such an attempt. A hook in the end of the 
handle of his adjustable speculum, one nut and angle lever in the 
shank, and a set of cross ridges on the moving blade convert it as ex- 
perience has shown, into a serviceable suspension speculum. It can 
be hung from a chain attached to the ceiling or as Murphy suggested, 


from the frame of an adjustable instrument tray holder. 'The reader 
\vill doubtless think of other ways. The crane of Killian is efficient, 
of course, but it is bulky and does not fit every table. For convenience 
in carrying the writer has had a folding frame constructed. The board 
which supports this slips under the back of the patient. So far it has 
met expectations. ("Fi&'s. 121 and 122.) 

Fig. ll'l. 
Mosher's folding frame for suspension apparatus closed. 

Fig. 1-2-2. 
Mosher's folding frame for suspension apparatus open. 




The direct examination of the trachea and the bronchi can be car- 
ried out by two routes. By the upper route the tube is inserted be- 
tween the vocal cords. When the lower route is employed the tube 
ii'ains access to the trachea through a tracheotomy wound. After the 
performance of the tracheotomy the second method is the simpler and 
so will be described first. 

Lower Tracheobronchoscopy. 

I'nless the lower route is used for the extraction of a foreign body 
it is well to wait a few davs until the surgical wound has healed a little 

I'rct hrascopr used as a 

before attempting thorough examination of the trachea and the bron- 
chial tree. The earliest examinations of the trachea by the lower rout>- 
were made through short tubular specula like the female urethraseopo, 
and the illumination was obtained from a head mirror ( ( 'oolidi^'e. ) At 
the present time self-lighted specula of this pattern are made. ( File's. 
ll'.'J and \-4.) For the examination of the trachea as far as the bifurca- 
tion these are the simlest and best instruments. 

LARYNOOSCOI'Y, UliO.M ' I lOSCOl'Y , I-;S( (l'IIA<;oS< '< 

Contraindications to Lower Tracheobronchoscopy. I'nless tra- 
cheotomy is contraindicated the performance of lower tracheobron- 
choscopy is permissible except in the presence of pneumonia. 

Anesthesia.- After a recent tracheotomy in a case in which the 
mucous membrane is normal, a drop of ten per cent cocain with adren- 
alin added, placed in the trachea is sufficient to produce anesthesia. 
Only in the region below t lie glottis is there excessive sensitiveness. The 
trachea tolerates the tube well. After the insertion of the tube the 

Fi.ff. ll'4. 

Urothrasoope used as a traohoosoopi 
showing individual parts. 

swab syringe may be used to apply cocain to the walls of the trachea, 
the most sensitive part being the anterior wall. In patients who have 
been wearing a traclieal caiiula for some time the mucous membrane 
about the tube is very irritable and it may be impossible to cocainize 
it. In children the strength of the cocain solution should be reduced 
to five per cent and in adults in the presence of bronchitis a twenty per 
cent solution should not be used or should be employed sparingly. If 
there is a foreign body in the trachea, the cocainization should be ac- 
complished with a syringe, not witli a swab. The parts of the trachea 

172 oi'KiiATivF. srnoF.nv OF TIII-: XOSK. THROAT. AND KAK. 

which are the most irritable are the neighborhood of the fistula, the 
bifurcation, and the bronchi below. The inflamed mucous membrane 
about a foreign body is always sensitive. 

Position of the Patient. Lower traclieobronchoscopy is easiest 
when performed with the patient sitting. After a fresh tracheotomy 
or if the patient is weak, the prone position is better. When a search 
is to be made for a foreign body the patient should be examined on his 
back and with the head lowered. If the prone position causes cough- 
ing or interferes with the breathing the erect position of the patient 
is the only choice. Better control is obtained with children if they are 
placed on the back. 

In some cases the examination succeeds best if the head of the 
patient is extended over a roll or if a sandbag is placed under the neck, 
as is customary in the performance of tracheotomy. In other cases 
the head is held over the end of the table. 

The Method cf the Examination. The ideal method of learning 
bronchoscopy is to make use of a patient who has had a tracheotomy 

The introduction of the examining tube offers some difficulty un- 
less it is done at the time of the tracheotomy when the tissues of the 
neck are wide open, and the trachcal incision can be spread with re- 
tractors. (Figs, IL'.'J and 124.) After the complete healing of the wound 
about the tracheotomy tube the fistula into the trachea is more or less 
oblii|ue. and is always narrowed from its original dimensions. The 
easiest way to insert, the tube without abraiding the edges of the fis- 
tula is to place a snugly-fitting elastic bougie through and beyond the 
tube, and then after having inserted the projecting erd of the bougie 
throii.u'h the fistula and well into the trachea to push, the tube down on 
the bougie. The bougie guides the tube into the trachea and keeps it 

erlor wall and centers it in the long axis of the 
Naturally the posterior wall of the trachea is 
the easiest to examine. The side walls offer some difficulty but the 
anterior wail, especially in the neighborhood of the fistula, is the 
hardest of all to inspect. In order to accomplish this the patient 's he,",d 
mu.-t be turned strongly to one side so that the tube can be made to lie 
flat wit h 1 he neck. 

If. in-te;i<l of inserting the tube downward it is inserted into the 
trachea with the point upward, the be^inniim' of the trachea and the 
-Tibii'lottic region of the larynx may be examined. Such an examina- 
tion may be called for in cases of adhesions between the cords after 
diphtheria or when there is subglottic narrowing due to the contrac- 
tion of -ear tissue. Tins method is called retrograde examination. For 

LAKYNKOSCOl'Y, I'.KO.Xf ' 1 1 OSCOI'Y , KSOI'H A< ;OS( 'Ol'Y, KTC. \i.> 

this procedure smaller lubes are necessary in order thai Hie breathing 
may not he interfered with. 

To return to the direct exaininat ion of the lower part of Ihe 1 ra- 
chea. If it is possible, to employ a large tube, just as soon as this is 
well engaged in the lumen of the trachea the observer usually can see 
the whole of the trachea to the bifurcation. It may be necessary oc- 
casionally to draw the tube to one side in order to accomplish this. 'Flic 
color of the trachea varies in different patients from a yellowish to a 
blood-like red. If the walls of the trachea are painted with adrenali 
solution less light is absorbed and the illumination is increased. Th 
tube slips down the trachea almost of itself and the beginner, often, un 



Fig. lL>ti. 
Jackson's bronchoscope, with beveled end. 

less lie keeps his bearings by moving the tube from side to side, misses 
the bifurcation and carries the tube into the right main bronchus. In 
this connection it should be borne in mind that the median septum is 
often pushed far to the left. The septum should always be located be- 
fore the tube is passed into a bronchus. 

The Endoscopic Picture. In a tubular organ like the trachea 
having a constant lumen, when the observer looks through the bron- 
choscope he sees at some distance ahead of the end of the tube the 
lumen of the trachea and its walls. (Figs. 125 and 12(1) The beginner 
is liable to introduce the tube too far at first and not to get the picture 
in perspective. If this is done pathologic narrowing of the lumen would 
not be recognized. The same would be true of any deformity of the 
walls caused by pressure of the neighboring organs. In order to ob- 



tain a proper perspective the tube should be held high, but for a good 
view of the walls the tube should be carried well down and as near to 
the wall to be examined as possible. The higher the tube the larger the 
field which appears iu perspective beyond it, the deeper the tube the 
smaller and clearer the field, lu order to obtain a clear picture of the 
walls the tube should not only be introduced well into the trachea, 
but the end should be displaced strongly to the side. The trachea 

Cast of the interior of the trachea and bronchi, with their chief ramifica- 
tions within the lung. This cast shows a type of division frequently met 
with, the right bronchus being almost in continuation of the line of the 
trachea. <i. epartcrial brunch: //. <. hyparterial branches (ventral and 
dorsal ) . ( Quain, after Aeby. ) 

and the bronchi are so movable that this procedure is constantly prac- 
ticed. Indeed, the movability of the bronchia! tree is as important for 
the success of bronchoscopy as is the forward dislocation of the base 
of the tongue for the performance of direct inspection of the larynx. 
In bronchoscopy the observer should look' ahead of the tube. The eye 
should precede and guide the tube and the hand. 

The elasticity of the bronchial tree makes the lateral displace- 
ment bv the examining tube painless. The lateral mobility of the 

LARYNGOSCOPY, JiHONCHOSCOPY, KSOIM l.\<;os< 'ol'N , I-.TC. ] t ,) 

bronchial tree is utilized to the greatest extent in bringing tin- first 
branch of the left main bronchus into view. In addition the tube is 
placed in the corner of the mouth and the head of the patient is bent 
sidewise toward the operator. The median septum of the trachea and 
the great vessels suffer in this manipulation a displacement of ."> cm., 
and the bronchi and neighboring structures a dislocation of 10 cm. 

Cast of the interior of the trachea and bronchi, with their chief ramifica- 
tions within the lung. This cast shows a type of division less frequent than 
the last, the right and left bronchi being at about a right angle with one 
another, a. eparterial branch: b. ventral hyparterial branches: h'. accessory 
(azygos) branch; c, dorsal hyparterial branches. (Quain. after Aeby. I 

The angle which the tube makes with the long axis of the body is iJO . 
(Fig. 127.) 

Much less displacement is required in order to introduce the tube 
into the third bronchus of either side. On the right, on account of the 
fact that the main bronchus is so nearly in line with the long axis of 



the trachea, the lateral displacement sufficient to bring tlie bronchus to 
the lower lobe into view is about 1.5 cm. 

In lower bronchoscopy even less lateral excursion is necessary. 
(Fig. 128.) 

The Interpretation of the Endoscopic Pictures. The greatest dif- 

Right recurrent laryngeal 

Transverse cervical 

Right common carotid 

Suprascapular artery. 

Internal jugular vein. 
Pneumogastric nerve. 
Subclavian vein. 
Inferior thyroid vein. 
Phrenic nerve. 
Left innominate vein 
Ascending aorta. 
Superior vena cava 
Right bronchus. 

Branch to superior 

lobe of lung. 
Upper branch of right 

pulmonary artery. 
Branch to middle lobe 

of lung 
Right pulmonary vein. 

Right auricle 

Right coronary artery 
Thoracic vertebra. 
Intercostal vein. 
Intercostal artery 
Vena n/ygos major. 
Intercostal vein 
Intercostal artery 
Intercostal vein 
Intercostal artery 

Thyroid body. 
Left recurrent laryngeal 

Pneumogastric nerve 

eft internal jugular 

eft common carotid 

eft subclavian artery 

Left subclavian vein 

Inferior thyroid vein. 
Phrenic nerve 

(hooked aside). 

Recurrent laryngeal 


Pneumogastnc nerve 
Ductus arteriosus. 
Left pulmonary artery 
Pulmonary artery 

Thoracic duct. 
- Thoracic aorta 

The arch of the aorta, witli I lie pulmonary artery and chief brandies ot 
the aorta. (Morris' Anatomy From a dissection in St. Bartholomew's 
Hospital Museum J 

ficulty which the observer encounters is to judge the perspective right- 
ly. As lie looks with one eye he is without the aid of the parallax 
which binocular vision affords and is constantly mistaking his dis- 



tance. In the trachea the observer can help himself by counting 1 he 
rings. In the main bronchi measurements are of more aid. The irreat - 
est lielp of all is obtained by laying the mamlrin of the examin'mir tube 
on the surface of the chest and judging the internal di>1anees from 
this. (Kit--. IL'!).) 

Tlie length of a stenotic area is hard to determine by si.irht, and 
is best made out by the use of a metal olive tipped bougie. Objects at 
the end of the tube appear smaller than they really are. Their true 

Right common carotid artery 
A. carotiscommunis dcxtra 
Innominate artery A. anonym. i 
Right aubclavian artery 
A. jubclavia dextra 
Right innominate vein 
V. anonyma dextra 
Superior vena cava 
V. cava superior 
Right bronchuf 
Bronchus c'extcr 


Left common carotid artery 

A. cari'l:-; com::ii::'. : ,:-:::. ::a 
Left Innominate vein 

Cervical pleura' 
Cupula pluiir.r 

Arch of the aorta 
Arcus n'Tt.i- 

Left bronchus 
,, V l ; i r.chus bini 

Esophagus (thoracic portion) 

Descending thoracic aorta 
Aorta descendens 

Quadrate lobe of the liver 

J.nbus quadratus hepatis 

Small or gastrohepatic 


Lig. hepatosastricum 

N'csica fclle.i ' 

"Hepatoduodenal ligament 

or omentum' 
*Lig. liepatoduodcnale 

Caudate lobe of the liver 

I'rocessus caudatu> 


Mediastinal p'.cura 
1'lcur.l :..' . , :.:: . : 

Pulmonary pleura 

1'lcu:. ..]...::. ::.u: 

Costal pleura 
1'lfiirac.. Ml; 

Great or gastrocolic 

ouicntum- anterior 


Great curvature of the 

Posterior wall of the 

Fig. 130. 
Showing the relation of the trachea to the great vessels of the neek. (From Toldt.) 

size can be reckoned mathematically, 1ml it is easier to obtain it by 
measuring a duplicate of the object. ( !.'!(>.) 

The Choice of the Upper or the Lower Route. For the he-inner 
lower bronchoscopy is easier and safer. In infants and youim' children 
it is safer and often the method of choice. The experienced operator 
will succeed with upper bronchoscopy where the novice will fail, but 
it is well to try upper bronchoscopy a> a routine in all cases. If it does 
not succeed the operator should not hesitate to abandon it for the lower 
route. There is no disgrace in so doinu'. It has been proved that in 
cases in which a foreign hody, like a bean, has been playing up and 
down in the trachea for some time the trauma so caused often produces 
spasm or edema of the larynx, so that after upper l>roncho>copy. even 


if it has been successful, m\ emergency tracheotomy may be necessary. 
The question of upper or lower bronchoscopy should never depend on 
the pride of the operator but on the good of the patient. 

The Dangers of Bronchoscopy. Operative bronchoscopy is nat- 
urally more dangerous than examinations merely for diagnostic pur- 
poses. Jackson's statistics of ninety-four cases of upper and lower 
bronchoscopy give a mortality of two per cent. The chief danger of 
the examination is its length. Under ether three-quarters of an hour 
is a safe limit. Rather than prolong the operation it is bettor to try 
au'ain at a second sitting. In one of Killian's cases of a foreign body 


Thyroid body j 

Glanduia thyrcoidta . ^ / 

Apex of the lu 
Apc.v pulmoni 

Right bronchu 

Ventral bronchial branch 
of the upper lobe 

lobi supenoris 

Bronchial branch of the middle 
lobe 'first ventral hypartenal 
branch of the right bronchus i 

.Showing the divisions of the traclna and bronchi. (From Toldt.) 

in the bronchus ten sittings were required before the extraction was 
successful, and many of these lasted two hours. Briinings gives the 
time of the ordinary operation as five to fifteen minutes. Jackson has 
reported the removal of three tacks in three minutes. (Fig. 1 .">!.) 



Asepsis. In bronchoscopy flic nioiilli of the patient should he 
made as clean as possible. .Jackson advises a thirty per cent solution 
of alcohol as a month wash. It; i'oes without saving that the instrn- 




Fig. I:!L>. 

Showing the relation of the main bronchi to the ribs and the chest 
wall (Anterior view). (From Anatomical Department. Harvard Medical 

nients also should be clean, (ienerally immersion in seventy per cent 
alcohol is depended upon for the sterilization, formalin vapor can be 
employed if preferred. 


The Size of the Tubes. Briinings uses tubes of four sixes. 

L'l'PEIi Bl!<>\< IIOSC OI'Y. 

Number Size Age 

1 7 mm 1 to 3 years. 

11.1 7}o mm 4 " 5 

2 8i L , mm 4 " 9 " 

3 10 mm 9 " 14 

4 12 mm Adults (men and \vonu-ni. 

LOXVKK Buoxc iiostoi'Y. 

Number Size Age 

1 7 mm 1 to 3 years. 

2 811, mm 3 " 8 " 

3 10 mm 8 " 14 " 

4 12 mm Adults ( men and women ) . 


In order to see the secondary bronchi the main bronchus is dis- 
located laterally and the tube brought into line with the bronchus to be 

The patient's head must be bent in the proper manner to allov\ 
this change in the position of the tube. In changing the position of 
the head the neck should not be held far backward and cramped be- 
cause this interferes with the mobility of the trachea and the bronchi. 

As soon as the lumen of the right main bronchus is entered and 
lighted by the tube, the observer sees in the distance the opening of 
the bronchus to the lower lobe and wit hin this smaller dark, oval patches 
which are the openings of the tertiary bronchi. .Between these dark 
patches appear the median septa. The picture constantly changes. 
With every movement of the tube new openings of new branches come 
into view, in the depths of which other divisions are seen. (Fig. 1X>.) 
In the deeper bronchi there is a rhythmical change of the picture with 

When the tube is placed high in the main bronchus the opening of 
the branch to the upper lobe as well as of that to the middle lobe gen- 
erally are not seen. It is only after inserting the tube to the proper 
depth and dislocating the bronchus between one and one and five- 
tenths cm. to the side and upward, that the lower circumference of the 
opening of the branch to the upper lobe is discovered. If the manipu- 
lation is not successful the tube is inserted below the origin of the first 
branch and lateral pressure is made as before and the tube withdrawn. 
As the tube comes up the opening of the bronchus springs into view. 





Fig. I'.'A. 

Diagram to show the bronchoscopic 
picture. (After Jackson.) 

A. The bifurcation of the trachea is 
shown to the left, of the middle lino. 1. 
Left main bronchus. 2. Right main 

H. I'icture of the loft main bronchus 
(see FJK. 128). 1. Hronchus to upper 
lobe. L'.-!!. Mronchi to lower lobe. 

('. Picture of right main bronchus. 
1. Hronchus to upper lobe. 2. Hronchus 
to middle lobe. :',.-4. Bronchi to 
lower lobe. No. 4 is the practical eon- 
lation of the right main l)ronchus. 

Iii lower bronclioscopy the 
opening of the branch to the 
upper lobe is easier to find. So 
readily can the opening be ap- 
proached that the circumfer- 
ence of the first two rings can 
be made out. The field often 
increases rhythmically with 
the respiration. 

The cavity of the branch to 
the upper lobe can be explored 
by placing a small mirror 
through the examining tube 
into the bronchus or by insert- 
ing a small cystoscope. With 
the latter Briinings has dem- 
onstrated even the tertiary 
bronchi. The cystoscope should 
have a diameter of 8 mm. and 
if designed for both upper and 
lower bronclioscopy it should 
be about 30 cm. long. 

Although cases have been 
reported of foreign bodies 
lodged in the branch to the up- 
per lobe (Wild and Gottstein), 
as a rule such cases are rare. 
Killian calls attention to the 
fact that Ihe examination of 
this branch might give a clew 
to tuberculosis of the right 
apex, that is, pus might be seen 
coming from the opening of 
Ihe bronchus in such cases. 
(Fig. 134.) 

Tin? direct examination of 
the branch to the middle lobe 
is easily accomplished when 
the tube is carefully introduced 
and pressure is made in a for- 
ward direction. This opening, 
however, can be readily con- 
fused with that of the branch 

LAKYNOOSCOI'Y. BliO N( ' 1 1 OS< 'Ol' Y , KS 


to the lower lobe. In all cases in which the observer is in doubt tin- 
tube should be withdrawn to the bifurcation and then carried down- 
ward aiaun step by step. 

The branch of the riu'ht main bronchus to the lower lobe is ivallv 

Fig. 135. 
Diagrammatic drawing to show the bronchoscopic picture at various levels. 

a continuation of the main bronchus. For this reason the opening of 
the third secondary bronchus is not only easy to see and enter with 
the tube but this is the bronchus which most often catches foreign 
bodies. (Fii>'. 135.) 

The left main bronchus leaves the trachea much more sharply than 
the riu'ht bronchus does.- For this reason it is harder to u'ain access 



a. . c 

;" 1* =4 S S i-^ 

LAUYXCOSCOI'Y, BKONCIIOSrol'Y, KS< >!' 1 1 A< i( S( '( >!"> . KT< . 

i sr, 

t<> it and to its branches, especially the lirst, into view. This 
bronchus is easier to see by lower bronelioseopy. In invot iirat intr the 
left main bronchus strong pulsations from the arch of the aorta are 
noticed. ( Fitr. l.'HJ. ) 

The origin of the branch of the left main bronchus to the upper- 
lobe is 4-f> cm. from the bifurcation. It is to be found on the 
lateral wall and somewhat anteriorly. It is often missed both on the 

Fig. 137. 

Horizontal section of thorax of man. aged f>7. immediately abov< 
bifurcation of the trachea, seen from above. (From Qnain.) 


V. L.. upper lobe of right lung; V. P.. L. L.. upper and lower lobes of left 
lung: II. B., L. M., origin of right and left bronchi, in this specimen the ter- 
mination of the trachea was lower than usual: A., arch of aorta: D. A.. 
descending aorta; D., obliterated ductus arteriosns: X.. left recurrent laryn- 
geal nerve; L. G., lymphatic glands; other letters as in Fig. 1?,8. 

insertion and on the withdrawal of the tube, and a siirlit of it is to be 
gained, if at all, by strong lateral and upward dislocation of the main 
bronchus and with the end of the tube held as obliquely to the lateral 
wall as possible. Naturally foreign bodies do not often train entrance 
to this bronchus. (Fig 1 . 137.) 

On the left the second branch of the main bronchus, the bronchus 
to the lower lobe, is for all intents and purposes a continuation of the 
main bronchus. The tube, therefore, rinds it readily and the picture 
seen throuirh the tube shows the lumen of the third branch and then 
the division into the dorsal and ventral branches. 


Lower bronchoscopy carried out as has been indicated is not diffi- 
cult. The bronchi should be examined both on the introduction of the 
tube and on its withdrawal. The examination cannot be considered 
complete unless both main bronchi, the secondary bronchus on the right 
to the middle lobe and the branch to the lower lobe on both sides have 
been examined. The exploration of the two main bronchi and the branch 
to the lower lobe on the right is especially demanded because foreign 
bodies often lodge in them. In the author's experience foreign bodies 

Fig. 138. 

Horizontal section of the thorax of a man, aged 57, at the level of the 
roots of the lungs, seen from above. (From Quain.) 

I. S., superior and inferior lobes of lungs; E., eparterial bronchus; 
A. M., anterior mediastinum; It. P. C., right pleural cavity; P. C., pericardial 
cavity; A. A., ascending aorta; P. A., pulmonary artery; R. P. A., its right 
branch; R. P. V., L. P. V., right and left pulmonary veins; A. V.. a/ygos 
major vein; other letters as in Fig. 136. 

lodge ol'leiiesl at the bifurcation of the trachea, in the dilatation where 
the first branch of the right main bronchus conies off, or in the internal 
branch of the bronchus to the lower lobe. 

The tertiary bronchi arc so small that neither the bronchoscope 
nor light can be made 1o enter them. In such cases the use of a sound 
will enable the operator to palpate these small tubes even to the peri- 
phery of the lungs. (Fig. IMS.) 

Lower bronchoscopy is easier with the patient in the sitting posi- 
tion. It can and often is carried out with the patient lying on his back. 

LAKYXCOSCOI'Y, Hl{< I XC 1 1 OS< '( >I'Y. KSOIM I A< lOSCOl'Y , KT< . 


It is harder to >iiana,n'e the position of the patient's head if he is upon 
his hack, because the handle of the elect roscope often u'ets in the way. 
( Fi.ii 1 . !.'>{).) With the Jackson tube, however, this difficulty is not en 

Upper Bronchoscopy. 

I'ppor bronchoscopy is much more difficult than lower broncho 
scopy on account of the more complicated technic required to insert 

Fig. 139. 

Horizontal section of the thorax of a man, aged 57, at the level of the 
nipples, seen from above. Note how the bronchi keep near the median line. 
This is fortunate in the removal of foreign bodies. (From Quain.) 

.., nipple; M., middle lobe of right lung; R. A., right auricle: R. V.. 
right ventricle; L. A., left auricle; L. V., left ventricle; R. V. P., right 
posterior valve of aortic orifice; r. p. <.. right pleural cavity: other letters 
as in Fig. 136. 

the brouclioscope, due to the form of the larynx, and because of the 
slighter mobility of the tube and its greater length. 

Anesthesia. The Gorman school are strong advocates of local 
anesthesia and the sitting position of the patient durin.u- the examina- 
tion. In this country general anesthesia is used laruvly and the pa- 
tient is examined lyin^ on his back. The use of ether does away with 
the sense of hurry which attends bronchoscopy under local anesthesia. 

The Method of Performing Upper Bronchoscopy. If local anes- 
thesia is to be employed the larynx of the patient is cocainized as for 


direct inspection. The reflexes of the larynx are the most active. After 
the anesthesia has been accomplished the vocal cords are exposed. If 
Briinings' instruments are selected, this is done with the tubular spa- 
tula used after the fashion of his speculum, employed for direct inspec- 
tion of the larynx. Jt is not necessary to expose the anterior commis- 
sure, so that the operator is content with disclosing 1 the posterior 
third, or the posterior half of the cords. If this much is not read- 
ily brought into view, the assistant pushes the larynx backward. 

The passage of the larynx is the difficult part of the manipulation. 
This is best accomplished by cautioning the patient to breathe quietly 
and regularly. TVhen he does this the cords part in inspiration and 
the tube is slipped between them and into the trachea. The cords need 
not be widely separated. Sometimes it is necessary to turn the spatula- 
like, edge of the speculum anteroposteriorly and to insert it in this 
manner between the cords and then to turn the speculum and force the 
cords apart. The introduction of the warmed and oiled tube is brought 
about not so much by force as by manipulation and a lever-like move- 
ment of the tube under the guidance of the physician's left forefinger. 

The Introduction of the Bronchoscope With the Patient Lying On 
His Back. Where the patient is placed on his back it is necessary for 
the introduction of the tube to have the head held over the end of the 
table. After the tubular speculum has passed the upper part of the 
epiglottis the head must be lowered for the exposure of the cords and 
the passing of the tube, between them. 

In the prone position of the patient the handle of the electroscope 
is somewhat in the way. This difficulty is not encountered it' the .'Jack- 
son tubular speculum is used because the speculum is discarded as 
soon as the bronchoscope has entered the glottis. If the introduction 
of the tube is difficult the patient may be turned on his left side. The 
tubular speculum is then carried in from the left corner of the mouth. 
The head is unsupported. The speculum easily passes into the tra- 
chea. After the speculum has entered the trachea the patient is turned 
upon his back again and the examination completed. The cords hav- 
ing been passed the rest of the examination is carried out as in lower 
bronchoscopy. \Vhen the tubular speculum has explored the trachea 
to the bifurcation the inner tube is inserted and advanced step by step 
to the main bronchi. Naturally it is not possible to move a tube when 
passed from the month as much as a tube introduced through a trache- 
otomy wound. Therefore there is less lateral dislocation of the trachea 
and the bronchi. To make up for this loss the alteration or moulding 
of the patient's body, chielly the position of his spine, is called into 
play. The bronehoscope is shifted to the corner of the mouth. 

LAIIYXOOSCOI'Y, I1IIO \< ' 1 1 OS< 'Ol'Y , KSO|'HA(,os< ol'Y, K'I'C. 1 s !' 

Upper Bronchoscopy with the Jackson Tubular Speculum and the 
Jackson Bronchoscope. The tubular speculum of .Jackson is very con 
venient for exposing the larynx and for introducing the bronchoseope. 
Jackson until recently has preferred to pass the bronchoscope under 
U'eiieral anesthesia and with the patient lyinu' on his hack. Lately lie 
has discarded both local and .u'cneral anesthesia. The experience of the 
writer of this article has been obtained almost wholly with irencral 
anesthetics. After the cords have been exposed with the tubular spec 
iiliiin a bronchoscope of the selfdi^htiu.u' pattern and of appropriate 
size is passed through the speculum and between the cords. Then the 
separable hood is removed and the speculum withdrawn. 

The Introduction of the Bronchoscope with the Open Speculum. 
-The introduction of the bronchoscope with the adjustable open 
speculum of the author is the simplest method of passing the hroncho- 
scope under vision. 

The Examination in Children. 

Owinii 1 to the flexibility of the neck in the child and to the shorter 
distances, the direct inspection of the larynx in infants and children 
is often comparatively easy. The structures are diminutive so thai the 
field obtained is small. The epiglottis is undeveloped and often very 
unruly when the speculum attempts to control it. 

The difficulties in the examination of children arise from the 
smallness of the structures which necessitates tubes as small as (i-7 mm. 
Through these it is hard to i>'ot a ,n'ood view and to manipulate instru- 
ments. In addition the examiner's difficulties are increased by the 
unruliuess of the patient, by the tendency to spasm, by salivation, by 
the strong respiratory movements of the trachea and the bronchi, and 
lastly by the greater tendency to collapse either with local or general 

In most cases bronchoscopy is undertaken in children for the de- 
tection and the removal of foreign bodies. Foreign bodies are most 
common in children, to summarize a table from Gottstein, between the 
second and the sixth year. Sixty-nine per cent of cases occur before 
the twelfth year, and only thirty-eiii'ht per cent from the twelfth year 

Instruments. "Relatively wider specula may be used in children 
than in adults. Forceps and all other instruments which are to be used 
through the diminutive tubes which are employed in children must be 
especially small in calibre. Briininju's has a special form of electroscope 
which lie advises for this work. Other instruments are the open spec- 
ulum of Briiuhiii's, or that of the writer. A self -lighted uretlirascope 


is of service for use through a tracheotomy wound. The size of such 
tubes varies between 7 and 8 mm. The sizes of the urethrascopes 
should be 5, 6, and 8 mm. Seventeen cm. is a sufficient length for the 

Direct Laryngoscopy. The simplest way to examine a baby is to 
wrap it in a blanket and to place it on its back on a table and expose 
the larynx with the open speculum or the children's size of the .lack- 
son speculum. The examination of the child held in a sitting posture 
in the arms of a nurse is also satisfactory. For this purpose the spec- 
ulum is passed along the center of the tongue or introduced from the 
corner of the mouth. In infants and children the author lias had no 
experience with local anesthesia. lie prefers to use general anesthe- 
sia. Briinings gives the impression that examinations conducted in 
this way are less satisfactory than when local anesthesia is employed. 
It is doubtful if the experience of operators in this country accords 
with that of Briinings. 

The Method of Examination. The method of making the direct 
inspection of the larynx in infants and children is the same as in adults. 
The distances are very short and the epiglottis is placed high so that 
only a slight depression of the tongue is required to expose it. The 
pharynx and even the glottis often close in a sphincter-like fashion, 
and from tiine to time the whole working field is flooded with mucus. 
A speculum with a broad end is especially serviceable in raising the 
stubby and elusive epiglottis. Often the anterior commissure of the 
larynx can be moulded into view by external pressure. In holding the 
head it should not be bent too far backward. 

Lower Bronchoscopy. Lower bronchoscopy is carried out with 
children in Ihe same manner as in adults. For the examination of the 
trachea in the neighborhood of the fistula the urethrascope or a small 
bronchoscope constructed on this pattern is of service. In examining 
the trachea and the bronchi the respiratory movements of the air pas- 
sages are a great annoyance. Jn strong respiration the field may be 
lost altogether. This is embarrassing in the bronchi because if the 
mucous membrane is swollen it is only during inspiration thai a view 
can be obtained. 

Upper Bronchoscopy. I'pper bronchoscopy in children is the 
most difficult feat which is attempted with this procedure. The exam 
iner should be ready and willing at any moment to supplant it by lower 

The author has had most experience with upper bronchoscopv 
performed under general anesthesia. Small doses of alropin control 
the secretions. The introduction of the tube is easily accomplished in 


the usual case with the small Jackson speculum or with the adjustable; 
open speculum. Ipper brouehoscopy in children should never be at- 
tempted without instruments and assistants enough for the execution 
of a rapid tracheotomy. The danger of subglottic swelling after 
bronclioscopy in children should always be in the mind of the operator. 
The patient may require an emergency tracheotomy not only durintr 
the operation but at any time during the next day or two. 

The general conduct of the examination by the upper route is 
along the same lines as the examination in the adult. 

Instruments for Bronchoscopy. 

The essential instrument for the 
performance of direct inspection of 
the larynx, the trachea, and the bron- 
chi, is a metal tube of appropriate size 
and length. For direct examination 
of the larynx the tubular speculum is 
constructed so that it is open for a 
part of its length. For the examina- 
tion of the bronchi the speculum be- 
comes a long tube. The speculum and 
the long tube can be lighted from 
within or from without. The simplest 
method of lighting the broiichoscopc 
is that popularized by Jackson. A 
small secondary tube is carried along 
the side of the larger and the main 
tube to its lower end. At this point a 
window turns the lumen of both tubes 
into one. Tn the secondary tube a 
small rod-like tube acts as a carrier 
for a diminutive electric lamp. TVhen 
the carrier is in position the lamp lies opposite the window and when 
the lamp is burning its light illuminates not only the end of the larger 
tube but shines ahead of it. 

The illumination of the tube by the second method is accomplished 
by attaching to a handle which can hold various sizes of tubes, a small 
but powerful electric lam]). (Fig. 140.) Above this a mirror is so placed 
that the light from the lamp is thrown down and through the tube. 
Briinings has developed this form of illumination to a high degree of 
efficiency in his various forms of electroscopes. Both methods of 
liii'htinir the examining tubes are highlv successful. Kadi has certain 


advantages. The examiner should provide himself with both sets of 
instruments. lie certainly should not allow himself to become so pre- 
judiced as to lie willing to use but one pattern. 

The disadvantage of the self-illuminated tube is that the light is 
liable to become clouded with secretions and blood. It is surprising, 
however, especially if the examination is conducted under general 
anesthesia and the secretions controlled by atropin, how long the light 
will burn before it becomes dimmed. As a rule suction will keep it 
clean. Theoretically a strong case can be made out against the self- 
lighted tube in the presence of abundant secretion, especially blood, 
but the results of practical work refute most of the objections. The lights 
call for a little more care than the larger lamp of the Briinings electro- 
scope. The thread of the small lamp and the thread in the light car- 
rier should be carefully standardized so that new lamps will fit and 
burn. If this detail is attended to, the small lamps give almost no 
trouble. The great advantage of the self-lighted tube is that its han- 
dle is not complicated and so at times in the way, and that the eye of 
the observer has the full diameter of the tube to look and work through 
from the beginning of the tube to its end. This reduces the eye strain 
the physician's eyes are his capital. 

The advantage of illuminating the tube by reflecting light through 
it is that the illumination is never lost in the presence of secretions. A 
candid observer must admit, however, that it is more tiring to look 
through the narrow slit in the mirror of the electroscope than it is to 
look through the full lumen of the self-lighted tube. The author has 
read the discussions which deal with the question of lighting from the 
standpoint of optics, but has settled the question for himself at the 
examining 1able. The beginner in bronchoscopy is advised to do the 

The Jackson Tubular Speculum. The .Jackson tubular speculum is 
shown in Fig. 11-5. This speculum is made in two sixes, the larger for 
adults and the smaller one for infants and children. The cut makes 
detailed description of the instrument unnecessary. 

Johnston has modified the Jackson speculum by making the handle 

The hriinings electroscope is shown in Fig. 140. It is made in at 
least three patterns. The author has found it necessary to provide 
himself so far with but one pattern. 

The Brunings Elongating Bronchoscope. The main tube is a long 
tubular speculum. This is used to examine the trachea as far as the 
bifurcation and the esophagus as far as the arch of the aorta. For ex- 


animation beyond these depths a smaller tube is fitted into the larger 
one and carried down and beyond it by means of a stout spring. By 
this device the tube can be lengthened at will. This form of tube is 
('specially useful in examinations performed under local anesthesia. 

The Brunings Elongating 
principle 1 of the elongating tube t 
of forceps is very useful espe- 
cially as the shaft is fitted with 
tips adapted for all necessary ma- 
nipulations. The operator should 
supply himself with a liberal as- 
sortment. It is vital to have a 
U'ood tip for iiTaspinu', a tip made 
in the form of a punch, and a tip 
of the proper form for seixinu' 
beans and other seeds. Special 
cases call for special instruments. 

Batteries. -- The lamp in the 
Jackson speculum and broncho- 
scope is most conveniently light- 
ed by a current obtained from dry 
cells. .Jackson employs a double 
battery. .After considerable ex- 
perimenting the writer has found 
four dry cells controlled by a 
small rheostat the most portable, 
the easiest to renew and alto- 
gether the most satisfactory. 
( IMU'. 141.) There are many 
forms of rheostats with which 
the ordinary street current can be 
used. These, however, are too 
bulky to carry about. The light 
in Briinings' electroscope calls 
for a reasonably powerful wall 
rheostat, such as is found in the 
equipment of the ordinary oper- 
ating room. 

Aspirator for Removing Secre- 
tions. --The Jackson broncho- 
scope has in addition to the sec- 

Forceps.- Briinings has applied the 
o his forceps. ( Fiii'. 14*.) This form 

Fig. 141. 
Rheostat and battery. 

The author has found the small de- 
tached rheostat and four dry cells united 
as a unit the simplest way of obtaining 
the current to run the lamp of the bron- 
choscope. The batteries are easily obtained 
and readily connected with the rheostat. 
Batteries that come in rases often have 
to be sent to special dealers for refilling, 
so that there is delay in getting them. 

In carrying a battery of this kind it is 
necessary to see that it does not become 
short-circuited in the instrument bag and 
its power exhausted. An amperemeter 
is used to test the battery before it is 
used. The physician always knows whether 
or not there is sufficient current. 



ondary tube which curries the lii'ht u second uuxiliury tube for the 
removal of secretions. A hund bull) may be used attached to the suc- 
tion tube or an apparatus such us in employed for removing fluid from 
the chest, oi' best of all an aspirator run by electricity. Small amounts 
of secretion are removed by folded .u'uuze swabs. The Cooliduv cotton 
carrier is excellent for this purpose. (Fiir. 142.) In direct examina- 
tions of the larynx, long angular forceps, the blades of which lock 

Fig. 142. 
Coolidge's cotton carrier. 

Angular forceps for use with the adjustable specu- 
lum. The forceps are employed chiefly for sponging with 
cotton or gauze, but are extremely useful for extracting 
foreign bodies from the mouth of the esophagus. They 
can also be used for removing intubation tubes. The 
author uses this instrument for cocainizing the pharynx 
and larynx preliminary to direct examination of the 
larynx, or osophagoscopy or bronchoscopy. 

Moslier's alligator forceps. These forceps have locking han- 
dles so that the blades hold firmly whatever they grasp. They 
are made in two lengths. The shorter length is useful for 
direct work upon the larynx, and the longer (14 inches) is 
very convenient for carrying cotton for swabbing out the 
shorter esophagoscope. It is much easier to load this forceps 
with cotton than the usual cotton carrier. 

f Fig. 14.'!), are useful for removing the thick secretions in the pharynx. 
Long alligator forceps (Fig. 144), also with handles which lock', are a 
luxiirv when short tubes are used because it is very easy to replace the 
swabs. ( Figs. 14.") and 14(i.) 

Acquiring Skill. 15 r finings in his course to students drills t he men 
in the extraction of foreign bodies placed in a rubber maimikin of the 
respiratory tract. Practice of this kind is very valuable. l>y it the 
beginner |earn> to see, and learns the best wav of using the different 

LAHYNOOSCOI'Y, 15KONC ' 1 1 OS< 'Ol >Y , KSI !' 1 1 A< ,( )SC( >l"i , KTC. 


kinds of force) >s. If Killian's inainiikhi ( Fi,n'. 14< ) is not at hand much 
the same kind of practice can lie obtained if a foreign body is placed 
in a rubber tube. Foreign bodies may bo placed in tlie air passages of 
narcoti/cd doi^s. The cadaver used for bronchoscopy u'ives both prac- 
tice in removing foreign bodies and what is even more important, a 

Fig. 14; 

Jackson's tube forceps. ]?, actual size of tube and jaws of forceps ; [) 
and K, dilators for bronchoscopic strictures, which can be used in con- 
nection with Jackson's tube forceps handle. 

Fig. 146. 
t'oolidiio's forceps 

knowledge of the applied anatomy of the bronchial tree. The \)\->{ 
practice of all is afforded by an adult patient wearing a tracheotomy 
tube if the physician is fortunate enough to tind such a patient \vh<> is 
willinu 1 to make capital of his infirmity. 

If the physician who undertakes bronchoscopy or osophaii'oscopy 
is mechanical, and, in addition, lias or will ac<|iiire an elementary 
knowledge of applied electricity, many difficulties in his ne\v work will 
be easily overcome. Jackson is fond of saying, and saying it in his 
forcible way, that the extraction of foreign bodies is purely a matter of 
mechanical skill. Inborn skill, however, can be offset and sometimes 
surpassed by the skill which comes from willingness to learr and at- 


tention to detail. And the details of instruments and instrumentation 
in bronchoscopy are many. The physician who is not willing,' to deal 
with these petty details is happier out of this kind of work. The moral 
of this little preachment is learn your instruments, how they are 
made, how they should work, and how they are to be kept in order, 
"(iridlev vou may fire when ready." Von must be Gridley. 

Kig. 147. 
Killian's manikin for practicing bronchoscopy and esophagoscopy. 

Direct Laryngoscopy for Diseased Conditions. 

Malignant Disease. Malignant disease often calls for the direct 
examination of the larynx in order to obtain a clear view of the growth, 
and especially to secure the removal of a satisfactory specimen. l>y the 
use of a ii'ood punch forceps ( Fiu'. 14.")) this can be taken from the most 
favorable place, that is, from the mar.u'in of the uro\vt h so that the 
di>ea>ed and healthy tissue appear side by side. In small growths 
direct la rvnu'oscopv and direct instrumentation should not be depended 
upon for a cure the larynx should be opened from the outside; but in 




advancod and inoperable malignant disease palliative procedures 
the removal of obstructing masses are justifiable and are easil\ 
edited. (Figs. 148-150.) 

Non-Malignant Disease of the Larynx. Benign neoplasms of the 
larynx offer a wide field for the employment of direct laryngoscopy. 
Chief among these tumors are papillomata. In the experience of the 
writer the removal of papillomata under local anesthesia has not been 
successful. Even witb the use of a general anesthetic and with the 
patient lying on his back the procedure is not always a calm one or 

Fig. 148. 
Br iinings elongating forceps. 

Fig. 149. 

Tips for Briinings 

Expanding tip 
for Briinings forceps. 

fully satisfactory. Direct laryngoscopy, however, is by far the best 
method of conducting the removal of these luxuriant and recurring 
growths. The management of these cases advocated by Clark is the 
one followed by the author. The child is examined under ether by the 
direct method, and if there is an abundant growth tracheotomy is per- 
formed. Then the larynx is freed from papillomata by using appro- 
priate instruments through the Jackson speculum or the open specu- 
lum. Where the vestibule of the larynx is nearly choked with the 
growth Mosher's spiral wire forceps (Fig. 151) will quickly remove a 
large amount and allow the remaining masses to be dealt with leisurelv 



and with the same instrument. The spiral wire forceps comes up with 
papillomata l)etweou the various wires like a fish net filled with 
fish. It is important in removing papillomata to wound the 
normal mucous membrane as little as possible because each abrasion 
is almost sure to have the growth transplanted upon it. When the 
papilloma is placed well forward on the cord or in the anterior coin- 

Fig. 151. 
Mosher's spiral wire forceps for removing papilloma of the larynx. 

missure it is often very hard to expose even under general anesthesia. 
In such cases the triangular guillotine tube is useful for securing it. 
( Pig. 152.) 

It lias been the experience of Clark that after a child has worn the 
tracheotomy tube a year or more the papillomata shrink markedly 
and in time disappear. At appropriate intervals the child is etherized 

Fig. ir,L>. 

Mosher's triangular fenestrated tube. Used for the removal of peduncu- 
late, d growths from the vocal cords. It is especially useful when the growth 
springs from the anterior commissure. In use the growth falls through 
the window of the tube and is cut off by forcing home the plunger which 
has a cutting edge and acts as a guillotine. 

again and the remaining growths thinned out or eradicated. Some 
operators like Jackson' do not practice tracheotomy in cases of papil- 
lomata but follow the growths through the cords into the trachea even 
without the safeguard of this procedure. An emergency tracheotomy, 
however, may be called for at any moment. This operation can be 
taken out of the emergency class and performed at the leisure of the 
operator if the patient is given air by intubing the larynx and trachea 
with a small bronchoscope. The author has made for this purpose the 
small instrument shown in Km'. 1 .").'! which he carries with his traclie- 


otoiny set. It is small enough to pass into any larynx and long enough 
to go well down the trachea. It is fitted with a plunger so that very 
little exposure of the larynx is necessary for its quick introduction. 
There are breathing holes on the sides near the lower end. To have 
this simple instrument always at hand is a great comfort. It can he 
used with adults as well as with children. 

Harris lias lately reported the disappearance of a papilloma under 

Other benign neoplasms occur, and these, just as papillomata, arc- 
best dealt with by direct laryngoscopy. Among these are fibromata, 
lipomata, cysts and edematous polypi. Singers' nodes might be treated 
bv this method should removal be advisable. 

Pig. 153. 

Small bronchoscope for emergency intubation which the author always 
carries in his kit. By means of it intubation can be quickly performed. 
The instrument is small enough for a child's larynx. By using an instru- 
ment of this kind many emergency tracheotomies can be avoided. If a 
tracheotomy becomes necessary, the procedure is made simple and easy, be- 
cause the patient breathes through the bronchoscope and the opening of 
the trachea can be done calmly and without hurry. In many instances 
familiarity with such a preliminary intubation would be a great help to the 
general surgeon. 

Tuberculosis of the Larynx. When tuberculosis of the larynx 
calls for surgical treatment direct operating is most satisfactory. 

Inflammatory Diseases. In infections of the pharynx accompa- 
nied by edema or abscess the patient can be relieved by direct laryn- 
goscopy and direct treatment and many a tracheotomy averted. 

Malformations of the Larynx, Congenital and Acquired. Congen- 
ital webs of the larynx are easy to make out and to treat by the direct 
method. An appropriate speculum and a long laryngeal knife are the 
only instruments usually needed. 

After diphtheria, especially when it has been necessary to intube 
often, the cords may glue together for a certain part of their length. 
Generally the anterior third or two-thirds of the inner surfaces of the 
cords adhere. Such cases can be managed by prolonged intubation 
with large tubes of the Kodgers pattern. The cords must be first sep- 
arated. This is done either with an Otis nrethrotome or with the laryn- 
geal knife. Then the aperture of the glottis and the region below, for 
the subglottic portion of the larynx is narrowed also, is stretched with 
the dilating mechanism of the urethrotome or better with a dilator 
constructed on the pattern of Kollman. As the Kodgers tube is con- 
ical and tends to slip out of the larynx it is retained by a clasp inserted 


and worn through a permanent tracheotomy wound. For dilating the 
cavity of the larynx male nrethral sounds may be passed through the 
tracheotomy wound upward into the larynx. Naturally the operative 
procedures are carried out by direct laryngoscopy. The insertion of 
the tube is most conveniently performed by direct intubation. In this 
country Wilson was the first to bring direct intubation before the pro- 
fession. The author has devised a set of instruments for handling the 
tubes. The author also has used direct inspection a few times for the 
detection of laryngeal diphtheria, the removal of loose membrane and 
immediate intubation. Direct inspection generally makes the waiting 
for the microscopic report of a culture unnecessary. It is a great satis- 
faction to look down and to see the membrane and to take the case out 
of the emergency class then and there by intubation. 

Retrograde Laryngoscopy. 

Retrograde laryngoscopy is the name given to the examination of 
the larynx from below by means of a tracheoscope introduced through 
a tracheotomy wound. This method may give valuable information. 
The tracheoscope should be f) mm. in diameter and 14 cm. long for a 
child, and S mm. wide and 20 cm. in length for an adult. (Jackson.) 

Tracheobronchoscopy in Diseases of the Trachea and Bronchi. 

Diseases of the trachea and the bronchi which call for broncho- 
scopy are divided into stenotic and non-stenotic. 

Since the advent of bronchoscopy many cases considered as ner- 
vous cough have been found on examination by tracheobronchos- 
copy to be due to visible and curable lesions. Bronchoscopy was given 
its first great impetus when it was proved that it is possible to remove 
by its aid foreign bodies lodged in the trachea and bronchi. This field 
has been well exploited. In this country at least, but little work has 
been done with it in the various diseases \vhich can be disclosed and 
treated by it. in the near future there should be a great advance in 
this line. Kor the fullest knowledge that we have on this subject the 
reader is referred to the book of von Schroetter. lacerations near the 
bifurcation of the trachea which were causing chronic cough have been 
found repeatedly and cured by applications. 

('hronic catarrhal inflammation of the trachea which does not 
yield to the usual forms of treatment justifies direct examination and 

As a surgical feat which as yet has not been duplicated many times, 
hut which may at any moment become a common procedure, the finding 
of pus near the periphery of the lung may be mentioned. Abscess of 
the limn' due to a foreign body can be localized by the bronchoscope 

LAKYMJOSCOI'Y, BUONTIIOSCOI'Y, KS( )l'l I A< i< >S( '( >!"> , KTC. 201 

and il' the foreign body cannot be secured through the tube, the tube, 
or a probe passed through il can be used as a guide to the surgeon cut- 
ting from the outside. 

Stenosis of the Trachea. Neighboring organs not infrequently 
press upon the trachea and cause its partial occlusion. The thyroid 
gland is a frequent offender. As a rule it presses backward and since 
one lobe is generally more enlarged than the other the resulting nar- 
rowing of the trachea occurs in the anteroposterior direction and 
somewhat laterally. When the retrotracheal portion of the gland as 
well as the anterior part enlarges the trachea becomes a narrow oval 
slit, the "scabbard" trachea. 

It has been denied that enlargement of the t hymns could produce 
difficulty in breathing, the so-called thymic asthma. .Jackson reports 
a striking case in which the condition was present. When the case was 
seen it demanded an immediate tracheotomy. This did not relieve the 
dyspnea. The passage of the tracheoscope showed that the trachea be- 
low the incision was flattened almost to complete closure from before 
backward, but the insertion of a long tracheotomy tube finally relieved 
this dyspnea and then the gland was removed, the case resulting in a 
cure. Tubercular glands, especially those at the bifurcation of the tra- 
chea, malignant disease of the esophagus or of the mediastinum, and 
aneurism often narrow the lumen of the trachea or of the primary 
bronchi. The diagnosis of these conditions may be confirmed or estab- 
lished by bronchoscopy. 

Jackson gives the following table of diseases of the walls of the 
trachea and the bronchi which cause stenosis: 
Malignant neoplasms. 
Benign neoplasms. 
.'). Specific inflammations. 

(a) Syphilis. 

(b) Tuberculosis. 

(c) Glanders. 

(d) Typhoid fever. 

(e) Diphtheria. 

4. Inflammations. 

(a) "Catarrhal." 

(b) Irritative. 

(c) Traumatic. 

(d) Operative. 

(e) Post-operative. 

5. Post inflammatory conditions as cicatrices, and adhesions. 
(). Yasomotor disturbances, angioneurotic edema. 


Benign neoplasms are not frequent but when they are present they 
are well adapted for removal through the bronchoscope. In asthma 
sensitive areas have been found in the trachea and bronchi and appli- 
cations made to them gave relief. Syphilis is the most frequent cause 
of stenosis. Xext come the narrowings caused by the healed ulcers of 
diphtheria or of typhoid fever. Stricture of the bronchi from similar 
causes is occasionally seen. 

Treatment. The treatment of stricture of the larynx by prolonged 
intubation has been described. Strictures of the cervical portion of the 
trachea associated with loss of the cartilaginous rings are probably best 
treated by plastic surgery which aims at holding the trachea open by 
the transplantation of some rigid material. The success of the trans- 
plantation of cartilage for the correction of nasal deformity may open 
ii]) a method of dealing witli these cases of tracheal stenosis combined 
with loss of cartilage. 

The treatment of low seated strictures of the trachea and of stric- 
tures of the bronchi is carried on along the same general lines as those 
employed for the treatment of strictures higher up, that is, the stric- 
ture is first dilated and then held open by intubation. Such strictures 
call for treatment because when they are small they interfere with 
breathing and expose the lungs to infection from the retention of in- 
fected secretions. Von Schroetter who has carried on extensive investi- 
gations in these cases first dilates the stricture with a sponge tent and 
then inserts a metallic tube so made that it is readily retained. It 
would seem that a mechanical dilator would accomplish the dilatation 
more speedily than the tent. 


Foreign Bodies in the Larynx. 

Foreign bodies lodged in the larynx in most cases are either 
couched up after the initial spasm of dyspnea caused by them or drop 
into the trachea or the bronchi. Occasionally the foreign body is 
loosened by the coughing and strangling and enters the esophagus and 
is swallowed. Sometimes the foreign body becomes impacted in the 
larynx and if it is large enough it speedily suffocates the patient. Xow 
and then the foreign body may be small enough like a piece of egg shell 
to remain in the larynx or it may be of the right shape like a button or 
a coin to lodire in the ventricles. Fxamples of cases of both kinds are 
found in the literature. When such cases present themselves direct 
examination combined with the use of appropriate instruments is flu- 
best method of removing 1 the offending foreign bodv. 

hAHYXliOSCOI'Y, HKOXrilOSCOI'Y, KS< )l'l I A< i( )S( '( )l'\ , KTC. 

The Removal of Foreign Bodies From the Trachea and the Bronchi. 

I ntil the advent of tracheoscopy and bronchoscopy the removal 
of a foreign body from the trachea \\"as accomplished hy performing 
tracheotomy. \\ T hen a loose body like a seed was playing up and down 
the trachea seeking to escape it was often blown violently out of the 
wound by the first spasmodic expiration caused by entering the tra- 
chea. Such an outcome was dramatic and satisfactory. If, however, 
the foreign body was not free in the trachea but was impacted or was 
of a different nature from a seed, the old practice was to introduce for- 
ceps blindly and to fish for it. Many successful extractions have been 
performed in this manner. Many times, however, and the records arc 
woefully incomplete as to how many times, the attempt at blind extrac- 
tion has failed and lias caused the death of the patient. 

It was a natural and great advance in the treatment of these cases 
when, instead of the blind groping after foreign bodies in the trachea, 
the physician began to work by sight. Coolidge was the first to do this 
in America, in 1S99. By using a female uretliroscope lie located and re- 
moved a piece of a tracheotomy tube which had become detached and 
had fallen into the trachea. Killian was the first to demonstrate the 
feasibility of removing a foreign body from the bronchus by means of 
a tube passed between the vocal cords. Killian devised and first 
practiced upper bronchoscopy, later he developed lower bronchoscopy. 
Einhorn in 1902 devised an esophagoscope having an auxiliary tube in 
the wall of the main tube. In the secondary tube a light carrier was 
inserted through which two wires ran to a small electric lamp on the 
end of the carrier. Two years later Jackson used the mechanism of 
Einhorn on the Killian tubes and added a second auxiliary tube for 
drainage purposes. Later the same investigator lengthened the bron- 
choscope and used it for exploring the stomach. He demonstrated the 
feasibility of introducing a straight tube into the stomach and tauuht 
the medical profession through his brilliant cases the value of the pro- 

The Choice of the Upper or the Lower Route. Experience has 
proved that lower bronchoscopy is safer and easier than upper bron- 
choscopy. It is by all odds the safer procedure for the beginner. In 
infants and children under three years of age it is the 
operation of choice. Even with older children up to the age of 
seven or eight, if there is a loose foreign body which by its violent 
excursions up and down the trachea has caused trauma to the lower 
part of the larynx, or if the form of the foreign body is such that it is 
impacted, for example, a bean or a pin, lower bronchoscopy is surer 


and safer. If the operator is skilled, upper bronclioscopy may be tried 
with children over three years old. Instances of success by this method 
are multiplying. Unless the procedure is soon successful, however, it 
should be abandoned for the lower route. It is not so much the in- 
creased length of tubes required for upper bronclioscopy, which makes 
it less advisable in many cases than lower bronclioscopy because the 
self-lighted tube carries its light at the end and increase of length is 
not a serious factor as it is the reaction of the larynx to the manipu- 
lations and the danger of cardiac arrest. (Crile.) This latter danger 
can be obviated or minimized by the use of atropin. Killian has col- 
lected nineteen cases in which after upper bronclioscopy an emergency 
tracheotomy was required. The gist of the matter seems to be that in 
the performance of upper bronclioscopy, a tracheotomy may at any 
moment be called for. Even after the successful outcome of the pro- 
cedure the same holds true. AVith infants and young children 
lower bronchoscopy is preferable. In a child of any age it is not good 
practice to persist in upper bronchoscopy unless it is soon successful. 

Indications. Tracheobronchoscopy is called for in any case in 
which the presence of a foreign body is suspected. The dangers of the 
procedure are so slight that even when the presence of the foreign 
body is not sure an exploratory bronchoscopy is indicated. This is 
especially true in the case of children. The only contraindication to 
bronchoscopy is the presence of serious organic or systemic disease. 

Dangers. The chief danger in bronchoscopy occurs in the use of 
the upper route. This danger, as has just been pointed out, arises 
from edema of the larynx or from reflex cardiac arrest. Tngals has 
reported two cases of death, one three, and one six hours after the suc- 
cessful removal of a foreign body. These unexplained cases may have 
been due wholly or in part to the second of the dangers just mentioned. 
Apart from these two dangers the most common one is septic pneu- 
monia, from the trauma occurring during the manipulations of extrac- 
tion. Another danger and one which can be easily avoided is that of 
delaying the performance of tracheotomy when the patient begins to 
show signs which call for it. 

The Danger from Leaving the Foreign Body Alone. The dangers 
to which the patient is exposed l>y leaving a foreign body in place are 
vastly u'n-ater than the danger to which he is exposed by the perform- 
ance of bronclioscopy at the hands of a man practiced in the art. The 
.UTcat danger incurred by a patient with a foreign body in the lungs is 
pneumonia, or abscess and gangrene of the lung. In most instances 
either complication is fatal. There are many cases reported in the 
literature of foreign bodies which have remained in the Innirs a lomr 


time whose presence was known or unknown, and which have been 
finally coughed out. But, judging even from the incomplete literature 
of the cases of the opposite nature, it is found that such fortunate 
terminations are rare. Should the patient escape septic pneumonia 
and the foreign body remain in the lungs, he is exposed to tubercular 
infection later. Killian is authority for the statement that such cases 
not infrequently terminate in this manner. It should be said in fair- 
ness, however, that sometimes the lungs will tolerate a foreign body 
1'or a long time. The author has in mind a case in which Coolidge re- 
moved a wire nail which had been in the right lung of the son of a phy- 
sician for seven years. The symptoms were only an occasional cough. 
Another case occurs to the writer. This patient was a nurse. For 
five years now and without any discomfort she has had a metal clasp 
pin in her lung. The attempt to remove this pin was made on two or 
more occasions, once by Killian and once by Jackson. 

The degree of danger which accompanies the remove! of a foreign 
body naturally varies with its nature, shape and size, its location and 
the condition of the patient. Rounded objects are liable to (it a bron- 
chus tightly and to shut off air to the portion of lung supplied by it. 
Therefore they are most liable to cause gangrene and abscess. A 
pointed object like a pin or a nail allows air to pass but it produces 
trauma by its excursions in the respiratory blast or produces erosion 
by lying long in one position. Either condition leads to infection. 

Inorganic substances macerate and decay. When this happens 
they may be coughed out unless they have produced a fatal pneumonia 
before this takes place. Seeds if uncooked do not macerate but swell 
on absorbing moisture and become firmly fixed in position. Peanuts, 
in this country at least, have proved to be very fatal foreign bodies 
to lodge in the lungs. The attempt at removal often crushes them and 
scatters the fragments dee]) in the tertiary bronchi. 

Roe collected 1,417 cases of foreign body in the air passages. In 
470 extraction was not attempted, and over 400 died, that is, the mortal- 
ity was '27 per cent. This is to be compared with !'4 cases of upper and 
lower bronchoscopy reported by Jackson in which the mortality was 
.'!.!' per cent. Tf a foreign body is to be coughed out this generally 
occurs in the first twenty-four hours. Jackson sums up the matter 
fairly when he says "we do full justice to our patients when we tell 
them that while a foreign body may be coughed up, the chances of this 
are remote and it is very dangerous to wait; and further, the difficulty 
of removal increases with each hour that the body is allowed to re- 

Results. Out of 94 cases of bronchoscopy the foreign body was 
removed in So per cent. (Jackson.) 


Symptoms. Cough is the most constant symptom of a foreign 
body in the air passages. As the foreign body passes the larynx the 
cough is paroxysmal. Later at every attempt of the air passages to 
expel the intruder the cough is again paroxysmal. Some minutes or 
hours may elapse between the seizures. After a time the cough be- 
comes more constant. 

Dyspnea is a very frequent symptom. It is usually inspiratory 
but it may occur on expiration. The dyspnea is worse during the fits 
of coughing and at such times the patient may become unconscious. It 
should be borne in mind that a foreign body in the esophagus may, by 
pushing forward the soft trachea of a child, produce dyspnea. 

The temperature is usually elevated. This might be taken as evi- 
dence in the doubtful cases against the presence of a foreign body. In 
late cases in which pneumonia has set in naturally the temperature is 

Chills occur when an abscess has been produced about the foreign 

Hemoptysis is not present as a rule. It is associated with the aspi- 
ration of sharp substances. 

Pain is often present but it is generally poorly localized. 

Diagnosis. The fluoroscope is not reliable in locating a 
foreign body unless it is very dense. An X-ray plate should be taken 
in all cases and interpreted by an expert. The physician who is not ac- 
customed to reading plates taken of the lungs is very liable to mistake 
spots of calcification along the main branches of the bronchi for for- 
eign bodies. Unless there is marked dyspnea it should be the routine 
to obtain a radiograph. 

Metallic substances with the exception of aluminum show well in 
the plate. So do pebbles and objects of glass. Bones unless they come 
in front of another bone like a vertebra also show well. Fish bones 
come out poorly in the plate. Vegetable substances with the exception 
of some kinds of wood, do not cast much of a shadow. The same is true 
of peanuts and chestnuts without their shells. It is difficult to obtain 
a satisfactory X-ray of a young child unless it is etherized. Only in 
the case of a metallic foreign body when the plate shows nothing is it 
safe to pei-mit. the patient to go without an examination. Intermittent 
contrh and dyspnea not to be explained in any other way and not asso- 
ciated willi fever is almost diagnostic of the presence of a foreign body. 

The Physical Signs. The physical signs arc of value in deterinin 
ing 1 he presence of a foreign body in 1 lie ai r passages i f 1 hey a re elicit ed 
and interpreted by a physician who possesses a good and sufficient 
hnic in auscultation and percussion. The phvsical signs are relied 


LARYXOOSCOl'Y, I5IJO X( ' 1 1 OSCOl' Y, KS( )]'! I A< iOS( '( >\'\ , K'I'C. _( 1 1 

upon most in those cases in which a positive X-ray cannot lie secured. 
The following paragraphs which hear upon the physical siu'iis and their 
moaning are ahstractcd from Jackson for whom they were written hy 

In the examination a distinction must he made hetwecn the signs 
due to the foreign hody and those which are due to inflammatory con- 
ditions which soon supervene. 

A foreign hody which is obstructing a bronchus may lead to atelcc- 
tasis of the lung. If so, the usual signs are present. This occurrence, 
however, is not as frequent as is generally supposed. The most com- 
mon finding is a marked local diminution of the respiratory murmur 
with preservation or accentuation of the normal resonance. This may 
be called the typical condition. When a foreign body partially ob- 
structs a bronchus it may give rise to a peculiar dry rale which is easily 
differentiated from that given by inflammatory or tubercular thicken- 
ings of the mucous membrane. These dry rales are limited to a defi- 
nite area and occur for hours at a time. 

Bronchitis is the commonest inflammatory condition following the 
inhalation of a foreign body. The secretions from this are soon dif- 
fused through the lungs and give the signs of a diffuse bronchitis. 
Diffuse bronchitis coming on suddenly and especially if it is accompa- 
nied by bloody expectoration is a most unusual condition and should 
raise the suspicion of the presence of a foreign body. The expectora- 
tion in foreign body cases is usually bloody and tends to become abun- 
dant, purulent and fetid. In such instances only the history and a care- 
ful examination of the sputum will rule out tuberculosis. If a localized 
abscess is present or lobar pneumonia, the signs of these conditions are 
the same as when they are not associated with a foreign body. In one 
case plural effusion resulted from the presence of a foreign body and 
the patient was twice tapped. (Ingals.) 

Tuberculosis "without bacilli in the sputum" particularly if the 
disease is located near the base of the right lung, unilateral or unilob- 
ular bronchitis and especially if liemorrhagic or fetid, atelectasis, ab- 
scess or gangrene, not otherwise explainable, should raise the sus- 
picion of the presence of a foreign body in the air passages. 

The Location of foreign bodies varies with the size and shape 
of the objects. Bodies of some size usually lodge at the bifurcation of 
the trachea or enter the right main bronchus. Pins often lodge at the 
bifurcation, one half the pin being in the trachea and the other half 
lying in a primary bronchus. (Fig. Io4. ) Pins and nails, however, not 
infrequently fall into the smaller bronchi. In the experience of the 
author pins and nails frequently lodge in the inner branch of the 



bronchus to the inferior lobe of the rig'lit luiiii 1 . Safety ]ins if they are 
open do not ,u'et beyond the trachea. 

The Technic of Removing Foreign Bodies. The first tiling to 
accomplish is to brinii 1 the foreign body into view. The manipulations 
of the bronchoscope which are necessary to accomplish this have been 
described. After locating the foreign body and obtaining a ii'ood view 
the next important step is to use the proper instrument for seizing it. 
Many a case has resulted in disappointment owin.u' to the fact that the 
physician went ahead without suitable instruments. I'nless the case is 

FiR. 154. 
Pin with glass head in left main bronchus. 

desperate time should be taken to procure a forceps with a tip fitted to 
irrasp the particular object dealt with. l>eans and seeds call for a 
special tip. Pins may be extracted with the ordinary forceps, but in 
case the pili is impacted the pin cutter of Casselberry ( Kit; 1 . l.V>) is 
essential. The usual bronchoscope has lateral openings in the lower 
third or half of its length so that air may not be shut off from the 
opposite limu' diinnir the examination. \Vhcn dealing with a pin these 
opeiinm'> should not come to the end of the tube, otherwise the pin 
may be canu'lit in them. Open safety pins are best extracted with a 
clox-r I I) ninnies, Mosher, or llubbard). 


Soft pliable substances like rubber call for a corkscrew-like instru- 
ment as in the case reported by Richardson. 

The greatest difficulty is found in the extraction of small bodies 
deeply placed in the bronchi. These are often macerated or imbedded 
in swollen mucosa. In working in the smaller bronchi and near the 
periphery of the lung the physician may find it necessary on account 
of poor light or the diminutive field to pass the forceps beyond the tube 
and to close them blindly. Before this maneuver is executed a mark is 
placed on the shaft of the forceps to show the length of the tube. 

Hooks of various shapes are useful to pass beyond a foreign body 
in order to prevent the forceps from pushing it down or to turn the for- 
eign body so that the blades of the forceps can grasp it. The hook is 
passed flat until beyond the object and then turned and brought up. 

- 2 

Fig. 155. 
Casselberry's pin cutter 

Care is required not to catch the end of a fully curved hook in the open- 
ing of a bronchus. 

In the case of hollow foreign bodies expanding forceps are of 
service. If the foreign body is lodged in a small cavity of the lung it 
may be necessary to dilate the opening into the cavity before the for- 
eign body will come into view and permit extraction. .Jackson has de- 
vised a dilator for this purpose. 

Usually secretion is seen coming out of the bronchus in which the 
foreign body is lodged. Inflammatory swelling may indicate that the 
bronchus is invaded. A probe may be required to locate the foreign 
body. A suction apparatus is useful for removing fragments of seeds. 

The After-Effects of the Removal of Foreign Bodies. I'M less 
edema of the larynx follows the manipulations required for the re- 
moval of a foreign body the after-effects of bronehoscopy are slight. 
There may be some hoarseness for few days or a slight localized bron- 
chitis. This is trivial and soon disappears. 



History. Soon after the invention of the laryngoscope attempts 
were made to see the opening of the esophagus by pulling the cricoid 
cartilage forward with appropriate specula and then obtaining a view 
by means of a mirror held above in the pharynx. These experiments 
led to no practical results. In 18(58 Bevan by means of a thin speculum, 
and two years later Waldenburg by means of a tubular speculum 
14 cm. long succeeded in seeing the mouth of the esophagus. The latter 
also made an ocular diagnosis of a diverticulum. 

Stork was the first man to pass a solid tube into the esophagus and 
to carry out direct esophagoscopy. Kussmaul (18(58) explored the 
esophagus with a rigid tube and published his observations on the nor- 
mal and the diseased esophagus, while his pupil Miiller established the 
important clinical fact that the normal esophagus should admit a tube 
I'] nun. in diameter. The observations of Kussmaul, however, made 
little headway; later they were revived and popularized by Killian. 

Stork and Kussmaul, then, were the two men who gave esophago- 
scopy its start. V. ^Mikulicz, a follower of Stork, was the next worker 
whose results proved to be fundamental. By the year 1881 he had car- 
ried out most important anatomic and physiologic researches and had 
noted common pathologic changes. For the next ten years no special 
advances in esophagoscopy were made. Since that time this method of 
investigation has been pursued with vigor. The advances have been 
along the line of improved teclmic and new instruments. 

Anatomy. The esophagus is a muscular tube which is the con- 
tinuation of the pharynx. It starts from the back of the cricoid carti- 
lage opposite the sixth cervical vertebra. At the mouth of the esopha- 
gus the lower border of the inferior constrictor muscle projects like ;', 
mound into its lumen and acts as a sphincter in a way similar to th; 1 
action of the superior constrictor (Passavant's fold) in the upper part 
of the pharynx. 

Structure. The esophagus has an outer muscular coat of two 
layers and an inner glandular coat covered with pavement epithelium. 
A connective tissue layer joins the two chief layers. The thickness of 
the esophagus is .'! to 4 mm. 'Die outer layer of the muscular part con- 
sists of longitudinal fibers and the inner layer of circular ones. (Fig. 
1 of).) The anterior longitudinal fibers arc attached to the back of the 
cricoid cartilage. The inner layer of circular muscular fibers is a con- 
tinuation downward of the fibers of the inferior constrictor muscle. 
Tin- upper end of the esophagus therefore is the lower end of the 
pharynx, so that voluntary muscular fibers predominate. From this 

LAUYNOOSCOI'Y, UUONC 1 1 OSCOI'Y , KS( )|' 1 1 A< ',( )S( '( >!"> , KTC. 


it happens that a foreign body arrested at the entrance of the esopha- 
gus is often thrown back into the pharynx and into the mouth. 

Lymphatics. The lymphatics of the esophagus enter both the 
mediastinal and the cervical glands so that in suspected cancer of th" 
esophagus the glands at the root of the neck should be examined. 

Position. The esophagus has the vertebral column behind it and 
the trachea in front, and lies in the posterior mediastinum. At the 
fourth thoracic vertebra the arch 
of the aorta makes a transverse con- 
striction in it and a vertebra lower 
down, the left main bronchus, at the 
fifth thoracic, makes an oblique line 
across its front surface. Below this 
point the heart lies on it like a 
weight. In the lower part, the right 
and left piieuniogastric nerves lie on 
the sides of the esophagus, and back 
of the arch of the aorta the thoracic 
duct crosses from right to left lie- 
bind it, on the front of the vertebral 
column. (Fig. 157.) 

Direction. -- The esophagus is 
placed for the most part a little to 
the left of the middle line. Midway 
in its course, at the fourth thoracic 
vertebra, it swings to the central 
line, back of the arch of the aorta, 
but at once goes to the left again 
and enters the stomach to the left 
and in front, of the aorta, at the 
eleventh thoracic vertebra. This 
deviation from the center does not 


Fig. 156. 

Section of the human esophagus (.Mod- 
erately magnified). The section is trans- 
verse, and from near the middle of the 
gullet. (Quain's Anatomy From a draw- 
ing by V. Horsley.) 

a. fibrous covering; b. divided fibres of 
the longitudinal muscular coat; c. trans- 

vers ? m V seular " bres: '/' Sllbnuieous r 
areolar layer; c. musculans mucosse: /. 

interfere with the passing of 1)011- mucous membrane, with vessels and part 

of a lymphoid nodule; </. laminated epi- 
gies or tubes except at the lower thelial lining; J,. mucous gland; i. gland 

part where the esophagus pierces dm ' t: m - striated muscular til)r '' s ( ' nr 


the diaphragm. (Figs. 1.5S and 1 .">}).) 

The Diameter. Only in the region of the month of the esophagi^ 
is the diameter relatively fixed. The esophagus is constricted at four 
points. Of these the upper and the lower ones are the most important. 
The upper one is caused by the projection backward of the cricoid carti- 
lage, the lower by the encircling fibres of the diaphragm. The up- 



per one hinders the introduction of the examining tube, the 
lower one obstructs the passage of the esophagoseope into the 
stomach. The first constriction is a transverse slit, slightly less than 
an inch wide; the second constriction is about of the same width. The 
loiiii 1 axis of this constriction is from right to left from behind forward. 

Right common carotid artery 
A carotis communis dcMra 
Internal jugular vein 
V. juRulnris internrx 
Pneumogastric nerve 
N. vagus 

Inferior thyroid artery 
A. thyreoidea inferior 

Laryngeal part of the pharynx 
I'ars larynsea 

Thyroid body 

Clan !ui:i tlivre'jidp.1 

tlic rdalions of llic csoplia^'iis from hdiiinl. (From Toldt.i 

The liinien of Ihe esojihagus al Ihis point is subject to wide variatii 
\\'liicli depend upon the relaxation or the contraction of the diaphragm. 
In addition to these two important constrictions there are two others. 
Often they are not seen unless closely watched for, and they disappear 


completely if large tubes arc used. The first of these minor constric- 
tions corresponds to the arch of the aorta, and is found at the level of 
the junction of the first and second pieces of the sternum and in front 

Fig. 158. 

View of the stomach in situ after removal of the liver and the intestine 
(except the duodenum and commencement of jejunum). (Quain, after 

A, diaphragm; B, B', thoracico-abdominal parietes: C, right kidney with 
<. its ureter; D. right suprarenal capsule: E, left kidney with c. its ureter; 
F, spleen; G, G', aponeuroses of the transverse abdominal muscles; H. right 
quadratus lumborum muscle; 11', left ditto; I, right psoas magnus and 
parvus muscles; I', left ditto; K, esophagus: L, stomach: M. duodenum: 
N, jejunum; the position of the duodeno-jejunal junction behind the stomach 
is indicated by dotted lines. 1. termination of oesophagus: 2. great curv- 
ature of stomach; 3, small curvature: 4. fundus: 5. ant rum pylori: t5, pyloric 
end: 7, right vagus nerve: 8. left ditto: !>. thoracic aorta: !'. abdominal 
aorta; 10, inferior phrenic artery; 11, coeliac axis; 12, hepatic artery: 1:',, 
right gastro-epiploic: 14, coronary artery: 15. splenic artery; 16, 1*5'. superior 
mesenteric artery and vein; 17. inferior mesenteric artery: IS. spermatic 
arteries; 1!, gall bladder: 20, cystic duct: 21. hepatic duct: 22, inferior 
vena cava: 23, portal vein; 24. sympathetic cord. 

of the fourth thoracic vertebra. The last constriction, which is the 
third from above downward, is made bv the crossing' of the left bron- 



elms in front of the esophagus. It occurs at the level of the fifth tho- 
racic vertebra. 

The Length of the Esophagus. In men the distance from the in- 
cisor teetli to the beginning of the esophagus is 15 cm. and in women 
14 cm. The distance from the incisor teeth to the bifurcation of the 
aorta is 26 cm. in men, and 1*4 cm. in women. In men the length of the 
esophagus from the incisor teeth varies between .'>(> cm. and f)9 cm., the 
normal average distance being 40 cm. In women the figures are a little 
smaller, '.I- to 41, the average being .'58 cm. \Vhen flexible bougies are 
used for measuring 1 to .'> cm. should be added to these measurements. 

Distensibility. All the constrictions of the esophagus are dis- 
tensible. The upper constriction is less dilatable than the others, so 
that this is the one which gives the greatest trouble in esophagoseopy. 

The normal esophageal wall according to Jackson will stretch 2 
cm. without rupture. At times foreign bodies stretch it more than this. 


l T n<lcr surface of the diaphragm. E, Hiatus esophagus. Xote the direc- 
tion of its axis. (After Jackson.) 

In infants a tube of 7 mm. should pass readily and in the adult a 
tube which has a diameter of 14 mm. In infants a flexible bougie S nun. 
should pass and in adults one that measures 14 mm. 

With light stretching the transverse diameter of the esophagus is 
L'.'! mm. at the erieoid cartilage and 17 mm. anteroposteriorly. The 
diameter of the esophagus as it goes through the diaphragm is 24 to 
2-") mm. Two stomach tubes can be passed side by side. Briinings states 
that the esophagus at its mouth can be dilated to .">(> mm. without dan 

At the lower end of the esophagus V. Mikulic/. in his operation for 
cardiospasm stretched the lumen to 7 cm. so that the hiatus had a cir- 
cumference of 1 (i cm. 


. ) wide. 

inch it 

< direc- 

The distensibility of the esophagus is much greater in the livini 1 
than in the dead. On the dead, when the esophagus is stretched trans- 
versely only, it dilates to 40 mm., or one and one-half inches. The or- 
dinary full-sized tooth plate is two and one-quarter inches (f>7 
broad. A fifty-cent piece is one and one-eighth inches (.'10 
Since the transverse diameter of the esophagus is about 
would seem as if this coin should pass readily in an a< 
tion in which the esophagus will stretch 
the most is from side to side. For this 
reason oval tubes take up the slack in 
the esophagus along anatomic lines bet- 
ter than round ones. 

The Subphrenic Portion of the Esoph- 
agus. Beginning at the level of the 
bifurcation of the trachea the esophagus 
comes to the front and passes over the 
descending aorta and enters the abdo- 
men through the hiatus or the opening 
in the diaphragm. This subphrenic part 
of the esophagus varies much in shape 
according as the stomach is empty or 
distended. In persons of spare build it 
has a lateral range of movement amount- 
ing to 10 or If) cm. (Fig. 100.) 

The Movements of the Esophagus. 
The esophagus is never twice alike even 
in the same individual. At the level of 
the fourth thoracic vertebra (-4 cm. 
from the teeth) the throbbing of the 
arch of the aorta can be seen if watched 
for and a little lower at the level of the 
seventh and eighth thoracic vertebra CIO Schema showing the range of 

motion of the gastroscope at the 

cm. from the incisor teeth). The back- mouth of the esophagus and at the 

T T s , ., hiatus of the diaphragm. (After 

ward mounding or the heart and its j a( .kson. 
beating are visible. 

If a relatively small esophagoscope is used for the examination the 
esophagus opens with inspiration and partially closes with expiration. 
These changes occur chiefly in the thoracic portion, and are due to the 
negative intrathoracic pressure. If a large tube is used the esophagus 
stands wide open after the cricoid cartilage has been passed and the 
respiratory changes nearly disappear. 

During swallowing peristaltic movements pass along the esopha- 



gus from above downwards, while in vomiting the movements arc re- 

There is good evidence to support the assertion that there is a 
sphincter at the cardiac end of the esophagus, due to the presence of 
two layers of muscular fibers as described by Hyrtl. According to 
Jackson, the presence of this sphincter is not the chief agency through 
which the regurgitation of food is prevented. This observer maintains 
that the kinking of the esophagus below the opening of the diaphragm 
and the increase of this twist by distension of the stomach has much 
more to do with keeping the food in the stomach than the presence of 
the cardiac sphincter. From a few anatomic findings which have come 
to the notice of the author lie is inclined to think that Jackson's posi- 
tion will be sustained. 

Measurements of the Esophagus. The following tables are com- 
piled from Stark. They are of use for reference. 

DlAMKTKUS OF I 1 1 K Ksoi'l ! ACiTS AT I 1 1 K Foil! Co X STKK TIO .\ S. 

Constriction. Diameter. 

Cricoid Transverse 2?> mm. (1 in.) 

Anteroposterior 17 mm. ( :; , in.) 
Aortic Transverse 24 mm. (1 in.) 

Anteroposterior l!t mm. ( :! t in.) 
Left bronchus Transverse 2:5 mm. ( 1 in. ) 

Anteroposterior IT mm. ( :: i in.) 
Diaphragm Transverse 2'.] mm. (1 in. +) ., 

Anteroposterior '!'', mm. ( 1 in. 

Sixth cervical. 
Fourth thoracic. 
Fifth thoracic. 
Tenth thoracic. 


Teeth to Cricoid. 



To Cardia. 


1 ye 

'1 ye 

fi ye 

lo ye 

If, ye 


7 cm. (2 :: , in. ) 12 cm. ( 4 : 

ir. 10 cm. (4 in. ) 14 cm. ( f> t 

irs, lo cm. (4 in. ) 1~> cm. ( *> 

irs. lo cm. (4 in. ) 17 cm. ( (>' 

irs, 10 cm. (4 in. ) 18 cm. ( 7 

irs, 14 cm. (">'._, in.) 2:! cm. ( ! 

in cm. ( fi in. i . . . 2t; 

in. ) 18 cm. ( >", in. ) 

in. i 22 cm. ( 8", in i 

in. i 2:! cm. (ft in. ) 

in. ) 2(i cm. (ID 1 ', in. i 

in i 28 cm. (11 in. ) 

in. ) )!:! cm. ( II! in. ) 

( lo ' i in. ) 40 cm. ( l.r : , in. i 2 

For memorizing the length of the esophagus at different ages the 
following approximate figures are given: IVirth, 7 inches; ."> years, 10 
incho; 1 .") years, 1.'! inches; '!') years or adult, l(i inches Add three 
inches for every five years. (Stark.) 

I M \ \i I.I i-.i: 01 Ti i:i-.s i-oi; DiHi.u.vr AI.KS. 

To S yi ars '.i mm. 

l-'rom ! to 1 ."i years 11 mm. 

From 17 years 12 to 11 mm. 

Adults . 11 m m. ( average. ) 

LAKYNOOSCOl'Y, BK< ).\( ' 1 1 < >S< '< >]'Y , KSOIMTAOOSCOI'V, KTC. _]/ 

The esophagus begins (5 inches from the ineisor leelli, hack of the 
cricoid carl ilage at the sixth cervical vertebra. It is ID inches long, and 
goes through the diaphragm at the tenth thoracic vertebra, Hi inches 
from the teeth. It is crossed by the arch of the aorta back of the middle 
of the first piece of the sternum, 10 inches from the teeth. The measure- 
ments to be remembered in connection with it are, then, (i and 10. 

Contraindications to Esophagoscopy.- -The only contraindications 
to the performance of esophagoscopy are acute inflammation as after 
the swallowing of corrosive fluids, and aneurism of the aorta. Th 
chief danger in the passage of the esophagoscope is rupture of the eso- 
phagus. This almost always results in infection of the posterior medi- 
astinum and death. Such an accident should be easily avoided by tin- 
selection of a tube of the proper si/e and by adhering always to the fun- 
damental axiom of all esophageal examinations, namely, the examin- 
ing tube must never be advanced unless the eye of the physician sees 
the open esophagus ahead through the tube. It is well, also, to remem- 
ber that in old people the esophageal wall may be thin enough to rup- 
ture of itself so that in the elderly smaller tubes and greater care in 
using them are necessary. It has developed of late years that there is 
considerable shock from manipulations carried out in the esophagus. 
Indeed, working in the esophagus causes more shock than working in 
the trachea and bronchi. Relatively children do not bear esophageal 
examinations as well as adults. When a patient is poorly nourished, 
and especially if he is on the point of starvation from the presence of 
a stricture, it is better practice to open the stomach and feed the patient 
through a gastric fistula until his resistance lias been restored before 
attempting any prolonged esophageal examination. 

Anesthesia. The esophagus may be examined under local or gen- 
eral anesthesia. In Kuropean clinics local anesthesia is employed for 
adults almost exclusively. Children are examined under ether or 
chloroform. In this country many examinations are carried out under 
U'eneral anesthesia. The author is very much prejudiced in favor of ;, 
general anesthetic. If the manipulations under cocain anesthesia are 
successful the operator gains his point, but if the examination is nega- 
tive no conclusions can be drawn from it and the case remains in doubt. 
On the other hand, if the examination lias been conducted under ether 
and the result is negative both the patient and the physician feel confi- 
dence in the finding. 1'nder ether larger tubes can be used which 
means a better view and a larger field for the manipulation-. In addi- 
tion under such conditions the treatment called for by the case, for 
example the dilatation of a stricture, can be made more efficient. 

Instruments. In esophagoscopy all bridges must be crossed before 


the operator gets to them. In other words the physician must be will- 
ing to supply himself at the beginning of his work in this line with a 
full set of general and special instruments. As everything depends 
upon light it is good economy to have two sets of tubes, one set being 
the self-lighted tubes of Einliorn- Jackson, and the other the extension 
tube of Briinings which is lighted by having the light projected through 
it from the electroscope. (Fig. 161.) 

Fig. 161. 
Jackson's esophagoscope. The drainage tube runs the whole length of the instrument. 

The list recommended is as follows: 

1. One 7 mm. Jackson tube. 

2. One 14 mm. Jackson tube. 

3. One adult tubular speculum (Jackson). 

4. One tubular speculum, children's size (Jackson): or one adjustable speculum 


5. One Hrunings' or Kahler's electroscope. 

6. One Briinings' extension esophagoscope, about 7 mm. 

7. One Briinings' extension esophagoscope, 14 mm. 

8. Xine Coolidge's cotton carriers. Three 25, throe 35, and three 50 cm. long. 

9. One grasping forceps with three shafts 25, 35, and 50 cm. long respectively 

(Coolidge or Jackson); or one extension forceps (Briinings) with three tips 
claw toothed tip, tip for grasping seeds, and a punch tip. 

10. One esopliageal dilator (Briinings, Mosher). 

11. One metal probe carrying three graduated olives (Bunt pattern). 

12. One set elastic esophageal bougies from the smallest si/.e to No. 4o (French). 

The series should be complete up to No. 20. 

13. One Casselberry's pin cutter. 

14. One Jackson's safety pin forceps; or one Mosher's safety pin closing tube. 

15. One tooth plate cutter (Kahler or Mosher). 

16. One metal staff having a perforated olive at the tip. A set of graduated oli\vs 

and a flexible introducer (Mixter and Mosher). 

17. One suction apparatus. Kit her a hand bulb, Jackson's secretion aspirator, or 

a suction apparatus run by electricity. When needed this last apparatus 
is a great luxury. 

The author does most of his esopliageal work under ether and pre- 
fers to use as large a tube as the esophagus under examination will 
take. Accordingly lie uses a large oval tithe of two lengths. (Kig. Hill.) 


The tube has a mandarin which projects from the end an inch and a 
half. The pointed end of the plunger readily finds the opening of the 
esophagus and pushes the cricoid cartilage forward and allows the 
tube to slip by. The tube has no secondary tube on the outside either 
for the light or for suction. The tube is therefore smooth. 
The introduction of the large tubes with secondary tubes on the 
side is dangerous because the tubes tend to cut. The author had one 
fatality due to this cause. Instead of the suction tube a short tube 
conies off from the main tube near its upper end. This is for the intro- 
duction of air. The tube is fitted with a metal plug which has a glass 
end. "When this window plug is in place the esophagoscope becomes 
essentially airtight and the esophagus may be ballooned at will by clos- 
ing the tube with the window plug and then forcing air through the 

Fig. 162. 

Mosher's short length oval esophagoscope. This tube 
is 11 inches (28 cm.) long, and : - 4 inch ( 1H mm.) 
in transverse diameter. The cut shows the mechanical 
device which locks the head of the light carrier into a 
notch in the side of the tube. This arrangement holds 
the carrier firmly in place and allows the insertion of 
the air-tight window ping in the mouth of the tube. The 
lower end of the light carrier passes through a small 
ring inside the oval tube and near the lower end. ( Sec 
Fig. 163.) 

secondary tube. A. stout foot bellows is used for this purpose. The 
light carrier runs inside of the main tube, and as it is not incased 
in a small tube of its own it runs freely at all times. (Figs. Kil'-HiT. ) 
The secondary tube for the light carrier is bitten and dented con- 
tinually so that the light enters it poorly. 'Flic light of the oval tube 
is incased in a hood. This protects it during insertion and while the 
tube is in use. The light once adjusted in its hood burns much longer 
than when it is exposed to the dangers of passing through the sec- 
ondary tube. Each tube is fitted with a second or extra carrier so 
that the operator seldom has the annoyance of having to n't a new 
lamp during an examination. 

The General Examination of the Patient. A general physical 
examination of the patient should be made before esophag- 
oscopy is attempted. Aneurism should be excluded and the 
condition of the heart ascertained. The patient's ability to swallow, 


Fig. 163. 

Fig. 164. 

Fig. 165. 

Fig. 166. 

Fig. 16:!. .Moslicr's esophagoscope (short length). This tube is made 
in ;\vo lengths 11 inches (L'8 cm.) and 17 inches ( 4'.'> cm.) 

The lower figure shows the method of holding the lower end of the light 
carrier in place by passing it through a small ring on the inside of the main 

Fig. 164.- Hood or cap which protects the lamp. This arrangement of 
the light carrier the author has found more satisfactory than the accessory 
channel on the outside of the tube. The outside channel makes a rib which 
on large]- tubes tends to cut the soft tissue. The outside channel is con- 
stantly becoming dented so that the light carrier runs poorly and the con- 
tact of the lamp is disturbed. When the light carrier runs inside the tube 
and is protected by the hood there is much less trouble in keeping the light 
in good condition. 

Fig. 16f>.-- Long cunjcal plunger for Mosher's oval esophagoscope. 
This plunger extends beyond the end of the tube 1 ' ._, in. This plunger 
readily enters (he esophagus and pries the cricoid cartilage forward and 
allows the tube to follow after easily. of .Mosher's oval esophagoscopes. 

LAKYNiiOSCOl'Y, BHOXC 1 1 OSCOl'Y, KS( )IM I A< IOS< '( >l'\ . KT< . __1 

the place where lie locates his trouble, and all the details about rcgnrii-i- 
tation or vomiting are important to obtain. The condition of the teeth 
is observed and the presence of crowns or bridges noted and remem- 
bered. The examination of the month and pharynx should S!IO\Y the 
existence of iilcerations or scars and the laryngoscope \vill give the con- 
dition of the larynx. If disease is present in the larynx it is often a 
part of a similar process in the esophagus or a clew to it. An X-ray 
plate is indispensable before many examinations. The plate sho\vs the 
location of metallic foreign bodies and pieces of bone and buttons; it 
shows enlargement of the arch of the aorta and enlargement of the 
niediastinal glands, and combined with the ingestion of bismntli it 
shows the position of strictures, the si/e and location of divertieiila, 
and the si/e of the dilated esophagus. 

The old practice of passing a bougie into the esophagus should be 
in Yen up in most cases. It' a foreign body is present the bougie may 
push it down or impact it or pass by and fail to locate it. If a carci- 
noma is present it will start bleeding and make the esophageal exam- 
ination more difficult. Many patients have been killed by forcing a 
bougie through the carcinomatous esophageal wall. If the physician 
is dealing with a case of cicatricial stenosis of the esophagus or a ponch, 
the bougie is safe and may gi\'e valuable data. This information, how- 
ever, is much better gained by the esophageal examination with the 

In speaking of the risks of esophagoscopy it was stated that 1 he 
greatest danger was the liability of perforating the esophagus. This 
can happen before the examination, as well as during it. If, therefore. 
a case presents itself for examination and the patient has great pain 
on swallowing along the line of the sternum, if the respirations are in- 
creased, if fever is present, and there is emphysema <>f the skin, tin- 
physician should suspect that the esophagus has already been perfo- 
rated and that an abscess is developing in the mediastinum. In such 
a case drainage of the abscess is indicated, not esophagoscopy. 

The patient should be examined with an empty stomach and if 
possible with an empty esophagus. 

The ease of esophagoscopy under local anesthesia depends upon 
the tolerance of the patient's pharynx. Briinings has a long, thin tongue 
depressor with which he tests the sensitiveness of the patient. The 
first introduction of the cotton swab in the preliminary application of 
cocain does just as well and soon settles the question as to whether or 
not the subject is an intolerable gagger. The experienced examiner 
always looks with anxiety at the patient 's neck and teeth. If the upper 
jaw does not project and if the teeth are short or better still if there 


are no upper tooth, if tho neck is long and thin and the lower jaw well 
rounded at the angle and freely movable the chances for a favorable 
examination are good. AVhen opposite conditions are present the ex- 
amination is often difficult, sometimes impossible. 

Technic of Esophagoscopy Under Cocain Anesthesia. By means 
of an appropriate applicator, that of Sajous is very convenient, a ten 
per cent solution of oooain is applied to the base of the tongue and to 
the posterior pharyngoal wall. After an interval of a few minutes, 
under guidance of the laryngeal mirror, coeain is placed on the 
tip of the epiglottis and allowed to run into the larynx. After another 
interval of some minutes the swab is carried down on the posterior 
pharyngoal wall to the opening of the esophagus and applied at this 
point and to the region of the arytenoid cartilages. It is well to repeat 
this deep cocainization at least once. It takes from fifteen to twenty 
minutes to obtain a satisfactory cocainization. 

Position of the Patient. The patient can bo examined either in 
the sitting position or on his back with tho head over tho end of the 
table and hold by an assistant. The sitting position is best adapted to 
short examinations. It is easier for tho patient especially if ho is old 
or stout. Where it is essential to have the esophagus clean as in cases 
of spasm of tho cardia with dilatation, stricture, or the presence of a 
foreign body, as well as with children or weak or sick patients, the 
prone position is preferable. 

If the sitting position is adopted the patient sits on a low stool 
25-.')0 cm. in height and an assistant stands behind him and holds the 
head. If tho patient is examined on a table he may be placed on his 
back or on his side. Of tho two lateral positions the left is the easier 
because the physician works with the right-hand. If the teeth are 
missing on the right side of the upper jaw the right lateral position is 
preferable. If the incisor teeth have been lost the prone position is 
chosen. This position is selected also if tho operator wishes to pass 
the osophagoscopo into the stomach because in this position it is easier 
to bring the shaft of the osopliagoscopo to the right and to make the 
point enter the hiatus of the diaphragm and to traverse the subplirenic 
portion. In either the lateral or the dorsal positions the knees are 
drawn up slightly because the muscular relaxation caused by this 
makes the passage of the tube easier. 

The Introduction of the Esophagoscope by Sight. The ideal way 
of introducing the osophagosoope is to insert it under the guidance of 
the eye. 'The patient, anesthetized with coeain, is placed on a low 
stool, and an assistant stands behind him and holds the head, ('arc 
-hoiild be taken that the head is not placed too far back as oxces- 

LARYNGOSCOPY, BKO.NC I losrol'V, KSol'IIA<;os< '< >l'\ , KTr. 

sive backward bending interferes with tlic insertion of tin- instrument. 
The room is darkened and the upper part of the extension esophago- 
scope, it' tlie Briinings tube is chosen, is warmed and smeared with 
vaseline and attached to the electroscope. The operator holds the up- 
per lip of the patient out of the way with the thumb and forefinger of 
the left hand. The first part of the extension csophagoscope is really 
an elongated tubular speculum ending in a pointed lip. It is. 
therefore, introduced like the autoscope. That is, it is introduced into 
the mouth and steadied by the tip of the thumb of the operator's left 
hand is carried back over the base of the tongue until the summit 
of the epiglottis is seen through the tube. At this point the handle of 
the gastroscope is raised and the lower end of the tube is passed over 
the epiglottis. The shaft of the tube is elevated until it lies snugly 
against the physician's forefinger which is guarding the incisor teeth 
or the gums if these teeth are missing. If the epiglottis is missed the 
point of the tube is almost certain to bring up against the posterior 
pharyngeal wall much to the discomfort of the patient. After the tip 
of the epiglottis is recognized and passed, the end of the tube is car- 
ried down until the arytenoid cartilages are seen. These are readily 
made out if the patient is asked to phonate. The point of the tube is 
now swung a little backward to clear the arytenoids and the tube is 
advanced a few centimeters to the opening of the esophagus. This ap- 
pears as a transverse slit. The end of the tube is now brought forward 
a bit in order to open the esophagus. If this does not happen the patient 
is almost sure to swallow and when he does so, the tube slips into the 
esophagus. Sometimes the patient must be asked to swallow before 
the tube will drop in. In difficult introductions the point of the tube 
may be placed dee]) in the left pyriform sinus and then swung round to 
the median line. As it does this it pries the cricoid cartilage forward. 
Once past the cricoid cartilage the progress of the tube is easy. The 
tube is now carried down, advancing slowly, to its full length, the ex- 
aminer all the while guiding the point by looking through the lube. 
The tube must never be advanced unless the esophagus ahead is open 
to receive it. When the tube has been advanced to its limit the second 
tube is inserted inside the first one and carried down by sight. When 
the Jackson tubular speculum is used for the introduction of the eso- 
phagoscope the steps are the same as for the first Briinings tube. After 
the mouth of the esophagus has been located and made to remain open 
a Jackson esophagoscope is carried through the speculum and into the 
esophagus. The speculum is then withdrawn. 

The Introduction of the Esophagoscope by Means of a Flexible 
Mandarin or Bougie. A beaked, partially open speculum is carried 


down to the opening of the esophagus and a snugly fitting bougie is 
passed through it and carried into the esophagus. The speculum is 
withdrawn and an esophagoscope is passed over the bougie into the 
esophagus. This procedure which often makes the introduction of 
the tube very easy should never be used when it is the purpose of the 
examiner to determine the condition of the extreme upper end of the 
esophagus or when a foreign body is impacted in this locality. Another 
method of using the bougie as a guide is to pass a Jackson esophago- 
scope of the proper si/e below and behind the arytenoid cartilages and 
then into the opening of the esophagus. A bougie is then passed 
through the tube and finally the tube is pushed down over the bougie. 
The Introduction of the Esophagoscope Under General Anesthesia, 
-The patient is prepared for ether in the usual way. He is given an 
injection of one one-hundredth of a grain of atropin and one-sixth of 
a grain of morphin. The atropin produces a nearly dry esophagus ex- 
cept in those instances in which the esophagus is dilaled and filled with 
food or a pouch is present and acts as a reservoir. A suction appar- 
atus is not usually necessary, but is always a great luxury. The author 
is using il more and more. If the operator works sitting, the table on 
which the patient is placed should be of the proper height to permit the 
surgeon to work at ease. If the operator prefers to stand the table should 
be placed on a platform large enough to hold not only the table but the 
stool for the assistant who holds the head and for the etherizer. The 
corner of the platform opposite the head of the operating table is cut 
out to allow standing room for the operator. During the examination 
should it become advisable to lower the head of the patient the oper- 
ator is not forced to work on his knees. An assistant holds the patient's 
head over the end of the table. His left hand supports the patient's 
head and his left knee supports his hand while his foot rests upon a 
support of suitable height. The assistant should so grasp the head 
that he can transfer it at any moment to the physician, be ready to re- 
ceive the head hack and to hold it in the new position indicated by the 
suru'eou. Thus the patient's head is continually passing from the hand 
of the assistant to that of the operator. It is vital that the head should 
not be extended too far backward. If this is done the cricoid cartilage 
is held ti.u'htly against the sixth cervical vertebra and \vill not move 
forward before the advancing tube without the application of great 
force. A rou.u'h introduction of the esophagoscope may cause slough- 
in. u - of the posterior esophageal wall. This may have a disastrous out- 
come in a weak patient. The formation of the mouth of the esophagus 
caHs for another word. It is bounded in front by the cartilaginous ring 
of the cricoid cartilage and behind bv the bodv of the sixth cervical 


vertebra. Only on the sides where the pyriform sinuses lead into il are 
tlie walls composed of soft tissues. The natural channel for food into 
the esophagus is by way of the pyrifonn sinuses and experience has 
shown that the pyrifonn sinus is the natural and the easiest channel 
through which to pass the esophagoscope. If the tube chosen for the 
introduction into the esophagus will not pass, the operator should at 
once select a smaller tube until one is found which will enter without 
being forced. The tubes which are most useful according to 
Bru'Miiigs are 10, 12, and 14 nun. Practically every patient will admit 
a tube of one size or another unless the body of the sixth cervical verte- 
bra is enlarged, or the cervical vertebne are diseased. 

It is usually possible to pass the tube by sight and this method 
should be attempted first. Suppose the Jackson instruments are se- 
lected. The procedure of introducing the esophagoscope by sight is 
as follows. If the teeth are intact or if they consist chiefly of stumps 
those of the upper jaw are protected by inserting a thin aluminum tooth 
plate. If the gums are bare of teeth the use of the tooth plate is just 
as important for the later comfort of the patient. Tn a hard introduc- 
tion, no matter which instrument is used, the tooth plate should 
be employed until the tube is well in the esophagus because notwith- 
standing assertions to the contrary, teeth may be nicked, broken or 
forced from their sockets. Patients do not readily forget such an oc- 
currence. The teeth, then, have been protected with a tooth plate and 
the assistant holds the head bent backward moderately. The jaws are 
kept slightly apart by a gag placed in the left corner of the 
mouth. The tongue is made to lie naturally and the end 
of the tubular speculum is carried along the central furrow 
of the tongue, and is pushed forward and downward until the 
tip of the epiglottis is recognized. The tip of the epiglottis and then 
the body of the epiglottis are picked up by the end of the speculum in 
turn and drawn forward until the arytenoids appear. These in turn 
are passed by inserting the point of the speculum behind them and 
forcing them forward, and the speculum is carried still further down. 
All the time the operator is making traction forward. AVhen the proper 
depth has been reached the back of the cricoid cartilage is encountered 
and this like the structures above is pushed forward. At this point 
the mouth of the esophagus opens and the operator looks into the lu- 
men of the esophagus for a considerable distance. In favorable cases, 
especially in infants and children, he can see down the esophagus al- 
most to the inner end of the clavicles. AVith the cricoid cartilage 
drawn forward and the mouth of the esophagus gaping it is a simple 
matter to pass the esophagoscope through the tubular speculum into 
the esophagus, to remove the slide and to withdraw the speculum. In- 


troduction by sight is the ideal method, because in this procedure there 
are no blind points. It is not necessary to describe the introduction by 
sight of the Briinings extension esophagoscope. The first part of his 
double tube takes the place of the Jackson tubular speculum and is 
used in the same manner. After the esophagoscope has been inserted, 
if the purpose of the examination is to explore the whole length of the 
esophagus, pathologic conditions permitting, the tube is swung to the 
corner of the mouth on the right. If any teeth are fortunately missing 
on this side the barrel of the esophagoscope is made to lie in the tooth 
gap. Should it happen that the missing teeth are on the left side and 
the introduction difficult it is well to shift the tube to the left corner of 
the mouth. 

The Use of the Adjustable Speculum for the Introduction of the 
Esophagoscope. The author has for some years worked with his open 
and adjustable speculum for the examination of the upper end of the 
esophagus and for the introduction of the esophagoscope. The spec- 
ulum is an adjustable tubular speculum with the right side cut away. 
Owing to this fact all the landmarks of the pharynx and larynx can be 
seen ahead of the speculum and in their proper perspective. There is 
a large lateral excursion for the eye, which reduces the eye strain, and 
makes the introduction of the tube easier thus giving a greater play 
for instrumentation about the arytenoids, in the pyriform sinus and in 
the upper part of the esophagus. The speculum is introduced in the 
same manner as the tubular speculum of Jackson. Should the purpose 
of the examination be to examine the esophagus below the clavicles, the 
cricoid cartilage is pulled forward, the upper portion of the esophagus 
is exposed, and then the esophagoscope is passed by sight through the 
speculum into the esophagus and the speculum taken out. The tooth 
plate, if it has been used, is retained or not at the discretion of the 

Passing the Jackson Esophagoscope by Sight. The .Jackson 
esophagoscope can often be passed by sight, especially if a lube of mod- 
erate size is selected. The manipulations are the same as in the intro- 
duction of the tubular speculum. The field given by the esophagoscope 
is of course somewhat smaller than that which is given by the tubular 
speculum. This difference in an easy examination amounts to nothing. 
When the esophagoscope has been passed by sight to the arytenoid 
cartilages the point is swung to 1 he right into the pyriform sinus and 
entered deeply at this point. When it reaches bottom, so to speak, the 
point is swung back" to the middle line. As this occurs the tube forces 
the cricoid cartilage forward and slips into the mouth of the esophagus. 

Passing the Oval Tube by Sight. As the author has done prac- 
tically all his work' upon the esophagus under ether anesthesia, he pre- 

LAKYXliOSCOl'Y, MHOXC H OSCOI'Y, KS< II' 1 1 A< i< )SC( >\>\ , KTC. 

fers to use for the esophageal cxainiiiatioii as large a tube as the eso- 
phagus can be made to lake. Oval lubes lake up the slack of tlie eso- 
phagus along anatomic lines belter than round ones. For this reason 
the writer employs large oval tubes. These are made in two leim'th^ 
an eleven-inch tube and an eighteen-inch tube. So many of the path- 
ologic conditions of the esophagus are found in the upper part and the 
eye strain is so vastly increased by looking through a long tube that 
it is economy of eyesight to have tubes of two lengths. The short oval 
tube is selected and passed by sight to the right pyriform sinus. At 
this point the transverse axis of the tube is made to lie anteriorly by 
rotating the tube to the right. The tube will then sink further into 
the sinus. AVhen the point of the tube is as far in the pyriform sinus 
as it will go without being forced, the tube is rotated back to its orig- 
inal position with the long axis again transverse. As this manipula- 
tion is carried out the left edge of the oval tube insinuates itself behind 
the body of the cricoid cartilage thus pushing it forward, and the tube 
enters the esophagus. All these manipulations are seen by the exam- 
iner as he guides them through the tube. The field which the large 
tube gives is so superior to that afforded by a round and smaller tube 
that every legitimate effort should be made to introduce as large a tube 
into the esophagus as will pass the cricoid cartilage-. Even 
a large oval tube seems too small for the calibre of the esophagus once 
the cricoid cartilage has been passed. The examiner gets this impres- 
sion even in the normal adult esophagus, to say nothing of the dilated 
esophagus of cardiospasm. 

The Passing of the Esophagoscope by Aid of a Mandarin or a 
Flexible Bougie. In the early days of the esophagoscope it was 
almost always introduced by means of a projecting plunger or man- 
darin. At first the mandarin had a rigid end; later flexible tips were 
added. To all intents and purposes the elastic bougie is a mandarin 
with a flexible tip and is so used today. The mandarin is ehielly em- 
ployed with the finger tip introduction of the esophagoscope or the 
gastroscope. There is no great or vital objection to the use of the 
mandarin if the examiner is sure that the pathologic condition is well 
down the esophagus or if, as in gastroscopy, he is to pass the tube 
through a normal esophagus. The procedure is carried out as follows: 
The examiner holds the esophagoscope in the right hand and with 
his thumb steadies the head of the plunger. With the forefinger of 
the left hand he feels the right arytenoid cartilage by forcing his finger 
well down the patient's pharynx. Along the inner surface of the left 
forefinger of the examiner the esophagoscope is carried into the ri.u'ht 
pyriform sinus. When the end of the instrument has reached this 


point a little twist of the end of the tube to the left carries the tube into 
the esophagus. With a tube of medium or small diameter this method 
of introduction is the quickest and easiest. The disadvantage of the 
procedure need not be dwelt upon after wliat has been said of the ad- 
vantage of the introduction by sight. The largo oval tube which is 
used by the author is fitted with a conical rigid plunger which projects 
from the end of the tube an inch and a half. The plunger is used 
in those cases in which the ocular introduction of the oval tube does 
not succeed. The oval tube is carried down by sight and the attempt 
is made to pass it by sight after the method which lias just been 
described. If this fails the plunger is put in and gently forced home. 
The plunger is so long and pointed that it finds its way behind the 
cricoid cartilage, dislocates it forward and allows the tube to follow 
on after it. 

The introduction of the esophagoscope with flexible bougies is 
best adapted to round tubes. The bougie can first be introduced by 
the finger tip method or the tube can be carried to the entrance of the 
esophagus by sight and then the bougie passed through it and into the 
esophagus. The tube may then be slipped down over the bougie. 

The impression may have been given by what has been said con- 
cerning the introduction of large tubes that they should be used at 
all costs. This is not the impression \vliich the author wishes to leave. 
If a large tube can be used, and it can be used under ether without 
danger oftener than is generally recognized, it should be employed. It 
must be remembered, however, that if the introduction of a chosen tube 
is not easily successful, that tube should be discarded at once for a 
smaller one. Obstinacy on this point will lead to disaster. 

The Appearance of the Normal Esophagus. Under good illumina- 
tion the color of the mucous membrane of the esophagus is a whitish 
pink like that of the mouth. Poorly lighted or when inflamed the color 
changes to a red of varying depth. After trauma, the mucous mem- 
brane soon becomes edematous. When examined with small tubes the 
walls of the esophagus are thrown into large longitudinal folds, and on 
looking through the tube they are seen indenting the circumference 
of the central dark area which represents the lumen of the esophagus. 
These folds are especially numerous at the mouth of the esophagus 
behind the cricoid cartilage. They make it hard to be sure of the path- 
ologic lesions in this locality. Below the criroid cartilage and in the 
cervical region the lumen is seen to enlarge 1 with inspiration and to 
close down again, but not entirely, during expiration. When a large 
tube is used the examiner can often look down the esophagus a 
long way ahead of it. As the esophagoscope reaches the first 

L,AKY\<;OS<'0|>V, BliONC IIOSC'OI'V, KSOl'll A<;osro|'\ , K'I'C. 

piece of the sternum the pulsation of the arch of the aorta can be >een 
1 hrough the anterior wall. A little lower the heart mounds into tli<- 
anterior wall on the left. The beating of the heart is visible an<l when 
the tube has passed beyond and the heart lies against it, the tube often 

Fig. ItiH. 

Fig. 170. 

Fig. 171. 

Fig. 168. The normal esophagus above the hiatus of the diaphragm, 
and with the diaphragm contracted. 

Fig. Kilt. The esophagoscope has been pushed through the hiatus of 
the diaphragm and entered the subphrenic portion of the esophagus. The 
characteristic longitudinal folds of this part of the esophagus are shown. 
They converge to the left upon an ill-defined transverse slit which is the 
cardiac opening. 

Fig. 170. The esophagoscope has been carried through the cardiac open- 
ing of the esophagus into the stomach. The stomach appears as a funnel- 
shaped cavity. On the lower wall of this the ruga> of the stomach are seen. 

Fig. 171. The drawing shows the esophagus just above the hiatus of 
the diaphragm. The patient was examined under ether and with an oval 
esophagoscope. On the patient's right the rim of the hiatus is partially 
contracted and mounds into the lumen of the esophagus. Later in the ex- 
amination when the diaphragm became fully relaxed this ridge dis- 
appeared. I5elow and beyond the ridge the subphrenic portion of the 
esophagus is seen. The characteristic longitudinal folds veer to the left 
and end in the cardiac opening. The cardiac opening is in a state of 

(Drawings by the author) 

vibrates in unison with the heart beat. The hiatus of the esophagus 
appears as a slit or a rosette. 'Phe axis of this opening through the 
diaphragm is oblique, running from right to left, from behind forward. 
The subphrenic portion of the esophagus usually shows no lumen, but 



Fig. 172. 

Fig. 173. 

Fig. 174. 

Fin. 17*;. 

Fig. 175. 

Fig. 1' 

Fig. 17.!. Normal esophagus during quiet breathing. Small esopha- 


Fig. 17!.. Normal esophagus during deep respiration. 

Fig. 174. Stricture of esophagus with scars radiating from its lumen. 

Figs. 17.~i and 17(>. Carcinoma of the esophagus. 

Fig. 177. Fish bone in the esophagus. 
(After Stark. I 


opens as the tul)c passes through it. Tlie mucous membrane of this 
part is so much like that of the stomach that il is hard to tell where 
the esophagus ends and the stomach begins. The mucous membrane 
of the stomach, however, is a darker red than that of the esophagus and 
the longitudinal folds of the esophagus give place to the familial 1 rouge. 

The mouth of the esophagus and the hiatus are the two places 
where it is always difficult for the examiner to be sure of his findings. 
The difficulty at the first place is due chiefly to the folds of the mucous 
membrane. These can be stretched out by passing the esopha- 
geal dilator well into the mouth of the esophagus and opening it suffi- 
ciently to displace the cricoid cartilage strongly forward. If a true 
web is suspected the withdrawal of the open dilator will make its size 
and position plain. The introduction of a small tube through the pyri- 
form sinus is very liable to push a fold of the mucous membrane ahead 
of it and produce an artificial web or fold. Once the cricoid cartilage 
has been passed the further progress of the esophagoscope is usually 
easy. The examiner should always see the open esophagus ahead 
through the tube before the tube is advanced. When no lumen appears 
the end of the tube is generally pointed too much to the side and is 
out of line with the long axis of the esophagus. If, on correcting the 
position of the tube, the lumen of the esophagus is still unnoticeable, 
its position can be made out by inserting the window plug and filling 
the esophagus with air. The author considers this expediency of the 
utmost value. Once the lumen has been found the tube can be carried 
further down. 

In order to enter the hiatus it is necessary to carry the shaft of the 
esophagoscope to the right corner of the mouth and the point of the 
tube to the left, beginning the search in the right posterior quadrant 
of the esophagus. It is at this point that the hiatus is most readily 
found. When the point of the tube cannot be made to enter the hiatus 
and to proceed through the kinked subphrenic portion of the esopha- 
gus, a bougie passed through the esophagoscope and into the sub- 
phrenic portion will often guide the tube into the stomach. The author 
relies upon ballooning the esophagus and thus finding his way. After 
the esophagus has been examined all the way to the stomach the tube 
is withdrawn and the whole of the esophageal wall is reexamined. 


The chief symptom of disease of the esophagus is obstruction to 
swallowing. Diseases of the esophagus, therefore, fall into two groups, 
those which cause marked stenosis and those which do not. Xew 
growths form an important subgroup. As elsewhere in the body a new 


growth may he benign or malignant. Foreign bodies in the esophagus 
make the final important group to he considered. 


Acute Inflammation. 

Following the swallowing of a corrosive such as lye (washing 
powders), carholic acid, or corrosive sublimate, the esophagus becomes 
acutely inflamed and more or less completely closed. Rough, impacted 
foreign hodies also cause a local inflammation. This may he more or 
Jess general if the foreign hody has caused extensive trauma. 

After the swallowing of a caustic it is hetter to wait for a few weeks, 
perhaps a month or two until the inflammatory disturbance has sub- 
sided before examining the esophagus with the esophagoscope or be- 
fore passing bougies by the aid of the esophagoscope in the hope of 
preventing the formation of cicatricial strictures. This caution is 
especially necessary in dealing with young children. In such cases it is 
probably better to open the stomach without delay and to nourish the 
child through the gastric fistula until it has regained its powers of 
resistance and is once more well nourished. If a foreign body has 
caused the inflammatory stenosis of the esophagus, i1 must be removed 
at once. 

Stenosis of the Esophagus Due to Cicatrices. 

Cicatricial stenosis of the esophagus may be the result of opera- 
tion, i. e., removal of the glands of Ihe neck, or excision of the larynx. 
Traumatic stenoses are caused by gunshot wounds and by swallowing 
sharp foreign bodies. Systemic diseases which are at times associated 
with ulcerations of the esophagus may also cause cicatricial stenoses. 
Syphilis and typhoid fever are occasionally responsible for such stric- 
tures. Pneumonia may produce the same condition, but cicatricial 
strictures are most common after the swallowing of some escharotic. 
When home-made soap was common, children drank" it by mistake. 
Today they drink solutions of corrosive sublimate, which are kept to 
destroy vermin, or the various washing compounds containing caustic 

It may he years before cicatrieial strictures finally shut down. 
Adult patients not infrequently present themselves who give a history 
of having swallowed some caustic in childhood and who have had only 
moderate difficulty in swallowing for years. 

The Location of Strictures. Caustic strictures form most readily 
at the points where the esophagus is the narrowest. They are found, 
therefore, most commonly at the upper or lower end of the esophagus. 


Occasionally a stricture is found at the level of the clavicles. Xot un- 
commonly there \vill l)e a stricture at the level of the clavicles and a 
second and larger one at the cardiac end of the esophagus. The usual 
tight stricture is about an inch long. At times the whole lower half 
of the esophagus is narrowed, making one long strict lire. The 
author met this condition once as the result of ulcerations of the mouth, 
pharynx and esophagus during pneumonia. Partial hand-like stric- 
tures may precede and guard the opening of the chief stricture. The 
esopliageal wall above a stricture is dilated. This sac-like pouch en- 
gages the end of a bougie and keeps it from finding the lumen of the 
stricture easily. \Ylien, however, the esophagus is examined with the 
esopliagoscope, especially if a tube of good si/e is used, the lumen of 
the sti'icture is easily made to come opposite the end of the tube. (Fig. 

The Diagnosis and Treatment of Esophageal Strictures. Tin- best 
method of determining the presence of an osophagoal sti'icture is to 
pass the esophagoseope. The larger the examining lube the easier it 
is to find the constriction and to make the lumen of the stricture center 
with the end of the tube. The mere presence of a stricture can be made 
out with a small tube and the examination carried on under eocain 
anesthesia. The accurate mapping out of a stricture, however, and its 
maximum dilatation are possible only under general anesthesia. For 
this reason the author feels that time is wasted in examining a cica- 
tricial stricture under local anesthesia. When, therefore, a patient is 
to be examined for a cicatricial stricture he should be etheri/.ed and 
placed on the examining table with the head hanging over the edge 
and as large a tube introduced as can be made to pass the 
cricoid cartilage easily. Under direct vision the tube is carried down 
to the stricture and the lumen of the stricture made to correspond with 
the center of the tube. The author's experience lias been that this is 
easy to accomplish. Occasionally ballooning the esophagus with air 
helps to find the opening of the sti'ictui'e. After the dilatation of a 
Miiall stricture has been begun the ballooning is an easy way of keep- 
in, u 1 the blood out of the mouth of the stricture. To return, after the 
sti'ictui'e has been found and its opening centered at the end of the 
tube, the lumen of the stricture should be tested with an elastic bougie 
of appropriate size. If it happens that the lumen measures 2<) F. or is 
easily dilatable with soft bougies up to this calibre, the metal dilator 
(Fig. 178) is carried by sight through the stricture and the dilating 
mechanism expanded until marked resistance is felt. The dilator is 
kept expanded for two or three minutes and then closed. After 
a short interval the stricture is again put on the stretch. P>y coaxinu 1 



the dilatation a marked gain in the lumen of the stricture is soon at- 
tained. It is surprising how readily even old strictures will yield. The 
author so far has not found it necessary to cut a stricture in order to 
make dilatation possible. Xo rule can be given as to how fast to dilate 
or how much. Until more data have been accumulated upon this point 
the operator must use his best judgment. The aim is to get the max- 
imum dilatation so that a good sized bougie can be passed easily after 
the examination. In a bov of seven vears with a vear old corrosive 

luiiimiiaiiiiiiiiuiiJiiiiiJiJiiiiiiiiJiiiiiiiiiiiiiiiiiiiniifiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiftiiiiirp""" 1 '""'"""' 

Fig. 178. 

Mosher's mechanical dilator, with two tips. A, tip for use in stricture 
of the esophagus; B, tip with larger expansion for use in cardiospasm. 

stricture which would not admit a 16 F. bougie without ether and in 
whom under ether a 20 F. passed firmly, 1 was content with a dilatation 
to .'54 V. In a woman of forty with a stricture which had existed since 
childhood and which admitted without ether a number 20 V. bougie 
with difficulty, the dilatation was carried carefully up to 42 F. This 
was sufficient to allow the passage after ether of a -'!2 F. bougie. The 
dilatation was subsequently increased by the weekly passing of elastic 
bougies up to .'Hi F. Rapid dilatation under ether saves months of 

Fig. 17!). 

Modified limit's olive-tipped metal bougie. This instrument is used 
for starting the dilatation of small strictures of the esophagus. 

Iv\ per ic nee has proved 1 hat rapid dilatation is safe if carried out 
wit h ordinary caution. 

In the treatment of strictures in which the lumen is so small that 
the smallest elastic bougies will not pass, much can be accomplished 
by the gentle use of a staff carrying small metal olives ( Kig. 17!)). With 
the smallest olive an eighth or a quarter of an inch of the stricture is 
picked or teased open. After this an elastic bougie of slightly larger 
si/e is introduced in the hope of increasing the dilatation. The use of 


the metal olive should he most guarded. All the while the operator 
must be conscious of the true axis of the esophagus because any devi- 
ation from the proper line will result in a perforation and the probable 
death of the patient. In long tight strictures it is not necessary that 
the lumen be restored through the whole length of the stricture at the 
first sitting, because experience lias proved that it is better in such cases 
to open the stomach at once and to get the patient properly nourished 
before very tight or very long strictures are dilated. When an emaci- 
ated, half-starved patient presents himself, and especially in the case 
of children, it is better surgery to open the stomach at once and to 
restore the patient's resistance by feeding before attempting the dila- 
tation of a difficult stricture. If this has been done there is no hurry 
so that the stricture may be opened up gradually. 

The following histories are given as illustrations of typical cases 
of stricture: 

Case Number 1. 

A boy two years old drank a caustic solution and three months later developed 
marked difficulty in swallowing. Milk became his only food. One day this would stay 
down, the next the greater part of the milk would be regurgitated soon after it was 
swallowed. A number 16 F. elastic bougie met with resistance at the lower end of the 
esophagus and would not enter the stomach. 

Under ether a stricture was found at the cardiac end of the esophagus, and a 
moderate dilatation of the esophagus above it. The stricture proved to be an inch long. 
It dilated readily with elastic bougies to 20 F. From this measurement the dilatation 
svas carried to 32 F. with the mechanical dilator. As was just said it was impos- 
sible to pass even a small bougie into the boy's stomach before the etherization and 
dilatation, but afterwards a number 32 F. could be introduced easily. The family phy- 
sician passed a number 32 F. bougie once a week. The boy soon became well nour- 
ished again. At the end of a year and a half the mother of the child reported that he had 
no difficulty in swallowing. 

Case Number 2. 

A woman in the forties gave a history of marked difficulty in swallowing for two 
months, and of pain in the epigastric region. She was moderately well nourished and 
was living on milk and soft solids. The patient stated that when she was a small child 
a playmate offered her a drink of vitriol. Since this happening she had had a moderate 
and stationary amount of trouble with swallowing. For the last month, however, the 
trouble had suddenly increased and she had begun to have pain in the region of the 

A number 20 F. bougie encountered resistance at the cardiac end of the esopha- 
gus and entered the stomach with difficulty. The X-ray showed that the lower half of 
the esophagus was narrowed. 

The ether examination disclosed a stricture at the level of the clavicle. The 
lumen of this was about 30 F. This stricture was easily dilated with the mechanical 
dilator so that it permitted the passage of a tube measuring half an inch. A second 
stricture was found at the cardiac end of the esophagus. The second and lower stric- 
ture was dilated with elastic bougies up to 22 F. and then the mechanical dilator w?.j 
introduced and the stricture stretched slowly and at intervals of a few minutes up to 
a final dilatation of 42 F. At this point the resistance to the dilatation became extreme 
and it was discontinued. 


Stricture of the esophagus. (Tracing from ai 
and reduced. ) 

This plate was taken from a woman forty years old. At the age 
of four a playmate gave In r a drink of vitriol. Since then she has always 
hail to chew her food very line. For a month or two before she came for 
examination she had b.-en living on liquids. 

A Xo. I'u F. elastic bougie entered the stomach with difliculty, encoun- 
tering a stricture at the cardiac end of the esophagus. The X-ray (date 
shows that the lower half of the esophagus is narrowed, ruder ether a 
stricture was found at the < ml of the clavicles as well as at the cardiac end 
of the esophagus. This had a calibre of L'8 F. The upper stricture was 
dilated first with the mechanical dilator and then the lower one. The lower 
stricture was dilated at the first examination from L.'n F. to ''>- F. 


The instrumentation was not followed by any rise in temperature, but for a few 
days there was an increase of the epigastric pain, and for three or four days the 
ability to swallow r was lessened. By the end of the week the pain had disappeared and 
the patient was swallowing better than before the operation. At this time a number 
30 F. elastic bougie passed without difficulty. For about a year afterwards bougies wei" 
passed on the average of every two weeks. Today a number 36 F. passes without diffi- 
culty and the woman eats every thing. 

This case shows that where there are two or more constrictions the 
bougie locates only the smaller one. From the age of the lower stricture 
and from its firmness at the beginning of the dilatation the author was 
of the opinion that it would have to be cut before any increase of 
its lumen could be accomplished. A little patience in the use of the me- 
chanical dilator, however, soon proved that this supposition, however 
natural, was wrong'. This case shows, therefore, the possibilities of 
rapid dilatation even in old strictures. It shows further, that the bis- 
muth X-ray examination reveals only the upper stricture and gives a 
false impression of the condition of the esophagus below the first nar- 

Case Number 3. 

Two years ago a boy of five was brought to the Massachusetts General Hospital 
starving from the effects of a corrosive stricture of the esophagus. His stomach was 
opened under cocain anesthesia, a tube inserted, and the boy brought back to proper 
nourishment and resistance by stomach feeding. Then attempts were made to pass 
the stricture from above by introducing bougies and by having the boy swallow a string 
to act as a guide for a perforated olive on a metal staff. These attempts failed. The 
attempt also failed when the stricture was attacked from below through the gastric 
fistula by means of a cystoscope. 

A year later the boy again entered the hospital. He was still fed through a tube 
in the gastric fistula. He was at this time the picture of health, fat and pink. The 
X-ray revealed a constriction of the esophagus beginning at the level of the nipples and 
continuing on to the stomach. Above the stricture the esophagus was much dilated. 
Examination with chemicals proved that nothing could reach the stomach. 

Dr. S. J. Mixter, to whose wards the boy was admitted, kindly asked the author to 
see the case. The examination under ether showed that the upper half of the esophagus 
was dilated and that the stricture began as the X-ray had shown, at the level of the 
nipples. The lumen of the esophagus was reduced to a central opening about one-six- 
teenth of an inch in diameter. A filiform bougie would just engage in this and then 
would enter no further. Having gained this information from above an attempt was 
made to pass the stricture from below through the gastric fistula, by using a small 
short bronchoscope. This was not successful. Then Dr. Coolidge took the broncho- 
scope and worked from below while the author worked in the esophagus from above 
using a small esophagoscope. This double attack on the stricture made no gain and the 
manipulations from below were discontinued. The author soon found that on using 
the small metal olives on the end of a metal staff the lumen of the stricture could b'j 
entered a short distance, perhaps an eighth of an inch. Encouraged by this he persisted 
in the use of the metal olive, using first the metal olive and then a small elastic bougie 
of slightly larger size. The result of the first day's work was the ungluing of about 
an inch of the stricture. No reaction followed the manipulations. 

Two weeks later the boy was etherized again and the same manipulations repeated 
A second gain of nearly an inch was secured. During this second session at the stric- 


ture the ballooning attachment \vas employed from time to time in order to clear the 
blood from the lumen of the stricture and in the hope that some of the air might find 
its way into the stomach. Air finally did enter the stomach and could be detected com- 
ing out of the gastric fistula. This happening was most comforting and encouraging. 
It proved that the metal olive was following the right line and that the lower inch of 
the stricture was pervious to air. Without the confidence which this finding gave the 
author might have given up the attempt to pick apart so long a stricture, because if the 
line of the stricture was not adhered to closely the olive would perforate the walls of 
the esophagus and convert the case into a tragedy. After a second interval of rest, about 
two weeks, the boy was etherized for the third time. The gain made at the other exam- 
inations was found to be retained. Air still could be forced into the stomach, and after 
a little manipulation the olive also entered. This was followed by soft bougies until 
the lumen of the stricture was increased to 20 F. The mechanical dilator was then 
put in and expanded at intervals to 28 F. The manipulations ended by carrying into 
the stomach a thread and bringing the upper end of this out of the mouth and fixing 
it over the ear. 

Three or four days later the perforated metal olive on a long staff was carried 
down on the thread into the stomach. The boy began to drink milk. It was soon pos- 
sible to pass the olive through the stricture without using the string as a guide. This 
was fortunate because the thread was vomited after a few days. The further treat- 
ment of the case consisted in passing larger and larger olives at appropriate intervals 
until a final dilatation of 36 F. was reached. 

In this ease an absolute stricture three inches long 1 and a year old 
was opened up piecemeal with a final lumen of 3(> F. The previous 
treatment of the case along' general surgical lines had failed. This 
fortunate case, therefore, shows in a striking manner the possibilities 
of the treatment of strictures by the esophagoscope and by appropriate 
instruments used through it. 

The Use of a Thread as a Guide in Esophageal Strictures. The 
procedure of having the patient swallow a thread was a great advance 
in the general surgical treatment of strictures of the esophagus. It is 
mentioned in connection with the use of the esophagoscope because 
occasionally advantage may be taken of this procedure in connection 
with the use of the tube. The swallowed thread may be used to guide 
the esophagoscope to the lumen of the stricture, although as the oper- 
ator becomes accustomed to the use of the esophagoscope and resorts 
to ballooning, he will find the swallowed thread less and less necessary. 
The chief use of the thread is its employment as a guide for the metal 
olive alter the rapid dilatation. When used in this way a yard or two 
of stout waxed thread is wrapped about a small button and the button 
is carried into the stomach through the tube during the examination 
and after the stretching. The upper end of the thread is brought out 
of the mouth and fastened over the ear. (Jenerally the use of the thread 
as a guide for the metal olive and its staff is necessary for a few days 
only, because the operator soon becomes orientated in regard to the 

n of the stricture and finds that the metal staff allows him to turn 


the olive in different directions and to probe for the opening of the stric- 
ture successfully. 

The Spiral Staff for Carrying Olives. The purpose of introducing 
the metal olive and its staff is that olives of increasing size may be 
passed on the metal shaft until the dilatation of the stricture is such that 
the passage of elastic bougies is possible. (Fig. 18.'}.) Instead of forcing 
the perforated olive down the staff and through the stricture by a second 
staff carrying a ring placed at right angles to the shaft, better results 

Fig. 181. 
Handle and staff' of Plummer's esophageal whalebone bougie. 

Fig. 182. 

Whalebone staff of Plummer's esophageal bougie fitted with two olives. 
The first olive is pierced to run on a thread. The olives are made in 
graduated sizes. 

Fig. 183. 

A, Metal staff carrying a perforated olive at the tip (Mixter) : B. Special 
wire carrier (Mosher), on which various sizes of olives are screwed; C, 
Graduated olives. 

can be obtained by employing the spiral wire carrier. The ilexible 
pusher buckles away from the line of the main staff, and so at times 
refuses to push a snug olive through the stricture. The spiral wire car- 
rier, on the other hand, hugs the guiding staff closely and gives a direct 
push on the olive. "\Vhen the olive is in position against the stricture if 
the operator puts his finger in the patient's pharynx and presses down- 
ward on the spiral staff, he can exert great pressure on the olive below. 
In fact the author found that this method of forcing an olive through > f \ 



stricture was so powerful that care was necessary or the stretching of 
the stricture would be too rapid and followed by a reaction. A series 
of olives of increasing sizes comes with the spiral staff. An olive of 
any size can be extemporized. In the case of the boy (Case -'!, page -37) 
an olive of the desired size not being at hand an olive was wound on 
the staff by using coarse surgical silk. The silk was given a smooth 
coating by smearing it with modelling compound such as dentists use 
for taking impressions of the teeth. The spiral staff permits two or 
more olives of increasing size to be put on at once. These may be placed 
at intervals after the fashion of Bunt's bougie. (Fig. 175).) 

The After Care of Stricture of the Esophagus. When a stricture of 
the esophagus has been dilated sufficiently to permit the patient to 
swallow readily, bougies of maximum size must be passed at intervals 
of a week or two or monthly, for months or years. Not infrequently 
adult patients learn to pass the bougie upon themselves. 

Fig. 184. 
Mother's two-bladed dilator with sliding knife for cutting strictures of the esophagus. 

Spastic Stenosis of the Esophagus. 

Esophagospasm (Esophagismus). Esophagospasm is an exces- 
sive irritability of the esophagus. It prevents the introduction of the 
esophagoscope under local anesthesia. I ndcr general anesthesia, how- 
ever, the esophagoscope passes easily. On examination the esophagus 
is found to be normal, or if any lesion is discovered it is almost always 
a simple nlceration. Ksophagospasni is the underlying condition in 
globns hystericiis. It should be remembered thai a diagnosis of globus 
liystericus is made less and less often since the use of the esophago- 
scope has become common. ()n this account the diagnosis should 
always be looked upon \vith suspicion. 

The treatment of esophagospasm is to pass t he esophagoscope under 
ether anesthesia and to treat any nlceration present with some mild 
caustic. If the esopliageal wall proves to be normal the regular pass- 
ing of elastic bougies in time establishes tolerance and does away with 
the sensitiveness of the esophagus. 



Cardiospasm. Cardiospasm is the name applied to a condition of 
spasmodic closure of the esophagus at the cardiac opening of the stom- 
ach. The name, however, is used in connection with spasmodic closure of 
the esophagus at any other point. This condition is one of the most im- 
portant pathologic affections of the esophagus. Its etiology is still ob- 
scure. .Jackson holds that the cardia is not a true sphincter in spite of 

Fig. 185. 

Cardiospasm. Retouched tracing from an X-ray plate. The esophagus 
is filled with bismuth gruel, and is narrowed to a very small lumen. Above 
the narrowing it is dilated. (Author's case.) 

the circular libers of Hyrtl, but maintains that the hiatus is an actual 
sphincter and acts as one. In Cardiospasm there are two chief features, 
spasm of the cardia and dilatation of the esophagus. In the majority of 
the cases there is atony of the muscular wall as well. The conditions 
which are responsible for these changes have been held by various 
writers to be a congenital defect, a primary neurosis, or an esophagitis. 
In some cases the atony is primary to the spasm and dilatation, in oth- 


ers the spasm comes first. Lerche maintains that an attempt should be 
made from the clinical histories to divide cases into the two classes just 
mentioned. Gottstein gives the following classification: (A) Cases in 
which excessive spastic nmsenlar contractions take place. (B) Cases 
in which the contractility of the muscles is weakened or lost. (1) 
Cases are classed as idiopathic in which no organic lesion can be dem- 
onstrated, (2) as secondary or symptomatic when due to some anatom- 
ic alteration as ulcer or cancer. 

Under class A (excessive muscular contraction) are grouped: eso- 
phagospasm, and cardiospasm. The first involves the esophagus 
proper and the second only the cardia. Cardiospasm may be acute or 

Leichten stern defines cardiospasm as a pathologic exaggeration of 
a physiologic phenomenon, due to abnormal innervation of the cardia. 
It produces an habitual, non-permanent, spastic closure of the cardia. 
This is greater than normal, lasts a long time, and occurs especially 
after meals. It is not known whether the condition is caused by a fail- 
ure of the inhibitory nerve fibers which control the normal tonns of 
the cardia or to some irritation which causes an increased tonus in the 
contracting fibers. 

FREQUENCY OF CARDIOSPASM. Both sexes are affected equally. The 
majority of the cases occur between the ages of twenty and forty, but 
cases have been reported in which the patients were eight and four 
years old. The latter case was one of acute cardiospasm. 

ANATOMIC CONSIDERATIONS.- According to Kumpel the capacity of 
the esophagus varies between 40 cc. and SO cc. but even 150 cc. may be 
considered within physiologic limits. The position of the cardia 
changes with age. In the infant it is found at the level of the eighth 
dorsal vertebra whereas in the aged it may be placed as lo\v as the 
twelfth dorsal vertebra. In the neck the esophagus is closed, but in 
the chest it is open and contains air. Mikulicz found that the intraeso- 
phageal pressure during rest was a little below that of the atmosphere. 
By (|iiiet inspiration the pressure is lowered to !) cm. water pressure 
ami by forced inspiration to 20 cm. or below. ()n quid expiration the 
pressure rises to 10 cm. water pressure, and by forced expiration to 
20 cm. Coughing may raise the pressure to (iO, SO, or even 1(50 mm. 
mercury. On swallowing the pressure varies between O.SO mid 22 cm. 
water. The normal esophagus opens easily without the aid of swal- 
lowing for the passage of fluids and gases from the esophagus into the 
stomach, but opens with difficulty for their passage in the reverse di- 
rection. The pressure necessary to open the cardia amounts to a frac- 
tion of the pressure of a column of water filling the thoracic portion 



of the esophagus. When irritating fluids such as very hot or cold 
liquids or carbonized drinks are taken the pressure necessary to force 
them down is higher. 

If the resistance of the eardia is increased, a part of the fluid swal- 
lowed will remain in the esoph- 
agus. Suppose that in order to 
effect automatic opening of the 
eardia under normal conditions 
a pressure of 12 cm. water pres- 
sure is necessary. In this case 
the excess of fluid over 12 em. 
would flow into the stomach by 
its weight, leaving behind a 12 
cm. column of fluid. The next act 
of swallowing which corresponds 
to about 12 cm. water pressure 
would carry this into the stom- 
ach. If the resistance of the ear- 
dia corresponds to 24 cm. water 
pressure, there will be left a col- 
umn of 12 cm. at the end of the 
act of swallowing. If the resist- 
ance of the eardia is still higher 
only so much fluid will pass the 
eardia as is pressed down by the 
muscles of the pharynx. The eso- 
phagus itself can overcome the 
resistance of the eardia only by 
energetic contraction. In a nor- 
mal esophagus the effect of this 
increased pressure on the eso- 
phagus is small but as soon as the 
esophagus becomes dilated the 
effect of the increased pressure 
which is necessary to force food 
through the unyielding eardia is 
to make the esophagus dilate 
more and more. Stagnating food 
leads to changes in the esopliageal wall which further weaken it. 

Mikulicz used the esopliageal pressure during swallowing as an 
indication of the contractile power of the esophageal muscles. He 
therefore measures this pressure. Lerche has devised an apparatus 
for doing this. (Fig. 186.) 

Apparatus for 
(After Lerche.) 

Fig. 186. 




THE SYMPTOMS OF CARDIOSPASM. The two chief .symptoms of cardi- 
spasm are difficulty in getting food into the stomach, and frequent 
regurgitation. Often the patient lias a troublesome cough at night, or 
is awakened by food running back into the pharynx and into the nose. 
If the condition has existed for some time the patient is much ema- 

EXAMINATION. The history of the patient should exclude syphilis, 
and the swallowing of caustics or foreign bodies. In the general phys- 
ical examination of the pressure from an aneurism, a goitre, or a tumor 
in the mediastinum should be constantly borne in mind. The esopha- 
geal examination should be ruled out in the presence of ulcers, and of 
malignant or benign growths. It must be remembered that a large 
or a low seated diverticulum of the esophagus may be present. 

Much light is often thrown on a case by filling the esophagus with 
bismuth and then taking an X-ray plate. 

The Examination ruder Local Anestl/esia. A large sized elastic 
bougie is introduced into the esophagus and the distance of the ob- 
struction from the incisor teeth is found. In a case of cardiospasm the 
bougie will occasionally pass through the cardia easily or on gentle 
pressure, at other times much pressure is needed to force it through. 
The esophagus is washed out and the throat cocainized. Then the eso- 
phagoscope is passed and a careful examination is made of the esopha- 
gus. The condition of the mucosa and of the esophageal walls is noted. 
It should be ascertained whether the walls are firm or flaccid and 
whether the esophagus is normal iu size or dilated. I'lcerations, diver- 
ticulum and new growths are excluded. When the tube reaches a proper 
depth the cardia is seen as a slit with the long diameter lying obliquely 
from the right posteriorly to the left anteriorly. This is not the cardia 
strictly speaking but the hiatus of the esophagus, though many writers 
use this name for the constriction of the esophagus at the point where 
it goes through the diaphragm. The hiatus appears either as a slit 
or as a rosette. In spasm it is usually like a rosette. It has been com- 
pared to the mouth of the cervix uteri. ( Fig. His.) The esophagoscope 
cannol be passed in cases of cardiospasm inlo the stomach without 
first cocainizing the hiatus. As soon as the hiatus gives way the tube 
is carried into the stomach and then withdrawn. On the withdrawal 
the esophagus is examined again in order to confirm the negative find- 

In a complete examination the next step is to determine the 
capacity of the esophagus. An esopliagometer is used for this purpose 
Lcrche has devised an instrument of this nature, ll consists of a rub- 
ber bag which is inserted into the esophagus and then filled with air. 
A recording mechanism registers the amount of air necessary to make 

LARYNCOSCOI'Y, BliOXCllOSroi'Y, KS( ) I ' 1 1 A< ;( )S( '( )l '\ ', KTC. '-'45 

the bag assume the same dilatation and shape as the esophagus. An 
X-ray picture may he taken with the I mi; 1 in place. This will demon- 
strate the shape of the dilation more sharply than the bismuth gruel. 

Tin-: TRKAT.MKXT ()!' ( 'A HDiosi'ASM . The treatment of cardiospasm 
consists in stretching the hiatus of the esophagus. This can be ef- 
fected with a pliable dilator like a rubber bag, or with an instrument 
modelled on the principle of the urethral dilator. The rubber bags 
are generally used under local anesthesia. The apparatus used by 
Lerelte is shown in Fig. 186'. It consists of a stomach tube the end of 
which is covered with a sausage-shaped silk bag K )-!'_' cm. lon.u 1 . The 
bag is distended by connecting the apparatus with a water faucet. 
A secondary mechanism regulates the amount and the pressure of 
the water and so the pressure exerted by the bag when it is in place. 

The use of bougies in pronounced cases of cardiospasm for dilating 
the hiatus does not give good results. 

(lUinprecht has stated that the maximum dilatation to which the 
normal cardia can be stretched is respectively .'> cm. and .'!..") cm. Schciber 
found that the normal cardia from the stomach side could withstand 
a pressure of .'550 grams for a few seconds. Strauss distended the 
rubber bag with air and had his apparatus so regulated that a pres- 
sure of not more than L'5() cm. of mercury could be brought upon the 
cardia. Jacobs using a mechanical dilator fashioned on the plan of 
the urethral dilator stretched the cardia to a diameter of IJ.o cm. 
Alikulic/ working from within the stomach stretched the cardia to 
a diameter of 7 cm. 

Tin- Trrtif n/rnf <>! Cardiospasm Cmlrr Ether. - - An examination 
under ether is much easier for the patient. The stretching of the 
cardia with the mechanical dilator is much simpler than the use of the 
rubber bags. There is one drawback, however, to the examination 
under ether. All spasm of the esophagus is done away with and the 
cardia itself may so be relaxed that unless the examiner bears this fact 
in mind he may feel that ho has not found the cause of the condition for 
which the examination is undertaken. After the ether examination in 
cases of cardiospasm and the dilatation of the cardia the author has 
been in the habit of leaving a thread in the esophagus and in the stom- 
ach and of passing the olive tipped staff on the thread for a few days 
until it was possible to pass the staff unguided. ( )n the staff metal 
olives of increasing size are passed for a time and then the unguided 
elastic bougie. Finally the patient is taught to pass the bougie for him- 
self. This he does at intervals according to the persistence of the 

The relief of cardiospasm is easily brought about. The patient's 
symptoms lessen almost immediately. Measurements show that the 



esophagus soon contracts unless there has been extensive weakening 
of the esophageal walls. Cases of this kind although they obtain 
marked relief from stretching of the cardia naturally still have a 
certain amount of residual trouble on account of the slowness with 
which food passes the weakened esophagus. Cases of cardiospasm 

('anliospiisni. From a print of an X-ray plate, showing a dilated eso- 
phagus. The esophagus narrows to a point in the shadow of the diaphragm. 
( Plate by Dr. F. 11. Williams.) 


are among the most dramatic of surgery. The following case is an 
example: A young woman had been regurgitating her food for fifteen 
years. She went from physician to physician. She was constantly 
eating but was always hungry, and consumed enough food for two or 
three people but continually wasted away. When she laid down food 
regurgitated into her mouth or her nose. This and a constant cough 
kept her awake. In a short ether examination lasting about the same 
number of minutes as she had been ill years the cause of the trouble 
was discovered and practically cured. (Fig. 187.) 

Phrenospasm. Phrenospasm is the name applied by Jackson to 
spasmodic closure of the esophagus at the hiatus. This condition is 
frequently seen in passing the esophagoscope without anesthesia. 
Frequently the esophagoscope is hugged so tightly that the subphrenic 
portion of the esophagus cannot be entered, ruder general anesthesia 
the spasmodic closure of the hiatus disappears. This characteristic 
disappearance of the spasm together with a normal mucosa establishes 
the diagnosis of phrenospasm. Almost invariably the esophagus is 
dilated above the hiatus. 

Jackson makes a clear distinction between spasm of the cardia 
and spasm of the hiatus. Many authors do not, but speak of spasm 
of the cardia when in reality they mean spasm of the hiatus. Then 
again the term spasm of the cardia is used to mean spasm either at 
the cardia or at the hiatus. Jackson's terminology leads to clearness. 

Benign New Growths of the Esophagus. 

Benign neoplasms of the esophagus occur but are not common. 
When it becomes the routine to examine all cases of slight trouble 
with swallowing in all probability more benign new growths will be 
discovered. Edematous polyps and pedunculated lipomata are prob- 
ably the commonest of the benign growths. Fibromata also occur. 

These benign growths are found chiefly in the upper part of the 
esophagus. Their pedicles allow them to play up and down so that 
they appear at one examination and may disappear at the next or 
they are present when the examiner first looks into the throat with 
the 7iiirror and they disappear when the patient swallows. Peduncu- 
lated lipomata have a fashion of dropping forward into the larynx 
and of causing cough and intermittant hoarseness. 

Treatment of Benign New Growths. Benign new growths should 
be removed with appropriate grasping or cutting forceps. An effort 
should be made to obtain as much of the pedicle and its base as is 
possible. Sometimes the manipulations can be carried out through 
the tubular speculum, whereas at other times the esophagoscope is 


necessary. The accessibility of the growth and the tolerance of the 
patient settle the question of the use of local or general anesthesia. 
With the exception of lipomata all supposedly benign growths are 
looked upon with a certain amount of suspicion. In any given case 
time alone can settle whether or not this suspicion is well founded. 

Malignant New Growths of the Esophagus. 

Any persistent difficulty of swallowing in a patient of the cancer 
age ought to lead to a prompt examination of the esophagus. Only in 
this way can malignant disease be detected early and the cases which 
are n't for operation sorted out. Cancer of the esophagus often gives 

Fig. 188. 
Section of normal esophagus (Low power). 

but .-li.u'ht symptoms for a number of years. It is not uncommon to 
have patients give a history of trouble with swallowing dating back 
three or four years. The horrors of cancel' are nowhere greater 
than in cancer of the esophagus. If for no other reason, therefore, 
these patients should be given the benefit of an early examination and 
of an early diagnosis. 

Malignant disease may start in the epithelium of the esophagus, 
or in its muscular wall, or outside of it. In late cases no conclusion can 
be arrived at a> to origin of the disease. 

Periesophageal disease when not far advanced appears through 
the esophagoscopc as a hard nodule projecting into the lumen of the 
esophagus and over which the mucous membrane is normal. 

LARYXOOSCOI'Y, IWOXC 1 1 OS< 'Ol'Y , KS< !' 1 1 A< :< )S( '< ) l"> , I-/I < . 1_'4!> 

Gottstein, quoted by .Jackson, describes the appearance of can- 
cer of the esophagus under live heads. 

1. The esophageal wall shows thickened whitish patches. These 
white patches alternate with patches of bright red. 

'2. There is a ring-like narrowing of the lumen of the esophagus. 
This is called the annular form. At some point in the rimr there is 
usually ulceration. FYequently the esophagus is dilated above the 

'.). Carcinomatous infiltration which is not only aiinnlar in form 
but funnel-shaped. 

4. Cauliflower masses surrounding 1 the lumen of the esophagus. 

5. Papillomatous vegetations. 

In the author's experience the most common forms are the first, 
second and the fourth. Syphilis may simulate any of the five forms. 
The microscopic examination of a specimen combined with the thera- 
peutic and the Wassermann test will rule out syphilis. 

Cancer of the esophagus occurs oftenest at the upper or the lower 
end. It is not uncommon, however, to find it located about half way 
down the esophagus. 

Symptoms of Cancer of the Esophagus. The chief symptom of can- 
cer of the esophagus is difficulty in swallowing. This symptom may 
be slight for years. Associated with the difficulty in swallowing, if 
the growth is located in the upper part of the esophagus, there is 
pain radiating to the ear of the affected side. Often the cervical glands 
are enlarged. They become infected even if the cancel 1 is situated at tin- 
cardiac end of the esophagus. Later in the disease when the ingestion 
of food is impeded, emaciation sets in. 

Diagnosis of Cancer of the Esophagus. The old method of making 
a diagnosis of cancer of the esophagus was to label the difficulty in 
swallowing by some such name as globus liystericus, or neurasthenia, 
and to temporize until obstruction became marked and emaciation 
noticeable. Then a bougie was passed, an obstruction was found and 
the bougie brought up blood. Today this is antiquated surgery, to 
call it by no harder name. The bougie has cost many a patient his 
life not only by delaying the diagnosis until too late but also by per- 
forating the weakened walls of the cancerous esophagus. 

Diagnosis and Treatment of Cancer of the Esophagus. Cancer of 
the esophagus is best diagnosed by the esophagoscope or by the open 
or tubular speculum. Palliative treatment is also best carried out 
through these instruments. The removal of a specimen for microscopic 
examination may seem a trivial affair in such an ugly disease, but 
the surgical satisfaction which comes from it is not to be despised. 


If the cancer is well advanced and happens to be in the upper part of 
the esophagus the tubular speculum gives a splendid view and enables 
the surgeon to remove a generous specimen quickly and easily. Good 
biting forceps are necessary for this procedure, and care must be 

Carcinoma of the; esophagus. 

taken to pierce \vell into the tumor. (Fig. ISO.) It' the mucous mem- 
brane over the suspected area is unbroken it may be questioned whether 
or not it is justifiable to cut into it. I'nless this is done, however, the 


case must bo left in doubt. If the examination is carried out under 
ether and the growth is situated at or near the mouth of the esophagus, 
the open speculum, given a favorable nock, affords a good view and 
enables the operator not only to remove a specimen but to clear away 
a great part of the fnngating growth. In cancel 1 below the mouth of the 
esophagus, if it is of the cauliflower typo, careful curetting will remove 

Fig. 190. 
Section of carcinomatous area (Low power). (See Fig". 189.1 

the obstructing masses and restore the patient's ability to swallow soft 
food. The author believes from his results that this procedure is justi- 
fiable. The curetting may be repeated two or three times. (Figs. 190 
and 191.) The examination of a case of cancer of the esophagus is not 
ideally complete unless the lumen of the cancerous stricture is ascer- 
tained and the presence of a secondary growth lower down is deter- 
mined. (Figs. 192 and 1911) In order to accomplish this a smaller 



Fig. 191. 
Section of earcinomatous area (High power). (See Fig. 190.) 

Fig. 19L>. 

Can-iiiomatoiis stricture of the esophagus. 
( Plate by [)r. \V. .7. Dodd.) 

LAHYNOOSCOI'Y, BHOXC 1 1 OS( 'OI'Y, KS( )|'l I A< ',( )S( '< >\>\ , 

tube should be passed through the larger esophagoseopc ;in<l carried 
down through the rest of the esophagus. It is not always possible to do 
this; nevertheless the attempt should be made. 

Fig. 193. 

Cancer of the esophagus. Retouched tracing from X-ray plate. (Lateral 
view.) The esophagus is tilled with bismuth gruel. At the point where 
the growth is the esophagus ends in an irregular cone. Splashes of bis- 
muth which have passed through the stricture are seen below. (Author's 

When the walls of the esophagus are surrounded with fungating 
masses of cancerous growth it is hard to tell where the lumen of t he- 
esophagus is placed. In such a case if the esophagus is ballooned 


with air the displacement of the cancerous masses reveals the site 
of the esophageal opening. If no opening is found but the air enters 
the stomach, pressure on the abdomen will force the air back and as 
it bubbles upwards through the structure the lumen can be located. 
In extensive disease of the esophagus the esophageal lumen can be 
saved for a time by intubing the carcinomatous stricture with a small 
clastic webbing funnel after the method of Mixter. 

It is justifiable to dilate a cancerous stricture with bougies or 
with the mechanical dilator only by using these instruments through 
the esophagoscope and under visual guidance. Even with these safe- 
guards the procedure must be employed with extreme care. 

What every physician hopes to find in a case of cancer is that the 
new growth is located at the upper part of the esophagus, that it is 
not extensive and that it is of a low grade of malignancy. Such cases 
offer a chance of cure if the larynx is removed and the diseased por- 
tion of the esophagus resected. Patients who might have been saved 
by this method have gone to their graves without any attempt having 
been made to relieve them. Such cases exist today, but they will never 
be found except by the routine use of the esophagoscope. When hope- 
less cases are encountered, and they are still in the great majority, an 
early opening of the stomach will save the patient from starving to 
death. The author cannot understand the reluctance of some surgeons 
to giving the patient the benefit of this operation. 

Compression Stenosis of the Esophagus. 

Structures which border on the esophagus may push upon it and 
cause compression. The conditions which are commonly found to 
do this are glandular enlargements, cervical or inediastinal tumors, 
aneurism, plural effusions and spinal deformities. 

The esophageal examination in these cases shows only a nar- 
rowed lumen. The general physical examination supplemented by an 
X-ray plate are the most efficient means of arriving at a correct 
diagnosis of the cause of the compression. In an aneurism the pulsa- 
tions may be seen through the fluoroscope. 



Inflammation and Ulceration of the Esophagus. 

In acute inflammation of the esophagus the usual signs shown by 
an inflamed mucous membrane are present. According as the inflamma- 
tion is general or local there is a small or an extensive area of redden- 
in ii\ Later the mucosa becomes edematous. The vessels of the inucosa 


arc not as a rule visible. Acute inflammation of the esophagus, if severe, 
is a contraindication to the passage of the esophagoscope. When, 
however, it is caused by the presence of a foreign body the inflammation 
should be disregarded and the foreign body removed at once. In acute 
inflammation where no cause is found, an underlying carcinoma should 
be suspected. 

Chronic Inflammation of the Esophagus (Chronic Esophagitis). 
Chronic inflammation of the esophagus may follow acute inflammation 
but as a rule it is the result of the long continued irritation of pus 
or food. These are held in the esophagus by spastic or anatomic 
strictures, or by diverticula. Uncomplicated chronic catarrhal inflamma- 
tion of the esophagus is seen most often in alcoholics. Here it is due 
chiefly to the irritation of the local irritant. The esophagus is usually 
a dirty gray or a pale red, at times mottled and with the vessels show- 
ing. Tenacious mucus covers it. 

Ulceration of the Esophagus. Ulceration of the esophagus occurs 
in two forms, ulcers located above the hiatus and ulcers below it. 

Fig. 194. 

Forceps with punch tip for direct work upon the larynx or 
esophagus. This forceps is made in various lengths so that 
the punch can be adjusted for any length of esophagoscope or 
bronchoscope. (Pfau.) 

Ulcerations above the hiatus may be due to any of the causes which 
produce acute inflammation of the esophagus, i. e., to infection or 
trauma. The ulcers occurring in typhoid fever are caused by throm- 
bosis of the vessels. Deep painless ulcerations occur in syphilis. The 
same is true of the ulcerations which occur in tuberculosis. The greater 
part of the esophagus may be involved in tuberculosis without the 
lesion being suspected. Tuberculosis of the esophagus usually is sec- 
ondary to tuberculosis of the lungs and is due to swallowing sputum. A 
tuberculous bronchial gland may ulcerate into the esophagus, though 
this happens but rarely. 

Ulcerations of the esophagus below the hiatus bear a strong 
resemblance to peptic ulcerations of the stomach. They are often 
assigned to functional insufficiency of the cardia. Jackson believes that 
the closure of the upper end of the stomach is due to a kinking of the 
esophagus at the hiatus and that the kinking is caused by the pressure 


of the contents of the stomach at the fundiis and by the structures 
about the hiatus. The contents of the stomach, however, frequently 
invade the lower part of the esophagus. Ulcerations of the esophagus 
at this point have a resemblance to ulcerations of the duodenum and 
may have the same pathology. Codman has made the observation that 
duodenal ulcerations are often associated with fissures of the cardia. 
He made the further observation at autopsies that fissures of the 
cardia were not uncommon. The analogy is at once suggested between 
fissure of the cardia and fissure of the anus. 

Where an ulceration cannot be explained the presence of a buried 
foreign body should be considered. 

The treatment of ulceration of the esophagus consists first and 
chiefly in the removal of the cause. After this is accomplished the 
topical application of nitrate of silver, argyrol, or tannin is useful. 
The same procedure is advocated for the peptic ulcer. The ulcer is 
cleaned and then dusted with bismuth powder or touched with nitrate 

Fig. 1 !;-,. 

Mother's curette for use in examination by the direct 
method of the upper end of the esophagus and the larynx. A 
similar but much longer curette is made for use with the eso- 
phagoscopo. In dealing with malignant diseases these instru- 
ments are indispensable. 

of silver. There is no danger of perforation or of hemorrhage if the 
manipulations are carried out gently, and always under clear vision. 

Neuroses of the Esophagus. 

Sensory Neuroses of the Esophagus. --The diagnosis of a sensory 
neurosis of the esophagus should he made with great care. Since the 
advent of the esopliagoscope the number of true cases of sensory 
neuroses of the esophagus has been markedly diminished. A routine 
examination of such cases will reveal a large number of instances in 
.\ liich the symptons have a real anatomic or pathologic basis. The 
old diagnosis of .u'lobns hystericiis should never pass un<|uestioned. 
A trifling anatomic ncculiaritv like a partial band at the mouth of the 

I . 

esophagus, can readily cause these cases. The writer feels that further 
study of the upper end of the esophagus will show that such bands 
are frequent. Small ulcerations from trauma could cause such partial 
bands or adhesions. Whether caused bv trauma or bv some slight 


irregularity of development the passage of a good si/cd bougie under 
the old method of treatment would break the band and clear up the 
symptoms but not the diagnosis. In order to make the diagnosis as 
certain as modern knowledge can make it the esophagoscope must 
be passed before the bougie. 

True sensory neuroses include hyperesthesia of the esophagus, 
anesthesia, and paresthesia. The patient groups his symptoms under 
the head of a feeling of contraction of the upper part of the throat and 
difficulty in swallowing, or as a sensation of itching, pricking or gen- 
eral uneasiness. Except in cases of true hysteria sensory neurosis of 
the esophagus is very rare. 

The appropriate treatment is along general medical lines. 

Paralysis and Paresis of the Esophagus. In cases where the in 
nervation of the esophagus is interfered with, all solid food is swal- 
lowed with difficulty. Fluids are usually swallowed easily. At times, 
even fluids may go down with difficulty and only in small quantities. 
After eating there is pain back of the sternum and regurgitation of 
mucus or food. 

Contrary to expectation the esophagoscope, even without ether. 
readily enters the esophagus and passes easily into the stomach. The 
ease with which it passes establishes the diagnosis, because in spastic, 
stenosis spasm occurs if no anesthetic is used, and if there is an anatom- 
ical stricture this persists even under ether. The paralysis may be 
demonstrated by Stark 's pill experiment. With the aid of the esophag- 
oscope and forceps a pill or capsule is placed in the esophagus 27 cm. 
from the incisor teeth. If the peristalsis is normal the pill will be car- 
ried into the stomach; if the pill remains where it is placed a paralysis 
or an abnormal feebleness of the esophageal wall exists. 

The chief causes of paralytic conditions of the esophagus are cen- 
tral nerve lesions, the most common being bulbar paralysis, and the 
neuritis which follows alcohol, diphtheria, and lead poisoning 

When a paralytic condition of the esophagus is suspected a neuro- 
logic examination is called for, and if such a condition is proved the 
treatment, of course, is along general lines. 

Congenital Anomalies of the Esophagus. 

Congenital anomalies of the esophagus occur occasionally. The 
esophagus may be bifid or double or it may end in a blind pouch. 
Children having these deformities seldom live for any length of time. 
Karely, a fistula joins the trachea and the esophagus. Cases of this 
kind have been reported and the patients have survived. This was 


possible for the reason that a valve-like fold of mucous membrane 
prevented food from getting into the trachea. 

Congenital Stricture of the Esophagus. A little girl about a year 
old was referred to the author with the history that she 
had swallowed a "pacifier," and had had almost complete 
obstruction to swallowing since the accident. The baby was 
very poorly nourished and it was found on questioning the parents 
that from birth she had continually thrown up her food. It was sup- 
posed naturally that the milk was not of the proper kind. Both the 
milk and the physician were repeatedly changed. The baby just man- 
aged to survive up to the time when it made a meal of the "pacifier." 
It speedily vomited the rubber nipple which was on the end of the 
"pacifier." Notwithstanding this it could not retain any milk. A local 
specialist passed an esophagoscope and through this introduced a 
bougie but could not make it enter the stomach. At this point in the 
case the author saw the child. The X-ray showed a small round body 
apparently in the esophagus and at the level of the bifurcation of the 
trachea. This was supposed to be a bit of bone from the "pacifier." 
On examination under ether this bit of bone was neither seen nor 
felt, but instead a stricture was found. This was at the level of the 
bifurcation of the trachea and readily admitted a Xo. 1(> F. bougie 
and was easily dilated up to Xo. '20 F. Subsequent dilatations carried 
the lumen of the stricture to L'b' F. After a few days the baby began 
to retain milk. A second plate showed that the bit of bone which gave 
the round shadow in the first plate had disappeared after the examina- 
tion. The stools were searched but it was never found. 

The following seems to be a reasonable explanation of this case. 
The child had a congenital stricture and she forced its discovery by 
swallowing the rubber nipple from the "pacifier" and perhaps a bit 
of bone from the handle. 'Die first examination pushed the piece of 
bone through the stricture and the second pushed it into the stomach. 
The second examination determined the presence of the stricture and 
led to its dilatation. 

Diverticulum. A diverticulmn is a pouch-like off-shoot from the 
esophagus. The so-called traction divert iculum is the easiest of ex- 
planation. It is caused by the contraction of scar tissue, arising from 
a suppurating gland in process of healing. This new tissue exerts a 
] nil upon a circumscribed part of the esophageal wall and makes a 
pouch. In certain animals pouches and dilatations of the esophagus 
are normal; for instance, the crop and the dilatation of the lower por- 
tion of the esophagus in birds. Something of this tendency to variation 
in form mav be retained in man. In one of the author's cases the 

LAHYXCOSCOI'Y, HKONC 1 1 OSCOPY , KSOIM I'A< ;oS( 'Ol'Y , KTC. '_'.")!) 

mouth of the esophagus was very wide as if the pharynx extended he- 
low the crieoid cartilage and had there attempted to make a double 
esophagus, the unsuccessful attempt being the pouch. 

Diverticula are encountered most often in the upper part of the 
esophagus near the crieoid cartilage. In every esophageal examination 
the possibility of finding a pouch must be borne in mind and its exist- 
ence ruled out. 

Si/)>i}>tonis. The symptoms of a small pouch are not marked 
enough to make the examiner do more than suspect its presence. The 
chief symptoms are slight difficulty in swallowing and soon after eat- 
ing the regurgitatiou of a small amount of undigested or putrid food. 
Where a poucli has existed a long time and has dissected its way 
downward between the muscles of the neck and perhaps into the chest 
the symptoms, although of the same general character, are much more 
marked. It is impossible from the symptons to differentiate such a 
case from one of phrenospasm and dilatation of the esophagus. 

Diagnosis. If the presence of a pouch is suspected the physician 
may give the patient bismuth and then take an X-ray: or he 
may give the patient bird shot to swallow and then take the plate; 
or he may pass a bougie. The bougie on its first introduction meets 
with an obstruction high up in the esophagus and then if it is with- 
drawn and reiutroduced it enters the lumen of the esophagus and 
continues on into the stomach. Xo one of these three methods is as 
satisfactory as the diagnosis of a diverticulum by sight. An X-ray 
plate of an esophagus filled with bismuth often gives the impression 
of a pouch where none exists. This is due to spasm of the esophageal 
wall. Briinings has a beaked tubular speculum the lower half of which 
lias a slit in the side. In using this the attempt is made to engage the 
beak of the speculum in the opening of the esophagus and after this 
has been located, to find the opening of the pouch by examining the 
esophageal wall through the slit in the side of the instrument. 

In the search for diverticula the ballooning attachment for the oval 
esophagoscope is of the greatest service. There is usually no trouble 
in finding the pouch, as the esophagoscope goes into it most readily. 
Once in the pouch, the examiner sees no esophageal lumen ahead. 
Instead there is an unbroken wall. On attempting to readjust the 
long axis of the tube to conform to the long axis of the esophagus 
still no lumen appears. If now the window plug is inserted and the 
pouch distended with air the fact that the end of the esophagoscope 
is in a closed cavity becomes (dear. Not only this, but the size of the 
pouch can be made out and the condition of its walls. The bottom of the 
pouch is found in many cases to be thickened and inflamed from the 


retention and maceration of food. When the pouch has been outlined 
in this way if the esopkagoscope is slowly withdrawn, and all the while 
air is forced into the pouch, at the moment when the end of the 
esophagoscope leaves the month of the pouch and is opposite the 
opening of the esophagus two openings will be seen through the 
tube. The new opening will prove on examination to be the lost 
opening of the esophagus. This is by far the best method of determin- 
ing the presence of a diverticulum. 

Tr<'af iiK'tit of Kxopliftf/cal Diverticula. Lf the pouch is large 
enough and not too large, that is, if it does not extend into the chest, 
it may be dissected out. This is the treatment advocated at the Mayo 
hospital. Small and medium sized pouches may be cured symp- 
tomatically by dilating the esophagus at the point where the pouch 
leaves it. This is done by first finding the pouch and cleaning it of 
food and then stretching the esophagus with the mechanical dilator. 
After this a thread is passed through the esophagus into the stomach 
and allowed to engage in the upper part of the intestinal tract. As 
soon after the ether examination as the thread has become well an- 
chored, the metal staff of Mixter with its perforated olive is carried 
down on the thread and olives of increasing size are forced down on 
the staff. After a week or two the metal staff will find the esophageal 
opening unguided by the thread and the thread may be allowed to 
pass on. The physician soon finds that he can pass elastic bougies 
also of increasing size, through the esophagus. .Lastly the patient, is 
taught to pass a bougie of reasonable size for himself. This has to be 
continued for an indefinite time. Mixter who has had much experience 
both with excision of the pouch and with the symptomatic cure by 
dilatation, favors for the general run of cases the treatment by dilata- 

Some day it may seem feasible to cut the common wall between a 
small pouch and the esophagus. When this procedure is attempted 
it will be carried out if it is to be performed in a surgical fashion, 
through the esophagoscope. The writer tried this in a rather hesitat- 
ing manner on one case, and is waiting for an appropriate case to try it 
again. The results were mediocre, i. e., no better than dilatation. 

Dilatation of the Esophagus. 

In dilatation of the esophagus the whole structure becomes en- 
larged and acts as a sac instead of a tube. The most common form 
is a spindle-shaped esophagus. From certain observations the au- 
thor is of the opinion that a dilatation of moderate degree of the 


lower third of the esophagus is common, it' not normal. It is certainly 
not unusual in dissecting room bodies. 

The lower part of the esophagus is the part most often enlarged. 
The dilatation is due either to an anatomic stricture or to a spastic 
closure at some point. The forms of stricture have been discussed. 
Spastic closure, as has been said, is due as a rule to spasm of the 
hiatus of the esophagus or to spasm of the cardia. Dilatation of the 
esophagus is spoken of at this point under a separate heading, and 
after diverticula of the esophagus have been discussed, because tin- 
two conditions have to be differentiated. 

The diagnosis is made by examining the lumen of the esophagus 
through the esophagoscope. In the normal esophagus the walls hug 
the examining tube and are seen to be continuous with the end of the 
tube for some distance ahead. If the esophagus is dilated the end of 
the esophagoscope finds itself in a large, dark cavern the walls of 
which become clear only as the tube is moved strongly from side to 
side. The opening of the esophagus below the dilatation may not be 
in the center of the dilated portion, but eccentric. Not only 
this, but the dilated portion may sag below the level of the esophageal 
opening and make a dee]) moat about it. Most often the sa.uging of 
the dilated part of the esophagus below the opening of the esophagus 
occurs to the right of the esophageal opening. It is into this sagging 
part of the esophagus that the point of the examining bougie invariably 
finds its way, and it is at this point that perforation of the esophagus 
from rough manipulation with bougies occurs most frequently. When 
this pouch-like collar occurs at the lower end of the esophagus the use 
of a metal staff with an olive on the end enables the examine] 1 to 
swing the point of the olive to the left and to iish successfully for the 
opening of the esophagus. Ballooning the esophagus smooths the folds 
and makes the lumen stand out clearly. 

The treatment of dilatation of the esophagus is to treat the con- 
dition which causes it. 'Phis has already been given. 

Foreign Bodies in the Esophagus. 

.Jackson begins his chapter on foreign bodies in the esophagus 
with the following sentences: "Considering the brilliant achievements 
of esophagoscopy in the removal of foreign bodies from the esophagus, 
it is time to pronounce the prevalent use of the sound, the vertebrated 
forceps, the coin catcher, the bristle and sponge probangs obsolete, 
dangerous, unsurgical and utterly unjustifiable. There are numerous 
cases on record of fatal results from their use, and there are many 
times as many cases that have never been reported/' This language 


is none too strong, especially when applied to the use of these instru- 
ments in cases of rough or sharp foreign bodies. 

Foreign bodies lodged in the esophagus fall naturally into two 
groups, smooth foreign bodies and rough or pointed ones. In the first 
class are penny whistles, buttons and coins. Prominent in the second 
are pins, needles and safety pins, fish bones, chicken bones, meat 
bones, and lastly, partial or complete tooth plates. Coins often lodge 
for a while and then go down, although there are many cases in 
which coins have failed to pass into the stomach but have remained 
in one position and ulcerated into the aorta or trachea. Pointed and 
sharp objects as a rule lodge and finally perforate and generally prove 

Ordinarily patients come to the physician with the history that 
they have swallowed a foreign body. This is not always the case, 
however, because it sometimes happens that they come simply for 
difficulty in swallowing. In infants regurgitation of food may be the 
only symptom. Older children may swallow liquids but not solid food 
and there is a persistent cough. Patients often think that a sharp 
foreign body is still in the esophagus when in reality it has passed 
downward. The scratch or abrasion caused by it, and this is especially 
+rue of fish bones, for some days makes the patient feel that something 
is wrong and lie interprets his abnormal sensations as the continued 
presence of the foreign body. Without an esophageal examination it 
is very hard to disabuse the patient of this idea. Patients seldom 
localize the position of the foreign body accurately. 

Places Where the Foreign Bodies Lodge. Foreign bodies in the 
esophagus lodge most often back of the cricoid cartilage. If they are 
dislodged from here they stop again at the level of the inner end of the 
clavicles. Anatomic narrowing is said to be responsible for this. Once 
beyond the clavicles smooth foreign bodies almost always find their 
way into the stomach and any smooth foreign body which gains the 
stomach as a rule can pass the pylorus. It is astonishing how large an 
object can do this. The author has known a flat, mother-of-pearl 
button one inch in diameter to pass from the stomach of a one year 
old child into the intestinal tract and to be recovered in the stools in 
twenty-four hours. 

Procedure to be Followed in Cases of Foreign Bodies. The his- 
tory of the case is taken and the parents or the friends of the patient 
are instructed to bring a duplicate of the foreign body if it happens 
to be a nail, a pin, or a button. The physician can probably furnish 
a duplicate it' the foreign body is a coin. I'nless the case happens to 
be desperate from pressure upon the trachea an X-ray plate is taken. 


This determines tlie position of the foreign body and in case its nature 
is not known often discloses it. Next appropriate instruments for the 
extraction of the foreign body are selected or obtained. Success in the 
removal of foreign bodies lodged either in the trachea or in the eso- 
phagus depends upon two things, the mechanical sense and dexterity 
of the operator, and suitable instruments. In the matter of instru- 
ments it is vitally important to select grasping forceps with blades 
adapted to seizing the particular foreign body in hand. ( Fig. 1!)(5.) 
On the duplicate foreign body the forceps chosen can be tested. If the 
duplicate foreign body is placed in a piece of rubber tubing the manip- 
ulations necessary for its extraction can be practiced. Such practice 
leads to siireness and confidence and these in turn lead to success. 

Before using the tubular speculum or the esophagoscopc a system- 
atic examination is made with head-light and mirror of the patient's 
mouth and pharynx. The crypts of the tonsils, the supratonsillar fossa 

Fig. 196. 
Jackson's foreign body forceps. 

and the vallecuhr at the base of the tongue and the pyriform sinuses 
are examined in turn. Impacted concretions in the supratonsillar fossa 
often give the sensation of a foreign body. If a good view cannot be 
obtained after cocainization and if the foreign body happens to be 
small like a fish bone or a pin, the base of the tongue and the pyriform 
sinuses are explored with the tip of the finger. Should the foreign body 
happen to be a coin this manipulation is not employed for fear that 
the gagging caused by it might dislodge the coin from the grasp of 
the mouth of the esophagus and start it downward. For the same 
reason sounds and bougies are not passed. 

Choice of the Anesthetic. After the examination of the mouth 
and pharynx has proved negative the operator decides whether 
the examination with the tubular speculum is to be carried out under 
local or general anesthesia. Many successful extractions of foreign 
bodies, notably in the German clinics, have been performed under 
local anesthesia. Even partial tooth plates have been so removed. 
Some allowance must be made for the temperament of the patient 



and also for the temperament of the operator. The author has re- 
peatedly expressed his individual preference for general anesthesia. 
If the operator prefers the sitting position and cocain anesthesia, 
well and good, provided that the results are good; if, on the other 
hand, he should prefer general anesthesia and the prone position of 
the patient he should not be ruled out of court. 

Coins and Buttons in the Esophagus. Coins and buttons and for- 

Fig. 11*7. 

Penny lodged in the upper part of (ho esophagus of a child. The 
penny is well above the level of the clavicles, that is, it is just below the 
mouth of the esophagus and opposite the cricoid cartilage. (X-ray tracing 
retouched and reduced. Drawing made by the author. From the throat 
clinic of the Massachusetts (General Hospital.) 

eign bodies of similar form usually lodge behind the cricoid cartilage. 
These cases usually occur in children. The first thing which the physi- 
cian should remember when he encounters such a patient is to keep 
his finger out of the child's mouth. (Fig. 1!7.) If the X-ray plate shows 
that the coin is sticking behind the cricoid cartilage and the patient is 
an infant or ;i young child, it is wrapped in a blanket, placed on its 
back on the examining table and the head is brought over the end of 


the table and held by an assistant. II' the child is too large to be con- 
trolled, ether is given. The operator has a choice of instruments for 
bringing the coin into view, the closed tubular speculum of .Jackson 
or Briinings and the adjustable speculum of the author. If the adjust- 
able speculum is selected the point of the speculum is passed under 
its own illumination or under the illumination of the head mirror 
and no illumination equals that of the head mirror for short distances 
until the point of the speculum is engaged behind the ring of the 
cricoid cartilage. When the ericoid cartilage is held forward it is 
possible to see down the lumen of the esophagus almost to the level of 
the clavicles. Coins and buttons lie flat against the vertebral column, 
so that the operator sees only the upper edge of the rim of the coin. 
This appears as a dark, transverse line. The edge of the coin being in 
view it is a simple procedure to pass a pair of angular forceps and re- 
move it. The tubular speculum can be employed in the same way. It 
does not, however, give such a wide field for operating as the adjust 
able speculum. If the coin is below the reach of the speculum an 
esophagoscope of appropriate size is introduced into the esophagus 
and carried down carefully until the foreign body conies into view. 
As large a tube should be used as possible, because it is humiliating 
yet true, that a small bronchoscope may pass a coin without the exam- 
iner seeing it, or detecting it by striking it with the end of the tube. 
A manipulation which will occasionally bring the coin to view is to 
elevate the handle of the tube strongly and to press the point against the 
vertebral column. This saved the author on one occasion from the 
embarrassment of defeat in the case of the child of a physician. When 
a button or a coin is lodged in the thoracic portion of the esophagus 
as the examining tube approaches it the lumen of the esophagus changes 
from the customary rosette to a transverse slit. In this dark trans- 
verse slit the foreign body is lodged and is holding the esophageal 
walls apart. The first grasp of the forceps upon the coin should be 
a sure one, because if the coin is nibbled and not firmly seized, the 
operator may have the mortification of seeing it disappear down the 
esophagus. If he catches sight of it again he is fortunate; generally 
it has gone into the stomach. If before or during the examination 
the patient vomits, examine the vomitus. The foreign body may be 
found in this. (Fig. 198.) 

The Bristle Probang. The use of the bristle probang is allowable 
only in case a bolus of meat or a smooth foreign body like a coin or 
a button is lodged behind the cricoid cartilage. Its use in such cases 
is often successful and is without danger. A more surgical procedure, 
however, is to use the speculum. When rough foreign bodies like fish 
or chicken bones or pins are to be dealt with the use of the bristle 



probang is contraindicated. In the rare cases in \vliieh the use of the 
tubular speculum or the esophagoscope fails to disclose the foreign 
body the bristle probang comes again to its own. If a coin or a button 
cannot be found and extracted it is good practice, at least from the 
standpoint of the patient, to push it down. Opening the side of the 
neck for the removal of a smooth foreign body of this nature is obsolete 

Pins in the Esophagus. AVhen a pin is lodged in the esophagus, 
especially when its point is turned downward, it does not as a rule 

Fig. litS. 

Penny whistle in the upper part, of the esophagus of a seven year old child. 
The whistle lodged just below the mouth of the esophagus and behind the 
cricoid cartilage. This is the favorite plaee for foreign bodies to halt. The 
whistle was removed under ether with the author's open speculum and 
angular forceps. Such cases are best managed with the tubular or the 
op< n speculum. (Author's case, X-ray tracing retouched and reduced. 
Massachusetts Charitable Eye and Kur Infirmary.) 

h trouble in the extraction. When, on the other hand, the 
of the pin is uppermost and embedded, its removal may be very 
difficult. ( 'asselberry 's pin cutter which divides the pin and holds the 
fragments is practically indispensable for the propel 1 management of 
such cases. 

l.ARYXOOSCOPY, I5KOXC 1 1 OSCOI'Y , KS( )!' 1 1 A< ;< )S( '< >I'Y , KTC. 20 I 

Safety Pins in the Esophagus. (Fig. 11M).) An open safety pin, 
point up, is ono of the hardest of foreign bodies to remove from the 
esophagus. The aim of the operator is to close the pin. 'Phis ac- 
complished, the extraction is easy. Coolidgo, some eight years ago, was 
ihe first to remove a safety pin from the esophagus. He used a safety 
pin closer devised by the author. Since the time of this case other 
methods have been devised for successfully closing a safety pin. Within 
the last year Jackson has introduced a daring and simple method of 
closing and extracting a safety pin. (Figs. 200 and 201.) Through the 
esophagoscopo with forceps tipped \\"ith two slender interlocking blades 
he grasps the ring of the pin. When the blades of the forceps are 

Fig. 199. 

Safety pin in the esophagus. Child two years old. Author's case. 
Extraction by means of the esophagoscope failed and the pin was pushed 
into the stomach and removed by incision. The child died of pneumonia. 
(Plate by" Dr. W. J. Dodcl.) 

locked in the ring, the pin is carried into the stomach and allowed to 
turn. Then the forceps are withdrawn with the pin he-ided the other 
way. As the pin conies into the tube it closes. The author has devised 
a safety pin tube the aim of which is to close the pin and to extract it 
without first pushing it into the stomach. 

A few years ago the author originated an instrument (Fig. 202) 
for closing an open safety pin, point up. The device consisted of a 
double bronchoscope, one tube being placed within the other. The outer 
tube had a slit in the side which engaged the pointed shaft of the 
pin. Rotation of the inner tube closed the pin. The device has been 
simplified by discarding the inner tube. The present instrument is 



made as follows: It is the usual self-lighted bronchoscope. There are 
two sizes, the smaller one for the trachea and the larger one for the 
esophagus. The end of the tube is bevelled on the side. From the apex 
of the V a slit runs upward about two inches. At the summit and at 
the side of this there is a second smaller and connecting slit. A pointed 
tongue separates the two slits. 

Suppose for the sake of illustration that the point of the pin is up, 
and imbedded in the right esophageal wall. The tube is used in the'. L'UO. 

Jackson's forceps for grasping and pushing open safety pins into the 
stomach for turning. A, illustrates point of forceps; B, illustrates method 
of procedure. 

Fig. 2U1. 

Schema showing Jackson's method of removing an open safety pin from 
the esophagus by passing it into the stomach, where it is turned and removed. 
The first illustration (A) shows forceps before soi/.ing pin by the rings of 
the spring end. (Forceps jaws are shown opening in the wrong piano.) At 
H is shown the pin seix.ed at the ring by the forceps. At (' is shown the pin 
carried into the stomach and about to be rotated by withdrawal. I), the 
withdrawal of the pin into the esophagoscope which will thereby close it. 
I From the Laryngoscope.) 



following manner: It is carried into the esophagus until the hood of 
the pin can be seen. This is grasped with forceps and steadied while 
the slit is turned so that il engages the pointed shaft of the pin. Then 
the tube is pushed onward until the top of the slit brings up against 
the crotch of the safety pin. This stage of the manipulations reached 
the tube is carried a little further down in order to free the point of the 
pin from the esophageal wall. This accomplished the hood of the pin 
is again held motionless by the forceps while the barrel of the tube is 
rotated to the right. By this manipulation the shaft which bears the 
point of the pin is made to lie in line with the accessory slit. The 
pin is now pushed straight down the tube. As it descends the accessory 
slit which of course is closed below acts as a ring and shuts the pin. 

Fig. 202. 

Mosher's safety pin removing tube. 1. end of safety pin closing tube. 
2, hood of pin grasped through tube. 3. tube carried down until main slit 
brings up against the crotch of pin. 4, barrel of tube rotated to the right 
in order to bring pin in line with secondary slot. 5, pin pushed down and 

The tube and the pin are withdrawn together. .V moment's practice 
outside of the body will show that these manipulations which seem 
complicated when described are in reality very simple. 

Uubbard has devised a useful loop guide for the wire snare, and 
employed it successfully for the closing and removal of a safety pin. 

Tooth Plates in the Esophagus. Tooth plates, especially partial 
plates with prongs, have the unpleasant distinction of being the hardest 
foreign bodies which the physician is called upon to remove from the 
esophagus. Many successful extractions of tooth plates, however, have 



been recorded. (Fig - . 204.) It is an axiom in dealing with these difficult 
cases that unless the extraction is fairly easy and is soon accomplished 
the forein bod should be removed b an incision throuh the side 

Fig. 203. 
Alosher's safety pin forceps. 

of the neck. It should be remem- 
bered, however, that the mortal- 
ity of this procedure is 12-20 per 
cent or ten times the mortality of 
esophagoscopy. Rough manipu- 
lation is not permissible. The 
chief difficulty presented by these 
cases is the locking of the prongs 
of the plate in the tissues. Some- 
times the plate can be turned by 
careful manipulation so that its 
short diameter may lie in the 
direction of the esophageal ax- 
is. Killian accomplished the as- 
tounding feat of cutting a plate 
in two by g'alvanocauterv. Hather 

Tooth plate in the esophagus. 
Dr. \V. .}. Dodd.) 

than attempt to turn the plate it 
is better surgery, unless the turn- 
ing should prove to be easy, to 
cut the plate. For this a power- 
ful for'-eps is necessary. A cut- 
ling forceps has been devised by 
Kahler. The one devised by the 
author is illustrated in Tig. 20."). 
The loolh plate should be at- 
tacked early before the irritation 
set ii}) by it has caused the eso- 
phageal wall to become inflamed 
and edematous. When this has 
occurred it is hard to get a good 
view. l>riinings has invented a 
dilating esopliagoscope for use in 
t hese cases. 



After all esophageal examinations, and especially after the manip- 
ulations necessary for the dilatation of a stricture, or for the removal 
of a foreign body, the patient, complains of a sore throat. Sometimes 
this is severe and makes the swallowing of food difficult for a few days. 
After the stretching of a stricture there may he pain along the course 
of the esophagus and sharp pain in the epigastrium. Also there 
may he a rise of temperature for twenty-four hours. Now and then 
there is emphysema of the side of the neck. These unpleasant symp- 
toms, which, put in perspective, must he regarded as trivial, soon dis- 
appear under simple treatment. 

Fig. 205. 

Mosher's instrument for cutting a tooth plate or large pieces 
of bone. A smaller instrument of this same pattern can be had 
for bending pins double and extracting them. 


History. In 1S81 Mikulicx, who did so much pioneer work in 
esophagoscopy, decided after experimentation that the ^astroscope must 
be rigid. The men who had attacked the problem of gastroscopy be- 
fore this time had used instruments which were jointed. .Mikulicx, 
however, placed a bend in his ^astroscope in order that it might accom- 
modate itself to the curve of the vertebral column. His instrument 
was closed and the picture of the gastric mucosa was produced by 
prisms after the fashion of the cystoscope. Rosenheim also worked 
with a rigid tube but he discarded the bend. In the construction of his 
tube lie also made use of lenses and prisms. It remained for .Jackson, 
using a straight instrument without optic apparatus, to make gastro- 
scopy feasible and comparatively easy. He elongated the esophago- 
scope of Kinhorn and added a drainage tube on the side. He dem- 
onstrated that such an instrument could be passed into the stomach 
readily, and laid down the axioms of modern gastroscopy, namely: 
The gastroscope must be passed by sight. The stomach should be 
examined in the collapsed state to permit cleaning of the mucosa by 
mopping, and to enable the operator to palpate the walls of the stomach 
with the end of the instrument. General anesthesia is indispensable in 
order to prevent retching. When this occurs the diaphragm clutches 
the tube and defeats the examination. 

Usefulness of Gastroscopy. Modern gastroscopy after the method 
of Jackson is a relatively new procedure, so that the part that it is to 


play in surgery has not yet been determined. All endeavor in this line is 
still pioneer work. When the physician in making a diagnosis is able to 
substitute sight for touch he has made a gain almost too great to meas- 
ure. Gastroscopy by the Jackson method has actually done this. It 
follows, therefore, that it is of the greatest service in determining the 
presence of cancer and in locating ulcers. By this method it is possible 
also to remove certain foreign bodies from the stomach. 

The cry of the surgical world in cases of cancer is, ''Make the 
diagnosis early." When cancer of the stomach is suspected let the sur- 
geon therefore turn to the gastroscope. 

Instruments. The gaslroscope of Jackson is a long esophagoscope. 
(Fig. 206.) Frequently in order to examine the stomach the tube must 
be 80 cm. in length. For many cases, however, 70 cm. is sufficient. Such 
a tube can be lighted satisfactorily only in one way, that is, by a light 
at the far end. This means that the tube must be of the self-lighted 
pattern. The diameter of the adult tube is 10 mm. Jackson states 
that he frequently uses a tube whose outside dimensions are 1 1 mm. in 

. J 

Fig. 206. 
Jackson's bronchoscope, esophagoscope and gastroscope. 

one diameter and 14 in the other. The distal end of the tube is made 
in the form of a thickened ring in order to prevent injury of the tis- 
sues. The tube is fitted with an obturator the conical end of which pro 
jects beyond the gastroscope and makes the introduction easier. An 
elastic bougie somewhat longer than the gastroscope can be employed 
instead of the obturator. 

The Technic of Gastroscopy. (Jelieral anesthesia is essential for 
the proper performance of gastroscopy and deep anesthesia is neces- 
sary to prevent retching and to relax the fibers of the diaphragm at 
the point where the esophagus passes through it. 

The patient is given the usual surgical preparation. Food is 
withheld for twelve hours in order that the stomach may be as empty 
as possible. Washing out the stomach is not a satisfactory substitute 
for fasting. 

The Position of the Patient. Jackson in his earlier work had the 
patient placed on his back and in a position half way between the Tren- 
delenburu- and the horizontal posture. This causes the fluid remaining 
in the stomach, and it is never possible to get the stomach completely 
dry except by mopping through the gastroscope, to drain from the 


stomacli by gravity. Of late Jackson lias elevated the head of the table 
after the introduction of the tube so that the operator can examine 
at his ease. In the final position, the head of the table is about .'50 
cm. higher than the foot. The assistants are placed as in bronchoscopy 
or esophagoscopy. The second assistant holds the head. This is a very 
responsible position. Boyce who has long assisted Jackson has given 
much study to this detail of the examination. The following state- 
ment of the method in which the second assistant should manage the 
head is taken from a detailed description given by Boyce. The mouth, 
pharynx and esophagus are brought into a straight line not by the lev- 
erage of the tube but by the position of the patient's head. The head 
is held steadily in extreme extension and the mouth is kept widely open. 
The jaws are kept apart by a gag placed in the left corner of the mouth. 
The assistant who holds the head also keeps the gag in place. 

The patient is drawn toward the operator until his shoulders are 
clear of the operating table by four or six inches. The gag is inserted 
on the left side. The assistant sits on the right of the patient on a stool. 
His right leg is held in the kneeling position while the left foot is sup- 
ported on a stool 26 inches lower than the top of the table. The assist- 
ant's right forearm is passed beneath the neck of the patient and sup- 
ports it. The right hand grasps the mouth gag and keeps it from slip- 
ping. The left hand of the assistant rests on his left knee and grasps 
the top of the patient's head and at the same time bends it backward 
and upward. The exact amount of backward bend and of upward pres- 
sure required, is determined by experience on the individual case. 

Passing the Gastroscope. The gastroscope should be passed 
gently. If the tube does not advance readily its position is wrong and 
it should be changed. The tube must be well lubricated with vaselin. 
The gastroscope is grasped and held by the right hand of the operator 
after the manner shown in Fig. 207 (Jackson). 

The forefinger of the physician's left hand is introduced into the 
right pyriform fossa of the patient and the end of the gastroscope is 
carried down with the finger as a guide. As the tube descends a cer- 
tain amount of upward leverage is made with it on the base of the 
tongue and the epiglottis and finally on the cricoid cartilage. The 
finger of the physician can seldom feel the cricoid cartilage in the adult. 
This is immaterial because once the end of the gastroscope is well in- 
serted in the right pyriform sinus it drops readily into the esophagus, 
provided there is no disease at this point. Disease at the beginning of 
the esophagus should have been excluded previously by the use of the 
laryngeal mirror. If this has not been done it is excluded at the time 
by examination with the speculum. It is seldom necessary to pass a flex- 
ible bougie through the tube and into the esophagus to serve as a guide. 



After the tube has slipped into the esophagus the head of the pa- 
tient is raised slightly, the obturator is withdrawn and the current for 
lighting is turned on. From now on the tube is passed by sight. The 
esophageal lumen must be made out ahead of the tube before it is 
advanced. AVith each inspiration the esophagus opens and guides the 
tube in the right direction. The end of the gastroscop*' is kept in the 
long axis of the esophagus, and not pointed strongly upward for fear 
of collapsing the trachea. After the introitus has been passed only two 
points give trouble. The first is the hiatus of the diaphragm, the sec- 
ond the subphrenic portion of the esophagus. The hiatus is passed by 
making the long axis of the elliptical tube correspond with the long 
axis of the hiatus. The axis of the hiatus, as has been said, is oblique 
from behind forward and from right to left. It helps very much if the 
hiatus is partially or fully closed as the tube approaches it. If it is, the 

Position of the right hand during the introduction of the ^astroscope, 
viewed from above by the operator looking downward. (After Jackson.) 

observer sees a central rosette-like opening ahead of the tube. The 
esophagus leading down to this is smooth. (Fig. l(i!>.) The end of the 
tube is placed against this opening and then a little pressure or a little 
deepening of the anesthesia allows the tube to slip through into the 
abdominal portion of the esophagus. The picture seen through the 
tube at once changes. Instead of smooth walls as before, the esophagus 
is now thrown into long, thick folds which center at the left of the field. 
(Fig. 170.) Xo regular opening is made out but if the end of the tube 
is crowded to the left and advanced slowly the folds part and the irreg- 
ular dark slit suddenly bursts open and the tube is in the stomach. If 
the cardiac opening of the esophagus is in a state of spasm the long 
longitudinal folds of the abdominal esophagus swing from left to right 
and radiate from a small circular opening which is placed in the left 
ouadrant of t he field. 

LARYXOOSCOI'Y, 1MOXC 1 1 <>S( '()!' V , KSOIMI A< lOSCOl'Y , KTC. 275 

Iii order to pass the abdominal esophagus it is necessary sometimes 
to bend the head and neck of the patient to the right. Full anesthesia 
is necessary for passing the hiatus, the subphrcnic portion of the eso- 
phagus and the cardiac, opening. 

When the gastroscope has entered the stomach it is necessary, 
owing to the small field given by the tube, to have a system in 
the examination. There are two plans of exploration. First the ^as- 
troscope is carried straight down to the greater curvature, inspecting 
on the way a strip of the anterior and the posterior walls. If the stom- 
ach is not sufficiently collapsed one wall must be taken at a time. After 
the first strip lias been gone over the end of the tube is moved slightly 
to one side and brought up and a new set of folds examined. This is 
repeated until the pyloric limit is reached. 

As much of the stomach as possible is examined strip by strip. 
Then the second method of examination is practiced. This consists in 
passing the tube down to the extreme left of the greater curvature and 
then swinging it along the line of the greater curvature to the riu'lit. 
Having reached the right limit the tube is withdrawn a little and swung 
back like a pendulum. In this way, retreating step by step and swing- 
ing the end of the tube back and forth from right to left, the examina- 
tion is continued until the cardia is reached. The examination is 
greatly aided by having an assistant manipulate by palpation the unex- 
plored portions of the stomach in front of the end of the tube. For 
this purpose the patient may be turned first on one side and then on 
the other. During these manipulations the tube is withdrawn into the 
esophagus and then pushed into the stomach again when the new posi- 
tion of the patient lias been adjusted. If the patient begins to retch 
when the tube is in the stomach it is withdrawn into the esophagus 
above the diaphragm. 

The vertical diameter of the stomach is determined by measure- 
ment. The distance from the teeth to the cardia is ascertained and 
then the gastroscope is pushed down to the greater curvature and the 
distance from the teeth determined again. The difference between the 
two measurements is the vertical diameter of the stomach. In these 
manipulations it is necessary to avoid pushing the greater curvature 

The smallest vertical diameter found by Jackson in an adult was 
4 cm. (one and one-half inches) and the greatest .'5(1 cm. (fourteen 

The end of the tube tends to drag the stomach walls along with it. 
This can be avoided by withdrawing the tube a little and then carrying 
it down again. The average time required to examine the stomach is 
thirtv minutes. 


The Area of the Stomach Which Can be Explored. Vertical and 
infantile stomachs afford the greatest range of exploration. The more 
horizontal the stomach the less the range. The lateral movement of 
the hiatus makes it possible to examine the stomach over an extended 
area. This lateral movement varies with the individual. It is great- 
est in feeble, elderly and emaciated patients. Also the deeper the anes- 
thesia the greater it is. The anteroposterior mobility of the hiatus is 
of but little use. If the diaphragm were rigid gastroscopy would lie 
much limited. Owing to its flexibility the end of the tube can be made 
to pass at the hiatus through an ellipse the small diameter of which is 
f) cm. and the large diameter 15 cm. The long axis of this ellipse is 
placed laterally. 

The full range of the thoracic aperture is made available by shift- 
ing the head and the neck to the side. The pivotal or rocking point of 
the gastroscope is in the thorax not at the beginning of the esophagus 
or at the hiatus. 

As a rule the tube can be made to point in turn to either superior 
spine of the ilium and the greater curvature can be forced down to this 

Any anomaly or disease of the esophagus may render gastroscopy 
difficult or impossible. 

Contraindications. The contraindications to gastroscopy are the 
usual conditions which make the giving of an anesthetic unsafe. 

Dangers. The dangers of gastroscopy in careful hands are only 
the risks of the anesthesia. The observations of Boyce show that the 
blood pressure falls when a rigid tube is introduced into the esophagus. 
This, however, lasts only a short time. As esophagoscopy and gastro- 
scopy are done by sight there is less danger than in the passing of a 

Difficulties. Any physician who has had a training in the use of 
the microscope can look through the gastroscope and see the picture 
which it presents. If he has not had this training it takes a little time 
for him to teach his eye to see. 

Lordosis, Potts' disease and other diseases of the spine make gas- 
troscopy impossible. 

The Stomach as Seen Through the Gastroscope. 

The Normal Stomach. The folds of the stomach are constantly 
changing so thai no two views are alike. When the gastroscope enters 
the cardiac opening the folds extend straight on from the mouth of the 
tube and a small tunnel of open stomach is seen. As the tube is carried 
down through this the folds take a lateral bend. Finally, the tube 
brings up against the stomach wall. This appears as a flat surface 

LARYXtJOSCOPY, BRO.NC 1 1 OS< 'OI'Y , KSOl'I I A< i()SC( >\'\ , KIT. 

which is sometimes mottled, sometimes slightly red. The greater 
curvature allows the tube to push it downward some 10 cm. be- 
fore it resists. When the tube is withdrawn the stomach wall which 
has been flattened against it follows the lube upward to the position 
whore the tube first encountered it or a little higher. As yet not 
enough is known about the arrangement of the folds to attempt to 
group them. 

The mucosa of the esophagus and that of the stomach at times are 
strongly contrasted in color. The color of the esophagus, however, is 
more constant. The esophagus is generally a pale pink whereas the 
mucosa of the stomach varies from a similar pink to a deep crimson. 
Jackson considers that the color of the empty stomach varies from a 
pale red to a pale pink. The mucosa appears moist and glistening but 
less transparent than the mucosa of the esophagus. In the walls of 
the empty stomach vessels are not usually visible. 

The pylorus is, of course, found on the right extremity of the 
greater curvature. As the tube approaches the folds guarding it it 
seems like a slit. This gives way when the tube lias fully reached the 
opening, and a round opening appears somewhat like the rosette made 
by the esophagus at the hiatus. The observer makes sure that the 
opening is the pylorus by advancing the tube into it until the small 
annular folds of the duodenum come into view. If bile colored fluid 
escapes upward at this point the localization of the pyloric opening is 
determined beyond a doubt. 

The Movements of the Stomach. Beside the ordinary peristaltic 
movements of the stomach there are movements associated with the 
heart and with respiration. 

The movements transmitted from the heart are best seen just as 
the tube enters the cardia. They come from the heart and the descend- 
ing aorta and are synchronous with the beat of the heart and the blood 
wave in the aorta. 

The respiratory movements in the stomach are less marked than 
in the esophagus. Just as in the esophagus, there is, in turn, a nega- 
tive and a positive pressure. This alteration causes an inflow and an 
outflow of air. 

'Jlif I'frixtdltic Mur<'uicntx. The peristaltic movements of the 
stomach which result from the action of its own fibres can he fre- 
quently soon. Those, however, are not as marked as the antiporistaltic 
movements. The latter are of two kinds, the reversed peristaltic move- 
ment which is seen mostly at the fundus and causes vomiting, and the 
antiperistaltio movement of the duodenal variety which is confined to 
the region of the pylorus. 

The pylorie third of the stomach is the most unstable part. Jack- 


son's description of the aperture seen through the tube as it approaches 
the pylorus states that in one instance the pylorus was surrounded by a 
rosette of annular folds. In another, the folds were larger. These 
curved in ahead of the tube and then were pushed aside by it. Finally, 
one la rye fold was encountered and when this was thrust aside a slit 
came into view. This changed at once into a rounded opening which 
was the entrance to a short tunnel in the lumen of which there were 
numerous small folds. From this opening and the tunnel beyond 
some bile-like fluid welled up. 

Gastritis. Jackson thus describes the gastroscopic findings in a 
case of gastritis. The walls of the stomach were covered with a thick 
pasty secretion and the folds were thickened. In another case the 
secretion was in patches. In still another case the color of the mucosa 
seemed darker red than the normal. In only one case did this observer 
find dilated capillaries such as are seen in chronic inflammation of the 

Peptic Ulcer. .Jackson has had the courage to examine the stom- 
ach in cases of ulcer. He reports his findings as follows: The first 
ulcer was a dirty grayish-yellow and was not punched out. The ulcer 
of the second case was punched out and had slightly infiltrated edges. 
In another case the ulcer appeared as a longitudinal slit. In still an- 
other the bed of the ulcer was dark and rough. 

Malignant Disease of the Stomach. Malignant disease of the stom- 
ach gives a varying picture in different parts of the stomach and 
in different parts of the same growth. There is a striking contrast 
between the mucosa over a cancerous infiltration and the normal 
mucosa. Over the growth the normal folds disappear and the surface 
of the lesion is irregular, granular or nodular. In most cases 
secretion covers the site of the growth. The growth varies in color 
from white through gray and yellow, to pink, red, crimson, purple or 
brown. Malignant disease gives the best picture for diagnostic pur- 
poses when the growth has reached the fungus stage. 

When the mucosa is infiltrated but unbroken the tube can he used 
to palpate the growth and to determine the extent of the infiltration. 
In this way the growth may be pushed up to the abdominal wall and 
made accessible to external palpation. The sense of touch transmitted 
through the tube is a great help in making the diagnosis of malignancy. 

Gastroptosis and Gastrectasia. The position of the greater curva- 
ture and the vertical diameter of (lie stomach are easily obtained. The 
position of the pylorus is essential in order to distinguish between an 
enlarged stomach and a stomach displaced downward. If the stomach 
is of the infantile variety the position of the lesser curvature is easy to 
make out, otherwise it is not. 


By .Joseph ( 1 . Berk, M. I). 

General Considerations. 

The borderline of general surgery and oto-Iaryngology is so indis- 
tinct by reason of the evidence furnished by the study of this subject 
that there is some question as to where it rightfully belongs. It is the 
conviction that the laryngologist and otologist have the greater claim 
that impels the author to treat this subject from the specialist's stand- 
point. The oto-laryngologic surgeon is better qualified to do this 
work simply because he is so well informed on the requirements of 
these structures from their anatomic characteristics and their physio- 
logic functions. Cosmetic considerations do not constitute the sole 
reason for the performance of these operations. 

The deformities or malformations which call for plastic proced- 
ure may be real or imaginary. The latter comprehend slight devia- 
tions from the normal, very much exaggerated by the individual, on 
account of which the patient becomes the patron of the beauty doctor. 
The psychiatrist would be of more service. Only real deformities or 
malformations are considered in this chapter. Kadi case is a law unto 
itself as to the techuic, yet many varieties and modifications of meth- 
ods must be described. The purpose here is to illustrate rather than 
to give extensive descriptions of definite methods. 

History. Reconstructive surgery with special reference to rhino- 
plastic operation dates back to the publications of Tagliacozzi in l.")H7 
(Figs. 208 to 222) although earlier reports of plastic surgery of the 
face were said to have been made by Benedietiis in 1492. Tagliacozzi 's 
work, however, was not taken up very enthusiastically until about the 
eighteenth century, when a large number of surgeons recognized the 
value of this branch of surgery. Since then important contributions 
have been made by Rosenstein, Dubois, Boyer, Carpeie, (\ Uraefe, 
Balfour, Zeis, Biinger, IFoffacker, Warren. Dieffenbadi. Blandin, Koux, 
Serre, Jobert, Mutter, Post, Pancoast, Buck, Andrews, Prince, Koberts, 
Koenig, Israel, Joseph, Langenbeck, Oilier, Xelaton, Keegan. Hoe, 



Fig. 208. 

Fig. 209. 

Illustrations from Tauliaoozzi'K work. 


Smith, Kolle, Beverdin, Wolfe, Krausc, Thiersch, (Jcrsiiny, Lexer, Carl 
Beck and many others. 

Indications. In considering the indications for plastic surgery of 
the nose and the ear, we have in mind the correction of defects; first 
for the re-establishment of certain functions, such as respiration, phona- 

Fig. 21' 

Fig. 218. 

Fig. 219. 

Fig. 220. Fig. 221. Fig. 222. 

Appliances and instruments employed by Tag'liacoz/i. 

tion, deglutition, audition; and secondly for cosmetic requirements. 
Of these the former purpose is by far the most important from the 
operator's point of view, but the latter is often of greater interest from 
that of the patient. At the same time the cosmetic indication must not be 
undervalued, as by reason of deformities and malformations many un- 
fortunate individuals are denied equal chances and privileges in life 


with their fellow man. It can bo stated unhesitatingly that even when 
the best results are obtained cosmetically, the patients are still much 
handicapped by their appearance, since such results still leave them 
objects of curiosity and comment. This of course is more especially 
true of extreme deformities of the rose and ear. 

The so-called better classes are annoyed by certain minor deformi- 
ties, malformations and blemishes which injure their pride, but which 
otherwise are of little consequence. However good a result is achieved 
by the operation, the patients are never entirely satisfied, and persist 
in their desire to have more work done. These unfortunates mostly 
self-centered and neurotic individuals become the prey of the so-called 
" beauty doctor," and many bad consequences result from the unscien- 
tific surgery of the latter. 

It is best to attempt to discourage them from having plastic opera- 
tions performed; furthermore, great care should be exercised when 
operating on them to have the patients or their immediate family as- 
sume all the responsibility as to the cosmetic results. 

As a preliminary to the performance of plastic surgery it is nec- 
essary in order to obtain the best results to ascertain whether or not 
some general or local pathologic condition, such as lues, tuberculosis, 
general anemia, malnutrition is present. These are among the most 
frequent causes of failure. A local chronic skin infection, as ec/ema 
or granuloma, will retard or prevent healing even if the plastic has 
been perfect. 

Important Factors. Since there are so many varieties of deform- 
ities there are naturally a great many procedures for their correction. 
After all it remains for the individual operator to use his judgment as 
to the selection of a particular type. Again, frequently a plan must be 
changed during the operation and an entirely different principle ap- 
plied, or perhaps a combination of different principles or operations 
must be adopted. 

It is of great help to know the condition and position of the struc- 
tures previous to the deformity. If this has existed from birth, the 
normal condition of the parts should be known. This is especially im- 
portant in nasal and ear plastics. For instance, in constructing a nose, 
the surgeon is very fortunate if he can obtain a photograph taken be- 
fore the deformity was acquired. Sometimes photographs of the 
closest relative who is known to have resembled the patient before in- 
jury, arc of u'reat service. To make a nose of the Roman style when, 
as a matter of fact, the patient had a short stubby, thin, straight or 
bulbous nose before, would he ignoring an important principle. 


In ear plastic the opposite ear inny be used as a model, in the ma- 
jority of instances. 

The selection of the method of operative procedure is naturally of 
great importance. A definite rule cannot always he laid down since, 
as has been said, each case is a law unto itself, and the operation indi- 
cated varies with the age, condition, and vocation of the patient. A 
rule which the writer has followed is to employ at first a method in- 
volving no loss of tissue, and consequently no additional deformity in 
case of failure. In other words, it is best to form the nasal structure 
by employing transplantation methods in preference to using flaps 
from the face or forehead. Similarly intranasal are to be preferred 
to external methods. 

Flaps should be properly selected and prepared. They should be 
measured out previous to the operation, one-third larger than the de- 
fect, and made very plastic, that is, with not too much underlying 
tissue. Making them too thin or devoid of subcutaneous tissue is even 
a greater mistake, since their nourishment is thus likely to be affected. 
It is necessary to make their pedicles conform to the blood supply; 
that is, to construct the flaps so that the greater diameter of the vessel 
is in the pedicle and not in the periphery. If the pedicle is too greatly 
twisted strangulation of the flaps may occur. 

While perfect cleanliness or asepsis is practically impossible in 
nasal surgery, great care should be taken not to introduce foreign 
microorganisms into the wound. 

Thorough removal of diseased tissues as well as of cicatrices is 
quite as important as the free undermining of the borders of the wound. 
Patches of skin or mucous membrane must be dissected out, since the 
retention of nests and the accumulation of epithelium may prevent a 
good result. 

Covering 1 Defects. It is advisable to study the principles which 
govern the covering of congenital or created defects. Dieffenbaeh, 
Langenbeck and others have developed this subject to such an extent 
that almost any form and size of defect in the skin may be covered with- 
out causing a marked deformity in the region from which the tissues 
are taken. 

1. Defect* may be covered by making incisions in certain direc- 
tions and uniting in the opposite direction, thus loosening the tissues 
and uniting them in the best possible manner so that the tension is the 
slightest. Counter-incisions, to relax the tissues and to facilitate easy 
approximation of the skin, are also frequently employed. Fig. '2'2'.l 
demonstrates various shaped defects and the method of covering them. 
The arrows indicate the direction in which the flaps should be turned. 



'2. Skin Graft 'nif/. A, Reverdin; B, Thiersch; C, Wolfe or 
Krause; I), Epithelial spread. 

(A) The Reverdin method is to raise a small bit of epidermis 


Incisions and flaps for closing defects. (Cclsus.) 



by means of a noodle, snip it off with knife or scissors and place it over 
the prepared granulating surface. (Figs. '2'24 and _T). ) 

(B) Thiersch grafts are obtained either from the arm or leg 
(from parts containing little hair) by placing the skin on a stretch and 
employing a very keen razor or special knife. ( Fig. _'(i.) With a steady 
side to side movement, the epidermal layer is cut off and folded on the 
knife. .By means of this knife; the graft is carried over to the granu- 
lating area to be covered, and by the aid of a needle it is laid and spread 
out on the defect. Particular attention is paid to the margins of the 
graft, so that they are thoroughly spread out, and not rolled in. This 
should bo done as carefully as when preparing a microscopic specimen. 
The next graft should not be applied too close to the first, and so on, 

Fig. 224. 
Making Hevcrdin graft. 

Fig. 225. 
Kovcrdin graft applied. 

since the epidermis grows quite readily from the margins and thus 
bridges over more easily than when the grafts are placed too close to 
one another. The grafts should not lie too large, since these do not 
survive as well as small ones. After the entire defect is covered, the 
grafts are held to the granulating surface by means either of strips of 
paraffin or of rubber tissue in the form of lattice work. 

(C) Wolfe or Kranse grafts are transplantations of the entire 
skin, that is, of epithelium and corium. These should be devoid of 
very much subcutaneous fat and should not be too large, since their 
vitality is much interfered with when they are of more than one-half 
inch in size. These particles of skin may contain hair where such is 
required, as for the formation of eyebrows or on the upper lip in the 
male, to form a mustache. 



(])) Epithelial (Anssaht) Spread. By means of a razor the sur- 
face epithelium is scraped until a slight oozing of serum (but not 
blood) occurs, and then this scraped oft' epithelium is smeared on the 
granulating surfaces in a very thin layer. It is best covered with a 
thin layer of paraffin before covering with gauze and bandage. 

Recording Cases Before, During and After Correction. As has 
been stated it is best in all cases to obtain a photograph of 
a patient before the occurrence of the deformity. This will give the 

Making and applying Thicrsch f^ral'l. 

operator the advantage of reproducing as nearly as possible tbe orig- 
inal condition of the parts. If no photograph is obtainable or if there 
be a congenital defect, the operator will be called upon to use his judg- 
ment in the reconstruction. This should be in conformity with the 
rest of the features and facial expression. It is necessary to know that 
a broad face, which is known as the eurygnathous variety, will require 



a formation or reconstruction of a broader nose than it' tin- face is 
protruding, or of the prognathous type. Again, if the face lie of the 
non-protruding variety, orthognathous, a short nose is best suited to 
it. (Roe.) 

The next step is to obtain a very detailed history and to make a 
thorough local and general examination. Tntranasal and pharyngeal 
inflammatory and obstructing conditions must be noted as well as the 
local pathologic changes that may be present on the external nose or 
ear. As to the general conditions existing, syphilis, tuberculosis, severe 
anemia, and malnutrition must receive the strictest recognition. 

Fig. 227. 
Stereoscopic photograph of plaster cast. 

A number of photographs from every angle should be taken. The 
author is now accustomed to take stereoscopic photographs, which are 
a vast improvement over the single exposure, since they bring out much 
more clearly the various defects, however small they may be. 

Plaster casts (Fig. 227) are excellent positive records of 
the condition present. The following inethod is used for making casts: 
Fill a one-half pint bowl half full with tepid water and plaster of Paris 
(dental) until the latter is submerged. Pour off excess water and stir 
to proper consistency. When one desires quick setting of the plaster, 
a pinch of table salt is introduced into the warm water before the plas- 
ter is added. Before applying it to the face a fine layer of vaselin is 
spread upon the skin and the anterior nares or the nasal apertures are 
plugged loosely with cotton. A small rubber tube is kept ready to 


place into the patient's mouth at the last moment, just before the plas- 
ter is put over the mouth, in order that the patient may breathe while 
the plaster hardens. The mask is begun by placing the plaster in thin 
layers about the forehead over the closed eyelids, cheeks, lower jaw, 
nose, upper lip, lower lip, and closely about the tube. This first layer 
is reenforced with a goodly quantity of plaster and the mask is allowed 
to harden. The subject should avoid any facial movements, in fact he 
should lie perfectly still until the plaster is set, which takes usually 
from three to five minutes after the mask is finished. 

The removal of the formed mask is now very carefully manipu- 
lated so that it may come off in toto. If it should unfortunately break 
into two or more parts, it is carefully placed together and cemented, 
as is done by the dentist in making plaster casts. In fact this whole 
procedure is so much like the making of dental impressions that the 
author would recommend that a dentist be employed for the purpose. 
To make the positive from this mask is the next procedure, and this is 
accomplished by painting the inner surface of the thoroughly dried 
cast (mask) with separating fluid and pouring into it plaster of Paris 
until it is thoroughly filled. This is now allowed to harden and dry, 
when the mask is carefully picked off from the positive at the pink 
line of demarcation of the fluid. The chips and defects on the positive 
cast, caused by this tedious process of picking off the mask, must be 
repaired with plaster. 

Secondary casts and photographs, showing the effect of treat- 
ment, are of service as additional records, while stereoscopic photo- 
graphs are even better than plaster casts. 


Classification of Nasal Deformities. 


Bony portion Cartilaginous portion 

Vertical Lateral Tip Wings 

I I I I 

Convex Concave Spatulated Deflected 

Collapsed Expanded 

Kxcessive Deflection from 

deficient tissue median line 


II. ACCORDING TO KOLLK. (In deficiencies particularly referable 
to paraffin injections.) 


Superior one t hird. 
Middle one-third. 

I. Anterior Nasal Deficiency. . [ Inferior one-third. 

j Superior one-half. 
I Inferior one-halt'. 

V Total. 


. . I Unilateral. 

J. Lateral Insufficiency., - r ,.. 

( Bilateral. 

3. Lo1)iilar Insufficiency. 

4. Interlobular Insufficiency. 

v , 7 x n \ Unilateral. 

o. Alar Deficiency 

I Bilateral. 

r ,, ,. . (Partial. 

(). feubseptal Denciency \ 

( Complete. 

ITT. Author's Classification. 

A. Etiology. Traumatic; Luetic; Congenital ; Tubercular and Lu- 
pus; Simple infections, as abscess; Periehondritic; Atheromatous, or 
Acne Rosacea; Neoplasms, malignant and benign; Gross Imagination, 
or Vanity. 

/>. Form. 

1. Large hump nose. 
'2. Twisted nose. 

3. Kinked and double kinked. 

4. Saddleback, kinked and with wide a he. 

5. Pinched pointed, with collapsed ahv. 

(>. Flat or squashed, with large ahv and large vestibules. 

7. Notched. 

8. Congenital absence of premaxilla and columellar cartilage. 

9. Pushed-in nose. 

10. Absence of external nose and septum. 

II. Unilateral deformities. 
\'2. Hare-lip nose. 

13. Combination of nasal and face deformities. 

14. Pound or hypertrophic nose. 


Methods of Procedures in Nasal Deformities and Malformations. 

I. German or French method, including skin grafting. 

II. Italian or Tagliacozzi 's method, with modifications. 

III. Hindoo or Indian method. 

IV. Double transplantation method (toe to hand, to nose). 
V. Finger method. 

VI. Clavicle method. 

VII. Implantation method (paraffin, tic.). 

VIII. Reduction method. 

IX. Artificial method. 

X. Orthopedic method (Carter's clam]), pins, etc.). 

XL Intranasal method. 

XII. Miscellaneous and combination methods. 

I. German or French Method. (Facial.) 

AVhen a subtotal destruction or an unilateral defect is to be cor- 
rected this method gives excellent results. The transposition of the 
newly-formed parts may be accomplished by sliding or pedicle forma- 
tion. Small defects may be covered by real-ranging flaps from the 
nose itself as shown in Figs. i2.'!4 and '2'.}'). 

The nasolabial fold offers the best place for pedicle flaps. Flaps 
for building up the prominence of a nose as well as for forming an epi- 
dermal lining of the nose are frequently formed from the cheeks and 
turned outside in, as shown in Figs. 2JS and 1'L'D. Columella 1 may be 
made from the point of the nose, from the outer part of the middle of 
the lip, or from the mucous membrane of the lips, and passed through 
in buttonhole fashion, as shown in Fi.u's. I'ol'-l'b'O. It is most impor- 
tant to loosen the parts thoroughly and to effect perfect adaptation 
of the margins. Portions of the nasal bones, nasal processes of the 
superior maxilla or of the premaxilla and the floor of the nose, are 
utilized for support of the nose formed after this method. (Figs. 'JSll! 
and 1_' S 7.) Other materials for support are cartilage from the septum 
resected from other patients, or, clavicle, and bones from the toes, 
'infers, and the anterior surface of the tibia. ( Figs. .'107-.'! 14.) 



Legg's Operation. 

1. Make a small tongue-shaped Ha}), with its hinge pedicle at the 
nasolabial crease. (Fig. 22S.) 

2. Turn over with skin surface into the vestibule, and suture all 
about the margins of the ala, which have been freshened up, and close 
created defect on the cheek. (Fin 1 . 22!).) 

Fig. 228. Fi.i;. 22<. 

Lc.Uii's operation for correction of unilateral and partial deficiencies of the nose. 

Out' \Vrrlc Litter. 

.">. Sever the pedicle and readjust, then suture to the remaining 
alar margins. 

4. Cover the (lap with a thin Thiersch uraft. 

Koenig's Operation. 

1. Make a seniilunar incision through the ala remaining and dis- 
sect the margin away. (Fig. :2-')().) 

'2. Take a Wolt'e graft fi'oni the thick skin of the back of the 
neck and implant into the alar defect. (Fig. l2.''>1.) 

Von Esmarch's Operation. 

1. Make a Hap in the nasolabial fold. (Fig. I'.'!-!.) 
L'. Turn on its pedicle with the skin outwards and suture. 
(Fig. 2:5:?.) 

.'}. Eventually sever the pedicle one week later and readjust parts. 


Fig. 230. Fig. 231. 

Koenig's operation. 

Fig. 232. Fig. 233. 

Vim Ksinaivli's operation. 

Fig. 2::4. 

Fig. 2:',f>. 

Von Laiitfonboek's operation. 


Von Langenbeck's Operation. 

1. Freshen up the surfaces on the defect. 

'2. Make a Hap on the healthy side of the nose wit h the pedicle over 
the side of the defect. (Fig. 234.) 

3. Dissect this Hap loose and stitch into the prepared defect, 
turning in the lower margin of the Map so as to make the nostril have 
a dermal surface. ( Fig. 235.) 

4. ("over the newly-formed defect either with skin graft or dis- 
sect loose the tissue of the cheeks and cover the defect by sliding the 
skin over it. 

Fig. 236. Fig. 237. 

Dieffenbach's operation. 

Fig. 238. 
Von Esmarch's operation. 

Dieffenbach's Operation. 

1. Make a reversed V-shaped incision through the a la above the 
defect and dissect freely. (Fig. 23(i.) 

'2. Reunite in the form of three three-cornered Maps. (Fig. 237.) 

Von Esmarch's Operation. 

1. Freshen up the margins of the defect 

'2. Make a Map of the side of the cheek with a pedicle on the side of 
the nose. (Fig. 238.) 

3. Implant flap and suture on three sides. 

One Week Later. 

4. Sever the pedicle and complete the closure of the defect on 
the ala as well as of the newly-formed defect on the side of the nose and 
cheek. (Fig. 23S.) 



Busch's Operation for Partial Loss of Tip and One Side of the Nose. 

1. Form a lateral flap. The pedicle is formed on the side of the 
cheek opposite to the defect of the ala, and the main body of the flap 
is made from the bridge of the nose. (Fig. 239.) 

'2. Remove the undesirable skin margin of defect. 

,'>. Dissect the flap and suture in position, the prominent convex 
border of the flap being fitted well into outer margin of the defect. 
The tongue-shaped portion makes a well-adjusted tip and columelhr 

4. The newly-formed defect is covered and corrected one or two 
weeks later, when the pedicle is severed. 

Busch's operation for partial loss of tip and one side of nose. 

Nelaton's Operation. 

1. Form two quadrangular flaps from the cheeks, the bases of 
which are situated over the bridge of the nose and angle of the eye. 
One of the flaps should have an additional central Map to form the 
columella. ( Fig. 240.) 

2. Freshen the margins of the defect. 

.'!. Bring flaps together and suture in place over the iiltrum of 
the columella. 

4. Cover created defect either by \Volfe or Thiersch grafts, or 
slide over the skin from the cheek's. 


Syme's Operation. 

1. Two lateral flaps are made, one to each side of the defect, 
extending to the lateral portion of the nose and to the cheeks, both 
these Haps having a common central pedicle over the root of the nose. 
(Fiii-. 241.) 

2. Freshen up the margins of the nasal defect. 

.'>. Suture the two flaps together in the median line. 

4. Turn the skin in at the lower margins of the flap, and suture 

Fig. 240. 
Nelaton's operation. 

so as to make a cutaneous surface where the nostrils will subsequently 
be formed. (Fig. 242.) 

5. Suture the two lateral flaps into the raw surface on the side 
of the nose. 

6. Dissect the skin of the cheek and bring- it close to the lateral 
flaps and suture. Any defect remaining may be covered by skin grafts 
or be allowed to granulate. 

7. Tubes of stiff rubber are placed in each primitive nostril. 

8. Subsequent formation of the columella from the upper lip. 


Helferich's Operation (French Method). 

1. Make a quadrangular flap from one side of the cheek with its 
pedicle on the side of the nose, for the purpose of support and to line 
the nose with skin. (Fig. 243.) 


opcrat ion. 



Fig. 244. 
Helferich's operation for total loss of nose. 


2. Make a somewhat oblong flap from the other clieek with its 
pedicle placed towards the inner corner of the eye, for the purpose of 
covering the first Hap, and reconstruct the nose. (Fiji, 1 . '24'.}.) 

3. Dissect and turn the quadrangular Ha]) across the nasal defect, 
and suture the previously freshened margins of the nasal defect, fac- 
ing its skin surface into nasal cavity. (Fig. 244.) 

4. Dissect oniony Hap and bring it in contact with the denuded 
surface of the Hrst Ha]>, and suture in place. 

f). Close, by sliding and readapting the skin about the cheeks 
over the newly-formed defects. 

One Wcrl- Later. 

6. Sever pedicles and readapt the parts to a smoother healing 
surface; secondary operation upon the ahv and columella. 

Roberts' Operation for Sunken Bridge With Upturned Lobule or Tip 
of Nose. Fie. 24."). 

1. A transverse incision is made into the nasal cavity, the tip of 
the nose being pulled down so that the nostrils appear horizontal. 
(Fig. 246.) 

2. An inverted V-shaped incision is made between the eyes up to 
the forehead. (Fig. 24f>.) 

.'5. The skin and subcutaneous tissue between the first transverse 
and the second V incision are dissected thoroughly. 

4. This dissected skin is brought down, the point of the (lap dis- 
placed as low as possible, and the lower defect broadly sutured. (Fig. 
247.) This forms a good prominence over the former depression. 
Dressing should be retentive so far as to hold the tip of the nose down. 

Roberts' Operation for Sunken Saddle-back Nose. 

1. Sever the lobule and ala> from their bony and cartilaginous 
attachments at the deepest part of the saddle. 

2. Draw the lobule and ala i down so as to bring the nostrils into 
an almost horizontal plane; this leaves a conical defect into the nasal 
cavity. (Fig. 24S.) 

.'!. Make two small skin (laps from the cheeks with their pedicle 
towards the root of the nose. (Fig. 24S.) 

4. When these flaps are dissected, they arc turned with their epi- 
dermal surfaces towards the nasal cavity and are united one to the 
other as well as to the upper portion of the newly-formed defect in 
the nose. 'Phis brings their raw surfaces externally for granulation 
formation and subsequent support for the newly-formed skin (laps 



Fig. 245. 

Fig. 246. Fig. 247. 

Robert's operation for sunken bridge with upturned lobule or tip of nose. 


Fig. 249. 

Robert's opcraliun for suiikdi saddle-back nose. 


The defects in the cheeks create*! by tliese flaps are at. once united. 
(Fig. 249.) 

5. About one week to ten days later, the irregularities about tin- 
base of tliese check flaps are corrected by incisions and proper sutures 
so as to obtain a smooth surface. 

(>. When all the inflammatory reaction has disappeared, usually 
in about three to four weeks, an inverted V-shaped incision is made 
down to the bone. Corresponding to this incision just above the mar- 
gin of the nasal defect, which is now covered by the inverted skin flaps, 
a similar incision is made except that the legs of the V run more hori- 
zontally. While the legs of the upper incision terminate below the 
eyes, close to the inner corner, the lower come out further on the cheeks, 
giving greater plasticity to the flaps. The apices of the two inverted 
V-shaped incisions are now joined by a vertical one immediately over 
the crest of the nose. (Fig. 250.) 

7. These two flaps, rhomboid in form, are dissected very freely 
from the underlying tissues and the cicatrized surface of the skin flaps 
covering the defect freshened by gently scraping with the knife blade. 
One flap is turned so as to fit its extreme point or tip into the opposite 
extreme point of the defect and is anchored by a suture; then the sec- 
ond flay) is brought above the first so as to fill in the defect to the great- 
est extent, and is anchored. This will leave a somewhat triangular 
defect at the root of the nose and lower portion of the forehead which 
is closed by three or more sutures in a vertical line. The two flaps are 
now sutured to the various margins and to themselves as shown in 
Fig. 251. 

Dieffenbach's Operation. 

1. Two parallel incisions, separated about one-fourth inch, are 
made through the entire thickness of the upper lip up to the margin 
of the nasal floor. (Fig. 252.) 

2. Turn this tongue-shaped flap so that the skin surface looks 
into the nasal cavity and mucous membrane externally, and locate a 
point where the free end of this flap will touch the nasal tip without 
undue tension or twist of the base of the flap. 

:>. Denude this located area of skin. (Fig. 252.) 

4. Remove the mucous membrane from the tip of the tongue- 
shaped flap. 

5. Suture this tip into denuded surface of nasal tip. (Fig. 25:5.) 

(). Liberate the margins of the newly-formed defect in the inid- 
dle of the lip. 


7. Suture skin and mucous membrane separately. (Fi.u;. l25.'x) 
S. If the operation is on a man, it may be necessary to denude the 
tongue-shaped flap of its dermal covering as the hair \vould subse- 
quently irritate the interior of the nose. 

Fig. 252. Fig. 253. 

Dieffenbach's operation for formation of new columella from the upper lip. 

Operation for formation of new colnni"lla from the dorsum of the nose. 
I 1 1 indoo im t hod. ) 

From the Dorsum of the Nose (Hindoo Method). 

1. An oblong flap is made, the pedicle bein.u 1 at the side of the ah 
ni n in iiu' to the tip of the nose. 

'2. A defect is made at the junction of the upper lip with floor ol 
the nose. ( Fiir. L ) .")4. ) 


M. 'I 1 he flap is turned downward and sutured into this defect. 

4. The defect on dorsuni of nose is sutured or a skin graft is 

f). Any slight irregularities are to he corrected at a subsequent 
time when the pedicle is severed. 

Fig:. 256. 

Fig. 257. 

Fie. 258. 

Fig. 259 

Fig. 260. 

Lexer's operation for the formation of columolla from the mucous 
membrane of the upper lip. 

Lexer's Operation for the Formation of Columella (from the Mucous 
Membrane of the Upper Lip). 

1. Construct a tongue-shaped flap with its hase towards th" 
ii'iiiiuval margin on the under surface of the upper lip, made up of 
mucous membrane and some underlying 1 submucous tissue. (Fig. iMd.) 

1*. Dissect it loose, and close to its hase remove the epithelial 
surface of a small transverse strip which will subsequently he within 
a buttonhole of the upper lip. (Fig. l2-")7.) 

o. Form the flap in a sort of a roll, suturing the margins. ( Fiu\ 


Fig. 261. 

Fit;. 2K1. 
Italian or Ta.^liarox/.i's method. 


4. Make a buttonhole in the center at the junction of the upper 
lip and floor of the nose, through the thickness of the lip, in front of 
the pedicle of the flap. (Fig. L.T)!).) Also make a notch at the tip 
of the nose. 

f). Bring the flap through and suture into the notch at the tip of 
the nose and also at the buttonhole. (Fin 1 . lM>0. ) 

Fig. 26;',. 
Italian or Tagliacozzi's method. 

II. Italian or Tagliacozzi's Method. 

This method, which is the oldest, is not employed to any great ex- 
tent at the present time, as the patient is very much inconvenienced by 
bavin, , 1 his arm held in a very constrained position for such a lonir 


period. Its purpose is to obtain a flap from the arm as shown in Fig. 

1. The flap may be allowed to become firm and of proper size by 
placing rubber tissue, Cargile membrane or anointed gauze between 
the denuded surface so as to prevent it from reuniting. The flap should 
always be made one-third larger than the surface to be covered on ac- 
count of the subsequent shrinking. 

'2. After the parts about the nose are freshened and loosened up 
the flap is sutured for about two-thirds of the distance, holding the 
hand over the top of the head and fixing it by means of adhesive plas- 
ter as in Fig. 262. The pedicle should not be twisted too acutely. 

3. A complete immobilization plaster cast is put over this pri- 
mary adhesive fixation, care being taken to protect the eyes while it 
is being applied. After it has thoroughly hardened, spaces or win- 
dows are cut out so as to expose the wound, the eyes, ears and month, 
as in Fig. 263. The wound is covered by a separate dressing. This 
cast is allowed to remain until the parts have healed, the stitches be- 
ing removed usually in one week to ten days. It is then time to sever 
the attachment of pedicle to the arm. The remaining portion of the 
defect about the nose is freshened and loosened up, the pedicle trimmed 
to fit the parts, making allowance for a columella, and the external 
parts of the nose finished. The skin defect on the arm is cleansed, 
the margins are freshened and loosened up and sutured. Grafts may 
be used, or the defect may be allowed to heal by granulation. 

Israel's Operation. 

Instead of obtaining the flap from the arm, one is made from the 
forearm and the arm and forearm are so placed as to make the patient 
most comfortable, as shown in Fig. 2(54. The retention of the arm is the 
same as in the Tagliacozzi method. 

1. Make incision in left forearm symmetrically on both sides of 
the ulnar edge, and form a trapezoidal skin flap. The small part of the 
trapezoid which points towards the wrist should be 4.f) cm. from the 
styloid process. (Fig. 265.) 

2. With a chisel, outline a bone (la)) from the ulna in connection 
with the partially dissected skin flap 0.75 cm. wide and (! cm. long. (Fig. 

3. With a fine saw this hone sliver is severed from the ulna, care 
being taken that it remains attached to the skin flap and to the ulna 
at the upper end. lodoform gauze is interposed to prevent reunion. 

A Fete Daifs L<ili'i\ 

4. Break the hone bridge at the point where the tip of the nose is 


to be formed and dress in this form. Allow for greater thickening of 
parts for another three to four days. 

5. Transplant flap to nasal defect and fix at the side as shown 
in Fig. l2()4. Immobilize by the usual method of plaster of Paris jacket. 

Fig. 264. 

Fig. 265. 
Israel's operation. 

Tico Weeks Later. 

6. Sever the bony and skin pedicle and readjust parts to form a 
nose. The bone should be united with the nasal spine at the floor of 
the nose and the skin sutured about the side of the nose. 

7. Form the columella and nostril from the remaining skin flap 
that was purposely taken for their formation. 



Dieffenbach's Operation. 

1. Outline a trapezoidal flap above the elbow on the inner sur- 
face, one-third larger than the newly-formed nose is to be. 

2. The heavy lines in Fig. 266 show the formation of incisions 
and this skin flap is dissected freely. 

o. Turn in one-half of this flap so as to bring the skin next to the 

Fig. - 
DiotTciihach's operation. 

raw surface of t lie arm in order to prevent adhesion and also to form the 
so-called roll of the dorsimi of the future nose; fasten by two sutures. 
(Fig. 207.) 

S/. I' \Vi'd:s Later. 

4. Sever the upper part of the Hap and turn downward. Remove 
the two stitches and lay the (hip open partially. ( Fig. 2(5^.) 

f). Freshen up margins of the nasal defect and suture in this new 
flap as in 1 he usual Italian met hod. 


Two Weeks L< 

(J. Sever pedicle and readjust the parts to form the ala- and 

Nelaton 's Operation. 

1. Form a pedicle (lap from the forearm and attach to the mar- 
gins of the defect. ( Fiir. _!()!'. ) 

Kim. 269. 
Nolaton's oporation. 

Tico H'tv/rx Later. 

'2. Sever the pedicle. 

3. Form two Ha])S from the outer margin of the alar openings 
outward and downward as low as the inferior maxilla in the naso- 
labial fold. (Fig. 270.) 



4. Turn these so as to make skin-lined nostrils and also a colu- 
inella or septum support for the new formed flay), which should also 
include a small flap for the formation of a double columella. (Fig 1 . 

5. Suture these flaps to one another and close the defect in the 
nasolahial fold. (Fig 1 . 1271.) 

Tiro Weeks Later. 

6. Sever the pedicles of the two flaps and adjust them to the ala> 
of the nose. Also reconstruct the columella. 

Fig. 27n. Fig. 271. 

Nelaton's operation. 


This is by far the preferable method when there is so much de- 
struction of the nose that insufficient tissue is obtainable in the imme- 
diate neighborhood, as the cheeks or the nose itself. 'The Haps may 
vary as to their shape and outline, according to the area to be cov- 
ered and according to the area of the ahe or upper portion of the nose 
that is present or can be ntili/ed. (Fig. '27 '2. ) 

The character and extent of the defect determine the side of the 
forehead from which the (laps are to be made. In this particular, the 
flaps should be so constructed that the pedicle should contain the angu- 
lar artery, which should be subjected to very little twisting. In fact 
no tension must be exerted anywhere on these (laps. The Haps may 


bo formed of the skin and part of its underlying connective lis>u<- only, 
or they may contain the periosteum and even a portion of the external 
table of the frontal bone. The frontal defects thus created by the turn- 
ing of the Hap may be covered in several ways. l>y loosening up the 

Fig. 272. 
Hindoo or Indian method of flap formation. 

Fig. 273. 
Thiersch's operation for total loss of nose. 


margins and drawing' the parts together as far as possible, the granu- 
lation may be encouraged; a Thiersch skin graft may be used, or the 
entire area may be covered by skin graft (Thiersch, Wolfe or 
Krause). After union takes place the pedicle is severed and the 
stitches are removed. It requires usually about eight to ten days be- 
fore the pedicle is cut off, and it is frequently very thick and large, so 
that it must be trimmed off and adjusted to the still existing defect 
between the eyebrows and root of the nose. 

Thiersch 's Operation for Total Loss of Nose. 

1. Make two small quadrangular flaps from the cheeks at the 
lower portion, forming their hinge at the side of the nose where they 
will constitute the inner surface of the nostrils and ala of the nose. 
(Fig. 273.) 

2. Dissect them loose and turn them with their dermal layer to- 
wards the nasal cavity. 

3. Suture one to the other in the median line. 

4. Make a frontal pedicle flap and suture into the freshly denuded 
margins on the side and lower part of the nose. (Fig. 273.) 

5. Cover newly-formed defects by Thiersch grafts. 

Nelaton's Operation for Total Loss of Nose (Indian Method). 

1. Expose entire length of costal cartilage of the eighth rib. 

2. Excise. 

3. Trim down to a size 2.f) cm. long by 3 mm. wide. 

4. Cut a notch where the point of the nose is to be formed by this 
cartilage, that is, about 0.75 cm. from the end nearest to the base of the 
forehead pedicle. 

5. Outline the forehead flap. 

6'. Incise the base of this flap down the bone for about 0.5 cm. and 
make a tunnel to fit the cartilage strip. 

7. Introduce cartilage strip with its notch towards the skin in- 
cision so that it is between the frontal bone and its periosteum. (Fig. 
274. ) 

*. Close skin-periostea! incision. 


!>. Make an incision about the nasal defects in such a manner that 
two lateral and one upper central flap will result. (Fig. 274.) 

1.0. Turn these over so that the skin surfaces will look into cav- 
ity of nose. 

11. Stitch with catgut so as to retain them in position. 

Fig. 274. 

Fig. -21->. Fig. -2!*. 

Xelaton's operation for total loss of nose. 


1:2. Cut forehead flap with its pedicle towards the opposite inner 
corner of the eye, over which the flap is situated as shown in Fig. 275. 
This flap contains the previously introduced cartilage with its under- 
lying periosteum. 

13. Turn the flap downward, over the previously turned flaps 
made from the margin of the defects. The flap should be fashioned into 
a sort of a tip of the nose by bending the cartilage where the notch had 
been cut in it, so as to make a proper columella. 

14. Stitch in place. (Fig. 276.) 

15. The defect in the forehead is closed by skin graft or sliding 
flaps. [Author's comment. This forehead defect can be covered rnnch 
better by sliding the skin and making counter release incisions in the 
hairy portion of the scalp.] 

One Week Later. 

16. Cut pedicle, trim it and implant in existing defect at the root 
of the nose. 

Koenig's Operation (Indian Method). 

1. Make a transverse incision across the depressed portion of 
nose into the nasal cavity and dissect loose the tip of the nose, so as to 
bring it into a more horizontal position. (Fig. 277.) 

2. Make a strip-shaped flap from the root of the nose straight 
towards the hair line, all tissues being severed to the bone. (Fig. 277.) 

.'). AVith a small chisel cut through the external table along the 
course of the incision made in this strip-shaped flap. 

4. Take off this layer of external table, periosteum and skin and 
turn it downward into the newly-formed defect, bringing the upper- 
most margin of the strip-shaped flap below the lower margin of the 
defect, and stitch it. This causes the skin surface to look into the nasal 
cavity while the raw bony surface is external. (Fig. 278.) 

5. Break the curved bony bridge of this turned down flap so as to 
give a curve to the nose. 

6. Make a lateral frontal flap and turn it down in the usual man- 
ner by twisting a pedicle covering the denuded bony surface. (Fig. 
277.) * 

7. Subsequent trimming of the pedicle at the root of the nose, 
with readjustment of the newly-formed irregularities at this point 
must follow, that is, excision of the skin between the root of the nose 
and the narrow (lap. (Fig. 271'.) 


Fig. 279. 

Koenig's operation. 


Keegan's Operation for Subtotal Loss of Nose, in Cases of Hacked 
Noses (Indian Method). 

1. Two flaps are formed from the remaining skin over the nasal 
bones, leaving their broad pedicles attached at the bony margins of the 
deformed nose. (Fig. 280.) 

mail's op. 'nit ion for subtotal loss of nose, in cases of hacked noses. 


2. These two (laps arc <lisscctc<l off and turned at the hinged ped- 
icles with their dermal surfaces towards the nasal cavity. They are 
sutured together and into the lloor of the nose. ( Fig. 2*1.) 

.'!. The- denuded surface from the root of the nose to where, the 
tip is to he formed, is now covered with a frontal flap which is so con- 
structed as to bring the pedicle at one or the other inner angle of tin- 
eye, that is, an oblique flap. (Fig. 281.) 

4. Suture the above (lap in place making a columella out of the 
remaining portion with the aid of the frontal flap extension. 

f). Close the defect in the forehead as shown in Fig. 2*1, and 
cover any raw portions with skin graft of Thiersch or Wolfe. 

G. After ahout ten days, sever the pedicle and implant properly, 
reconstructing the skin over the root of the nose. 

Nelaton's Operation for Subtotal Loss of Nose. 

1. An incision in the form of an A is made, the apex of the A 
coming close to the hair line (Fig. 282 ) and continuing laterally to the 
nasal defects. 

2. By means of a fine saw the skin and underlying hone of the 
frontal nasal and superior maxilla are taken along in the shape of a 
triangular Hap (Fig. 28.'!), leaving the attachments at the ahv. 

.'!. Tt is then bent into the shape of the tip of the nose point and 
folded so that the uppermost point of the flap comes in between the 
eyebrows. (Fig. 2S4.) 

4. Suture in this position. (Fig. 28").) 

.1. Close forehead defect by sliding flaps. 

Von Langenbeck's Operation for Collapsed Nose; Making Supports, 
Especially When Soft Parts are Wanting (Osteoplastic). 

1. An incision is made on the side of the nose from the nasal 
process of the frontal bone to the floor of nose. (Fig. 28(1.) 

2. Dissect the skin laterally so as to expose the apertura pyri- 
formis and the bones that are to be employed, namely nasal bones and 
the nasal process of the superior maxilla. 

.'). With a small saw or chisel cut from above downward a small 
strip of bone on each side of the margin of the apertura in such a 
manner as to leave its lower attachment at the superior maxilla. (Fig. 

4. Elevate these two pieces of bone outward and bring over them 
the previously dissected skin which is further sutured to these bone 
] (articles. (Fig. 28(5.) 


Fig. 282. 

Fig. 284. 

Fig. 28:5. Fig. 285. 

NY-hit on's operation for subtotal loss of nose. 


f). A similar procedure is practiced on the nasal hones, which 
arc usually depressed. They are sawed or chiseled off from the nasal 
processes of the superior maxilla and elevated, leaving their attach 
inent with the frontal hone as a sort of hiiitfe. (Kit;:. 1'S?. ) 

(i. Form a proper forehead Hap and cover this newly-made bony 
support, and suture in the usual manner. 

Schimmelbusch's Operation for Total Loss of Nose. 

1. Cut out a rhomboidal-shaped Hap from the forehead with the 
broad part above, measuring 2 to .') cm. between the margins below and 
to 7 cm. at its upper part. Its length should depend on the length of 
the nose to be covered. This incision includes the periosteum. 

Fig. 286. 

Fig. 287. 

Von Langenbeck's operation for collapsed nose; making supports. 
especially when soft parts are wanting. 

'2. By means of a broad chisel a thin plate of bone is taken away 
with this Ha]); in most instances it will be in several pieces, although 
endeavor should be made to keep the periosteum attached. ( Fiu\ 2S8.) 

.'). Turn this skin-boue Map down and in order to prevent these 
bone plates from falling off, a sort of lattice work of silk thread should 
be passed about this flap and covered with irau/e to allow .u'ranulation 
to form. 

4. Cut out two curved skin Haps as shown in Fii>'. 2SS, to allow 
the sliding forward of the lateral skin Hap for the closure of the frontal 


Fig. 288. 

Fig. 28!). Fig. 2!H 

Schimniolbusch's operation for total loss of nose. 


f). Continue incision up to the periosteum in a curvo-linear man- 
ner back of the ear and loosen the entire lateral flap. (Fig. 2K9.) 
This is done on both sides. 

(>. Slide the two lateral flaps so as to make them meet in the cen- 
ter of the forehead and also join the skin where the two little flaps 
were removed. As a result there will be two small defects on the side 
of head, which can be allowed to .granulate and can be corrected subse- 

Four to Si,)' Week* Later. 

I. By means of a saw divide the bony portion of the nose to be 
formed, and shape it in the form of a trough. In the event that the 
pedicle is again adherent at the root of the nose, it should be thor- 
oughly loosened and the flap turned with its dermal surface outward. 
(Fig. 289.) 

8. To form the eolumella, dissect off from each side of the pyri- 
form aperture two skin flaps and unite them as shown in Fig'. 289. 
This will leave their pedicle attachment at the usual insertion of the 
eolumella and their free end is to be attached to the newly-formed tip 
of the nose. 

Three Weeks Later. 

9. Freshen up the lateral portion of the defect, especially at the 
apertura pyriformis and dissect away the skin so as to lay bare the 
bony margins of the defect. The good result of this procedure de- 
pends upon this, since the implantation of the bony portion of the new 
nose on a raw and bony area makes a substantial support. Sutures 
through the bone are additional supports for g'ood union. 

10. Pass a wire through the lower portion of the nose, trans- 
versely, and fix by two small rolls of gauze or small rubber tubing so 
that the wire does not cut in. The purpose of this wire is to insure a 
roof-like form to the bridge of the nose. (Fig. 290.) 

II. Sever the pedicles of the frontal flaps of the nose and place 
them into the defect where the two lateral flaps join in the middle of 
the forehead. (Fig. 290.) 

Schimmelbusch's Operation for Saddle-back Nose. 

1. Prepare the frontal (skin-bone) flap in the same way as in the 
Scliimmelbusch operation for total loss of nose, and make the lateral 
flap in the same manner, uniting the created defect newly-formed in 
similar manner. 

2. Turn the frontal flap directly down without twisting the ped- 
icle, that is, the skin downward and bone externally, cover the flap with 


Fig. 291. 

Scliiiniiiclbiisch's o])cration I'o: 1 saddli'-liack nose. 


the thread lattice work to prevent the dislodgment of the hone and 
wra]) the whole Hap in gauze to allow the hone to granulate. 

(hie Week Later. 

.'). Make a vertical incision in the middle of the bridge of the nose 
and cut loose subcutaneously the lower part of the cartilaginous por- 
tion of the nose, so as to bring down the tip, making an opening into 
the nasal cavity with the nostril,-; looking downward. (Fig. 291.) 

4. Freshen up the bony apertura pyriformis and dissect the skin 
freely from the side of tlie nose. 

f). Saw and break the bony portion of the frontal flaps in such 
fashion as to give a roof-like appearance. (Fig. 291.) 

6. To insure healing, trim off the dermal layer of the frontal flap 
where it will come in contact with the tissues about the apertura pyri- 

7. Place the frontal flap in position between the dissected lateral 
skin margins of the nose and firmly against the apertura pyriformis, 
where an anchor suture may be placed and brought out at the outer 
corner of the al.T. (Fig. 292.) 

Our Week Later. 

8. Sever the pedicle at the root of the nose in such a manner as 
to utilize as much of the turned over skin as possible to fit into the 
still remaining defect between the eyes, where the two lateral parietal 
flaps come together, and then suture. 

9. Freshen up the lateral skin margins of the nose and bring to- 
gether over the middle of the nose. (Fig. 293.) 

Sir Watson Cheyne's Operation (Indian Method). 

1. An incision is made in the median line of the nose over the 
cartilaginous portion. (Fig. 294.) 

'2. Two transverse incisions are made at each end of the first in- 
cision, forming two lateral flaps when dissected, like an open door. 
(Fig. 294.) 

o. Dissect these lateral flaps and take along any fragments of 
nasal bones or periosteum that may be attached to them. (Fig. 295.) 

4. Sever the cartilage from the bony portion of the external nose 
and cut into the septum so as to pull down the point of the nose in the 
proper shape. 

5. Two vertical incisions are now made slightly above the root 
of the nose and about one-eighth of an inch from the median line, as 
far ii|) as the line of the hair. A third transverse incision unites these 



Fig. 295. 

Sir Watson Clicync's operation. (Indian method. 


t\\'o vertical ones at the hair line. These three incisions 
structures down to the bone. (Fig. 294.) 

(i. Insert a narrow chisel along the margin of these three incis- 
ions and separate a portion of the external table of the frontal hone, 
leaving it attached to the periosteum and the remains of the flap. ( Fiir. 

7. This whole flap is now turned downward so that the skin is 
looking into the nasal cavity while the outer surface comprises the de- 
nuded bones. 

S. Shave off the epidermis at the root of the nose as well as at 
the uppermost portion of this turned down flap so that these two may 
adhere at this point. 

9. Suture the lowest point of this turned down flap to the fresh- 
ened cartilaginous portion of the nose that was pulled down, thus clos- 
ing the nasal defect. Care should be exercised at this point not to 
bend the upper pedicle too acutely and not to have any tension what- 
soever. If there he trouble of this sort, two little incisions may be 
made on the side of the nose from the base of this flap and the tension 
thereby relaxed. (Fig. 296.) 

10. Unite the defect on the forehead. 

11. The lateral flaps are now replaced and united over the raw 
bony surface of the forehead flap, also above and below. (Fig. 297.) 

Tiro or Three JJVrVrx Later. 

12. The pedicle is cut, turned back to till up the defect and any 
irregularity trimmed down and corrected; any granulating surface 
may be covered by skin graft. 

Von Hacker's Operation (Indian Method). 

1. Outline the usual flap from forehead with pedicle at the root of 
the nose. 

2. Dissect the skin on the three free margins of the flap to a 
point in the median line measuring S mm. in width and the full length 
of the flap; this portion is to form the subsequent bony support of the 
newly-formed nose. 

.'>. The dissected skin is now sutured temporarily in the median 
line by two or three interrupted sutures and a few small pins driven 
into the bone-periosteal flap (Fig. 29S) in order to facilitate its dissec- 

4. By means of a chisel this bone-periostea! skin flap is now sev- 
ered ii]) to the root of the nose, where the pedicle only consists of skiii 
and periosteum, in order to be able to twist it easily. (Fig. 299.) 


Fig. l^'.t. 

Fig. :w>. 

Von Hacker's operation. (Indian method.) 


5. Break away the entire (lap and rotate downward into the 
proper position, having previously prepared the defect for union by 
freshening up the margins and the remains of the septum with which 
the bony bridge is to come in contact. This bony strip is broken at 
the lower portion and a proper point of the nose is formed. It is 
sutured into the floor of the nose and a columella and ahe are formed 
from the skin flap. Rubber tubes are inserted into nostrils to give 
shape to them. (Fig. ."00.) 


Fig. 301. Fig. 302. 

Sedillot's operation for total loss of nose. (Indian method.) 

Sedillot's Operation for Total Loss of Nose (Indian Method). 

1. Form a tongue-shaped flap from the upper lip, not going 
through the mucous membrane, placing the pedicle at the nasal floor. 
(Fig. .",01.) 

'2. Form a forehead Hap, taking care to make a longer median 
flap for the formation of the columella. 

I!. Freshen up the nasal defect. 

4. Bring down frontal flap and suture in laterally, and to form 
the columella suture central flap to the little flap from the lip in such 
a manner that there is skin surface externally as well as. in the nose: in 
other words, one on to]) of the other. (Fig. .'>0l?.) 

IV. Double Transplantation Method. 

A skin flap may first be made from the chest or abdomen and at- 
tached to a part of the hand or forearm, and after it lias healed on and 


ii'ood circulation has been established, it is severed, and then attached 
to the nose as in the Italian method. Or a toe from which the nail has 
been removed is implanted into the palm of the hand, and after it is 
thoroughly healed it is severed and made ready to use in constructing 
a firm support for a nose. Bone which has been removed from an am- 
putated le,i>' and formed in the shape of a nose, implanted under the 
forearm below the periosteum of the ulna, is prepared in the form of 
a pedicle after it has united and remained viable and is then sutured 
into a nasal defect, as in the Italian method. A similar method is em- 

Steintlial's operation for total loss of nose. (Double transplantation method.) 

ployed in implanting pieces of cartilage under the skin and periosteum 
of the forehead before making the frontal Hap. 

Steinthal's Operation for Total Loss of Nose. 

1. Make a tongue-shaped Hap from the sternal region with its 
pedicle towards the sternal notch, measuring "> cm. at its free end and 
'! cm. at the pedicle end, the length hein^ 1 about 1'J cm. 'The Hap is com- 
posed of skin and periosteum. Suture the defect over sternum in part. 


-. Make an incision through the skin of the forearm near the 
\vris1 and over the radius to accommodate the free end of the above 

.'!. Suture in this free end of the Hap for subsequent transplanta- 
tion. (Fig. :!o::.) 

4. Apply immobilizing plaster of Paris jacket. 

'J'/rc/rc Dd/js Later. 

."). Sever pedicle from sternum and leave it unattached to allow 
perfect circulation to be established in the Hap for two or three days. 

Fig. 305. Fig. 306. 

Kauaeh's operation for collapsed nose. (Double transplantation method.) 

b'. Freshen up the surface at the nasal defect. 

7. Suture free end of Hap situated on the forearm to this pre- 
pared surface about the nasal defect. (Fig. .''04. ) 

8. Apply again a retention plaster of Paris jacket for about one 
week to ten days. 

9. Sever the Hap from the forearm and suture in about the re- 
maining nasal defect to form a properly shaped nose, including 
columella and alar skin lining. 

Kausch's Operation for Collapsed Nose. 

1. Kemove the nail of the fourth toe of the same side as the hand 
that is to be employed. A portion of the skin from the tip of the toe is 
turned back to obtain a u'ood raw surface. 


Make an incision in the thonar eminence of the palm of the 
hand of a proper size to accommodate the tip of the toe. 

3. Bring 1 hand and toe together approximating the tip of toe to 
the incision and suture \vell on all sides of the skin. 

4. Place a retaining device either of plaster of Paris or leather, 
to keep the parts immobile. 

T ten Weeks Later. 

5. Sever the toe at the metatarsophalangeal joint, leaving it at- 
tached to the hand. (Fig. 305.) Close defect in the foot. 

Tico Day* Later. 

6. Freshen up the bony surface at the floor of the nose and the 
skin on the side of the nasal defect. 

7. Bring hand in proximity to nose and suture the free end of 
the transplanted toe, which has also been freshened on, into the bone 
exposed at the prepared nasal defect. (Fig. 306.) 

8. Iietain by plaster of Paris bandage as in the Italian method. 

Tu'<> Wf'clix Later. 

9. Sever the attachment of the toe to the palm of the hand and 
close this temporary defect. 

10. Remove the skin from transplanted toe from the part that 
is to come in contact with the subcutaneous tissue of the ridge of the 
nose. If the mass of bone is too large one may bite out a portion and 
also shape it in the form of a columella and ridge, giving the nose a 
proper shaped point. Suture the distal end towards the root of the 

11.. Subsequent smaller corrections of making proper shaped 
nostrils, etc., should be done not before two weeks, when the circula- 
tion is well established. 

V. Finger Method. 

In cases where a greater part of Ihe bony portion of the external 
nose is absent and most of the soft pacts, the employment of the finger, 
sacrificing this member for Ihe formation of a nose, has been followed 
by good results. The cases especially suitable for this operation are 
those in which the greater part of the ala* and probably the skin por- 
tion of the tip of the nose are still present, even though this latter por- 
tion be markedly drawn in and adherent. 

Watt's Operation for Subtotal Loss of Nose. 

1. Sever the columella at its attachment to the upper lip. 


-. Take the left little linger and remove its nail an<l matrix, also 
the skin from its tip anteriorly. 

.'!. Pass this (in^cr through remnant of tip of nose and (i.\ at tlie 
root of the nose close to the frontal hone by means of silver wire, an 
area having been prepared in this region. (Fi,u\ .'107.) 

4. Apply a plaster east to hold parts immobilized in place. 

Tu'o UVr/.'.s' Ldfrr. 

5. Amputate tinker at metacarpophalangeal joint and close de- 
fect in hand. 

A Fete 7)r///.s' Later. 

6. Trim down the free end of the finder so as to make it narrow 
enough to obtain two separate nostrils. 

Fig. 307 
Watt's operation for subtotal loss of nose. 


7. Push this end of the linger into the nasal cavity and fix by 
other suture. 

S. Suture back the previously severed columella to the lip by re- 
freshing their surface. 

One Week Later. 

9. "Remove skin from dorsum of the now healed-in finder at the 
nasal defect. 

10. A flap from the forearm is made and sutured in above the de- 
fect, fixed airain by plaster jacket and treated as in any Italian 


Fig. 308. 

Fig. 309. 

Fig. :ilO. Fig. :ni. 

\\"<ilko\vitsch's ope ration for total loss of nose. (Finger method.) 


Wolkowitsch's Operation for Total Loss of Nose (Finger Method). 

I. Take the fourth linger of the left hand. 

-. Make a median incision ovei- the dorsal surface of the same 
from the metacarpophalangeal joint to the nail, through the skin and 
siihcutaiieous tissue. 

.'!. Dissect loose to cither side f reels'. 

4. Remove the nail and he sure of the removal of all of its mat- 
rix. Tendon must not he disturbed. (Fig. .'JO*.) 

."). Remove the skin from the tip of the finder in front for its at- 
tachment at the root of the nose. 

(i. Split the skin and underlying tissues through to the hone in 
the median line at the root of the nose, and separate freely to eith-T 
side, including the margins of the remaining' apertura pyriformis. 

7. In the bony structures at the root of the nose make a dent by 
means of a gouge, into which the tip of the finder \vill fit so as not to 
make a perceptible hum]) at this point. (Fig 1 . .'50!).) 

5. Bring 1 the finger to the prepared area of the nose and tuck its 
skin Haps below the dissected lateral Hap about the apertura pyrifor- 
mis, the tip of the finger being fitted into the depression at the root. 

!'. Fasten the finger at the root by sutures, as in Fig. .'510, and 
stitch the skin flaps of the finger, which are tucked under the dissected 
skin of the nose defect, with two mattress sutures on each side. 

10. (Mose the median incision at the root of the nose as far down 
over the finger as possible. 

II. Place a quantity of marly (Scotch gau/e) below the finger to 
hold it u] in the shape of a nose and place a dressing over the surface. 
Then apply a fixation bandage as in any Italian operation. 

]'2. Remove the stitches and extend the incision over the dorsum 
of the hand so as to expose the entire metacarpophalangeal joint tor 

!.">. Dissect the skin laterally and incise it on either side of the 
finger, but do not sever in front at this time. 

14. During the next five days in two separate sittings the skin 
pedicle is severed and the metacarpophalangeal joint disarticulated. 

1."). Cover the defect on the hand as in a regular disarticnlation 
operation by the remaining skin anteriorly. 

K). Bend and shape the now attached finger in the form of a nose, 
place some more marly below it and allow it to remain for three more 
days for firmer attachment. (Fig. .'Ml.) 

17. Bend sharply between the first and second phalangeal joints 


Fig. 312. 

Von Esmarch's operation for collapsed nose or absence of the pre- 
maxilla or an anterior perforation of hard palate. 

Fiji. :n:{. Kin. :>14. 

Clavicle method. ((Justav Mandry.l 


to such a decree that the first phalanx may be pushed into the nasal 
cavity. *>; 

18. Prepare the floor of the nose and if there is a portion of sep- 
tum remaining, remove all the mucous membrane and expose its bony 

19. Remove all the skin and granulations from that end of the 
finger that has been disarticulated and push it into the nose against 
the raw surfaces prepared at the floor. 

20. Dissect now the lateral margins of the apertura pyriformis 
low down to where the a UK are to be formed, and tuck under the 
remaining portions of the skin flap of the finger, which are again 
attached by one mattress suture on each side. 

21. Cover the entire denuded surface of this bony reconstructed 
framework with a Krause flap or with any flap either from the fore- 
head or arm. Further slight corrections, as formation of nostrils 
and cover for columella, are subsequently performed. 

Von Esmarch's Operation for Collapsed Nose and When There Is Also 
Absence of the Premaxilla or an Anterior Perforation of Hard 

1. Remove the nail of the little finger of the left hand and freshen 
up the tip anteriorly. 

2. Freshen np the surface on the inner side of the tip of the 
nose and what is still existing of the floor of the nose anteriorly. If 
nose is retracted, it should be freely dissected and made movable. 

3. Fasten the finger with wire to the bone of the superior maxilla 
about the defect and stitch to the soft part at the nasal tip. (Fig. 312.) 

4. Apply a plaster jacket. 

Two Weeks Later. 

5. Disarticulate, usually at the junction of the second and first 
phalangeal joint. 

Two or Three Days Later. 

(>. Freshen up the margins of the perforation or defect at the 
roof of the mouth and suture in the properly prepared stump of the 

VI. Clavicle Method (Gustav Mandry). 

1. Form a flap over the region of the clavicle, consisting of skin 
and subcutaneous connective tissue and of the periosteum and bone 
of the clavicle. The broad pedicle is situated over the shoulder and 
the free end at the sternoclavicular articulation. (Fig. 313.) 


'2. Dissect this skill Hap up to the upper and lower margins of 
the clavicle, leaving it here attached to the bone. 

3. Chisel or saw out a sliver of the clavicle measuring 4.5 cm. 
long by O..j cm. wide (indicated by <i-d ] -b-l^ Fig. .'>!.'>) near the sterno- 
clavicular articulation without detaching the skin and periosteum. 

4. In the free end of this sliver two small holes are bored for 
subsequent anchorage to the nose. 

~). In the middle of this large Hap, right over the clavicle, a Hap 
of skin and subcutaneous tissue is made in the form of a window, 
directing the pedicle towards the sternoclavicular articulation, in 
order to turn it on the under surface of the bone sliver, in that way 
assuring its nourishment from both sides, besides subsequently form- 
ing a dermal lining for the interior of the nose. This central Ha]) is 
turned ISO degrees and made to come beyond the terminal end of the 
bone sliver, where it is fastened with the skin above, thus surround- 
ing this bone. 

(5. Close this newly-formed central buttonhole in the large flap 
by a few interrupted sutures. (Fig. .'514. ) 

7. Allow this whole Ha]) to rest over its dissected area where it 
will attach itself temporarily, getting additional nourishment for its 


S. Separate this whole pedicle, including the double skin covered 
bone sliver, and liberate it more freely by commencing the outside 
incision over the shoulder and back, thus giving a greater motion to 
the Hap for its adaptation to the nose region. 

!). Freshen up the nasal area, making a pocket at the root of 
the nose in which the clavicular bone sliver will be slipped. 

10. Fxpose this bone sliver and place two strong sutures through 
the holes which have been previously drilled. 

11. Turn the head towards the shoulder where the Hap is formed, 
and bend it slightly downward so that the flap can be brought in 
close approximation with the nose without any tension. 

ll'. Bring the two strong sutures through periosteum and skin at 
the root of the nose and tie over a pad of gau/e, fixing the bone sliver 
in the newly-formed pocket. 

1.'!. Apply a few additional sutures at the top and side of the nose. 
(Fig. ::14.) 

14. Fix the head in the twisted flexed position in a plaster cast, 
as in the Italian operation, and provide proper windows in the cast 
for feeding and for dressing of the wound. 


One Wed: Later. 

If). Sever the bridge pedicle at the place where il is decided 
thai proper skin flaps may he made to complete the ahe, cohmiella, etc. 

Hi. Dissect off the epidermis laterally from the flap and freshen 
iij) the margins of the apertura pyriformis so as to obtain proper 

17. Fxpose tlie end of the transplanted bone sliver and eventu- 
ally fracture it so as to make a tip of the nose. 

IS. Freshen up an area of the bone at the floor of the nose 
just in front and suture in this free end of the bone sliver. 

11). ("over this by the newly-formed columella. 

-0. Turn in the redundant skin flap at the alar region to line the 
newly-formed nostrils and put in two small rubber tubes. 

L'l. Readjust the shoulder flap and cover the newly-formed bone 
defect with it as nearly as possible; what remains may be covered 
with skin ^raft or allowed to granulate. 

'2'2. Subsequent correction on the nose may be necessary. 

VII. Implantation Method. 

Aside from the very popular and successful method of injecting 
paraffin, many varieties of implantation operations were formerly per- 
formed for the correction of defects or malformations. Gold, German 
silver, filigree wire, hard rubber, etc., have been generally abandoned 
for newer and better methods, inasmuch as these foreign bodies very 
frequently, after healing in beautifully, became the seat of irritation 
which necessitated their removal. The implantation of a sliver of the 
anterior border of the tibia was successful in one case of the author's; 
in another it became necrotic and removal was required. Senn em- 
ployed decalcified bone chips in some cases of saddleback nose. 
Recently the author removed a septum by submucous resection, allow- 
ing one layer of perichondrium to be attached and placed it in a dis- 
sected pocket of a saddleback nose of another patient. This healed 
in very beautifully and resulted in success. 

In another case three different implantations were made into 
collapsed ala* which healed in, but appeared to have become absorbed. 

Another method advocated recently is to implant a mass of fat 
from a patient upon whom a laparotomy is performed, into a dis- 
sected pocket of a saddleback nose. The author has tried this method 
in one case and it appears that the fat tissue remains alive. The one 
difficulty is that the nose looks very lari>'e for a time as a i>'reat amount 
of fat is used to fill up the defect, in order to anticipate the absorp- 
tion or shrinkage of the mass. 



The employment of a sliver of bone from the anterior border of 
the tibia or a part of a rib is a method that has many advocates. 

Israel's Operation for Saddle-back Nose. 

1. Make an external incision '2 cm. lonij 1 over the saddle and 
dissect to all sides subcutaneously, until by pulling on the tip of nose 
the appearance is normal. Close this external incision. 

-. A piece of bone 3 cm. lon,<>; from anterior border of tibia is 
chiseled off and formed into sharp points on either end. 

3. From the interior of the nose the previously dissected tunnel 
is found by means of a dissection and the sliver of bone is introduced 
in this direction, the upper end of the bone fragment coming in contact 

Israel's operation for saddle-back nose. 

with the nasal bones, the lower at the tip between the external skin 
and the lining of the vestibule. ( Fiii'. 31-").) 

Goodale's Operation for Depressed Nose. (Fi.n. 31(i.) 

Modified by Watson-Williams. 

1. The mucopcrichondriuni is dissected over the entire cartilag- 
inous area on both sides and pushed up and back. 

-. Loosen up the tissue below the depression int ranasally. 

3. ('lit out a flap of cartilage with its loosely adherent pedicle 
towards the depression. (Fi.u 1 . 317.) 

4. Slide this cartilage flap below the depression and brinu 1 down 
the mucoperie bond Hum into its original position. ( Fii>'. 31 S.) 


Fig. 316. 

Fig. 317. 

Fig. 318. Fig. 

Goodale's operation for depressed nose. 



5. Hold by transfixing- gold-plated pins for three 1 weeks. 
The writer suggests silk worm gnt suture tied over rubber tubing 
or gauze. (Fig. 319.) 

Custom's Operation for Depressed Nose Below the Bridge. 

1. Separate the cartilaginous portion of the depressed nose sub- 
cutaneously from the nasal bones and nasal process of superior maxilla 

Fig. 320. 

Oustoifs operation for depressed nose below the bridge. 

on either side; also sever the cartilaginous septum, the incision being 
made latterly lengthwise. 

'_'. Transfix all these cartilaginous structures with one of ( Mis-- 
lon's needles ( Fig. '>'_!()), just below the nasal bones. 

3. Pass another needle through the nasal bones which serve to 
support and lift the loosened cartilaginous portion of the nose. 

4. Wind a thread or gaii/e in the form of a figure eight (S) 
from the upper to the lower needle while the loosened cartilaginous 
portion of the nose is held up. (Fig. '.'>-}.) 


Carter's Operation for Saddle-back Nose. 

1. J>v means of a lar^c curved needle, which is threaded with 
Xo. 14 silk, one of the hard rubber splints is anchored. ( Ki.u'. '!__. ) 

-. Pass the needle from within outward at the junction of the 
cartilage and nasal bone, just at the middle of 1 he dorsuin. ( Fi.u'. '.\'2'.\.) 

.'!. Repeat the first stop on the other side of the nose. ( KILI'. .'!J.'!.) 

4. Apply the metal (Carter's) bridge and set it by means of 
the thumb screw so that it tits firinlv at 1 he base of the nose ( l-'i^. ill'4.) 

t\ section 


f). Draw firmly upward on the two threads so as to raise the 
Hat or depressed nose and tie them over the hinge of the bridge. 
(Fig. .m) 

If the tissues are fixed or if it is impossible to lift the nose by 
the threads, it may be necessary to loosen the nasal bones from the 
nasal process of the superior maxilla by means of chisels and forceps 
and then by fracturing. The septum of the nose may at times be so 
short as to necessitate incision. This treatment is best carried out 
with the patient in the recumbent position, but by employing adhesive 

Fig. 326. 

Carter's operation for saddle-back 

plaster the bridge may be fastened to the forehead and then the patient 
may he allowed to walk' or sit up. This bridge is allowed to remain in 
position from ten days to two weeks. (Realising the interior of the nose 
wit h I )obell spray is advised. 

Carter's Operation for Saddle-back Nose (No. 2). 

1. Make a curvilinear incision to the periosteum from one eye 
brow to the other, with convexity of the incision downward. ( Fig. '>-").) 

Lift the skin Hap and make transverse incision through the 
periosteum into the bone. 

.'!. Klevate the periosteum upwards for three-eighths of an inch. 

I'LASTIC SritCKKY ()! T 1 1 K NOSK AND KAII. )4.' 

4. Klevate the skill and subcutaneous tissue over the dorsum of 
the nose and side of the cheeks as far as the deformity exists. 

5. Remove a strip of the ninth rib, with periosteum, about two 
inches long and split it transversely so as to shape it to correct the 

(i. Scrape the cancelloiis tissue off the bone. 

7. Without removing the blood from the prepared pocket, insert 
the bone graft as far down the tip of the nose as necessary and place the 
upper end well under the periostea! Hap. (Fig. .'!_!(>.) 

S. (Muse the skin Hap with horse hair sutures. 

!*. Apply collodion dressing. 

Beck's Method for Saddle-back Nose. 

1. Lift up tip of the nose and make a small semicircular incision 
in the anterolateral portion of the vestibule at the mucocutaneous junc- 
tion of the cartilage and bone. 

'2. With Mayo's scissors dissect over the hump as in Fig. .'Il'b' 
With the same scissors engage and sever the hump which is usually 
made ii]) of cartilage. 

.'>. Kmploy a portion of the rib, the anterior surface of the tibia, 
or a portion of the septal ridge, from the patient himself or from an- 
other patient who has just been operated on for siibmiicous resection. 
The size of the bone splinter should correspond to the si/e and shape of 
the deformity to be corrected. 

4. The blood expressed from the cavity is mopped away and 
an adhesive plaster is drawn tightly over the bridge of the nose with no 
dressing between it and the skin. 

f). One silk stitch closes the wound. 

Walshaus' Operation for Collapsed Alae. 

1. Make a Hap of the mucous membrane of the most anterior 
portion of septum, one-eighth of an inch wide and one-half of an inch 
long, leaving the pedicle at the dorsum of the nose. (Fig. '.\'2~.) 

'2. Roll up this mucous membrane Hap and fasten in the upper 
angle of the nostril. (Fig. .'>l27.) 

'.}. Repeat the same on the opposite nostril. 

Lambert Lack's Operation for Collapsed Alae. 

1. Remove a strip of mucous membrane from the right side of 
the most anterior portion of the septum, measuring about one-eighth 
inch wide and one-half inch long. 

2. Cut through the cartilage and mucous membrane into the left 
nostril corresponding to the defect, leaving however the Hap intact at its 
hinge pedicle at the dorsum of nose. 


:]. Denude the surface of its mucous membrane where the septum 
and lateral cartilage of ala come together; also of the dermal layer of 
the inner side of the ala. 

4. Turn the cartilage mucous membrane Hap up in the right nos- 
tril placing the two denuded surfaces together. 

"). Make a similar flap back of this one, only reversing the denu- 
dation on the septum. 

(>. Turn this flap into the left side and fix to a similarly denuded 
surface of the ala, only further back. (Fig. .>28.) 


Fig. 327. Fig. :-!i>8. 

Walsliaus' operation for collapsed alae. 

Paraffin Injections in Nose and Ear Deformities. 

The history of this means of correcting nose and ear deformities 
dates back to 1900, when (lersuny corrected a saddle-back nose by the 
use of melted vaselin, injecting it below the skin. Eckstein in 11)01 em- 
ployed hard paraffin which has a melting point of 140 V. for similar de- 
fects, and claimed for it superiority in that there was less chance for 
pulmonary embolism. This method was very warmly received and 
employed by Broeckaert, Brindel, Karenski, Lake, and others abroad 
and by Harmon Smith, Kolle, (^uinlin and others in the I nited States. 

The principal indication for paraffin injection is deficiency of tis- 
sue about the nose or ears, since excessive; growth or absence of tissues 
of the external nose and ears are not within the limits of this method of 
treatment. Frequently there are post-traumatic or inflammatory con- 
ditions about the nose which leave scars and adhesions that will pre- 
vent proper injection of paraffin. In such cases, preliminary dissec- 
tion or loosening of these scars may be necessary. The introduction 
of a small quantity of paraffin after such dissection to keep the skin 
trom readhering is irood practice. Subsequently one may comji 

i) eie 


injection in one or more sittings. Xo anest liclic is required except in 
young individuals \vlio would not remain qnict during the injection. 

Many untoward results have been reported from the use of par 
aflin injection and according to Council, who has leathered them from 
the literature, they may he grouped as follows: 

1. To.ric absorption or ii/to.ricl ion. 'Phis condition is most 
probably due to the impurities in the paraffin and not to the chemical 
absorption and reaction of the paraffin itself. Too large a quantity, 
about 1 10 of the body weight, would have to be injected before any 
toxic symptoms would be observed, according to Jukiill. 

'_'. Inflammatory reaction when the proper teclmic has not been 
carried out, in injecting too large a quantity of paraffin at one time, 
or if the material contains any impurities. 

,'!. Loss of fisstK' due to infection and secondary abscess forma- 
tion has been observed to follow these injections when the usual asep- 
tic, precautions which are expected to be carried out in any surgical 
operation have not been observed. Instruments, the field of operation, 
and the material itself must all be sterile. The skin offers the great- 
est difficulty, since there are constantly many varieties of microorgan- 
isms about the nose, ahe and vestibule, which are located in and incor- 
porated with the sebum in the glands, and are very hard to eradicate. 
However, since tincture of iodin lias been employed before operation 
for painting the area even without previously using any soap or water, 
there is less chance for infection after these injections. 

4. Pressure necrosis will invariably follow when the paraffin is 
injected into the skin proper rather than subcutaneously. It will also 
follow when too great a quantity is injected at one time by shutting off 
the blood supply, with a greater chance for secondary infection. Again, 
it is essential to be most careful if there exists some constitutional dis- 
turbance or local devitalization of the tissues, such as results from scar 
tissue. Firmly bound down skin must always be first liberated before 
the injection of paraffin. 

f). Slout/lihtf/ has been reported, especially when the paraffin was 
injected while very hot. The author agrees with many operators that 
this is very unlikely, because by the time the paraffin is injected into 
the tissue it has cooled off to a decree approximating 1 the body temper- 
ature. Since the hard paraffins (Eckstein 140 ) are now employed, 
complication from this cause seldom occurs. Slough ing 1 , however, does 
occur when the injection is made into the wrong place, as into the 
skin especially where it is firmly bound down naturally or by scars. 
This complication may be avoided by first making a subcutaneous in- 
jection of sterile or normal salt solution or by the subcutaneous dissec- 


tion and an injection of three-fourths vaselin and one-fourth paraffin 
so as to prevent reaclherence of tlie dissected surface. An incision 
should be made and plates of paraffin or Cargile membrane introduced. 
Then injections are made small in quantity until the deformity is cor- 
rected. It is well to observe the general condition of the patient and 
in syphilitic cases a AVassermann reaction should always precede the 
injections to be sure that the blood is in good condition, even when the 
patient shows no active symptoms. 

(5. Sitbinjection or the injection of an insufficient quantity can 
scarcely be classed as an untoward result; it is only necessary to inject 
again. If subinjections were common, less disagreeable results would 
be reported. 

7. Hyperinjection or the injection of too great an amount occa- 
sions the most disagreeable results met with in this procedure. This 
is especially true when this mass undergoes early organization. 
lender these circumstances its removal by surgical measures is 
required, since the various solvents, as ether, xylol, benzine, chloro- 
form and heat have very little effect. Electrolysis, the negative pole 
being introduced into the mass, has been suggested as beneficial, but 
the author has found it of no value in a case of paraffinoma so-called, 
in which he employed this method. Instead of making external in- 
cisions the vestibule may be opened. It is well to remove the excess of 
paraffin just as soon as possible before organization has taken place. 

8. Air embolism may occur, especially when cold paraffin is em- 
ployed. In rilling the syringe, the needle is as a rule obstructed and an 
air chamber remains between it and the paraffin taken from the glass 
tube. This should be avoided by completely emptying the syringe and 
needle before refilling and then forcing out fresh paraffin through the 
end of the syringe. If a small air bubble gets in below the skin it will 
do very little harm. 

!). Paraffin embolism is of a more serious nature. In fact, it must 
be named as the most dangerous accident in connection with paraffin 
injections. Tin-re are several reports of death from this cause and 
many grave symptoms, as blindness, pneumonia, and cerebral embol- 
ism, have been recorded. If the needle is introduced below the skin 
separately from the syringe and no blood allowed to escape then the 
immediate danger of embolism following the fragmentation of the par- 
affin is obviated. It is thought that these small particles getting into 
the circulation cause the trouble, but the explanation is more theoretic 
than real. After eight years of personal experience with paraffin in 
various methods and locations in ;i goodly number of cases, the author 


cannot report a single instance or even a symptom referable to par 
affin embolism. 

10. I'i'hinu'1/ ill/fusion or c.i'h'usinn of paraffin will occur espe- 
cially after injecting for the correction of a saddle-back nose, when 
the needle point is allowed to go beyond the limits or after injecting a 
larger amount than one should, and especially when using Cnpiid (hot) 
para (Hi n or \ - aseliii. The loose areolar tissues of the lower lid, cheeks 
and eyebrows are the principal location for diffusion of the parallin. 
By having the assistant hold his (infers (irmly down on the bony struc- 
ture over the root of the nose, as well as at its side, a great deal of this 
danger will be avoided. Semi-solid or cold paraflin practically makes 
this accident impossible. The author takes a piece of dental modeling 
compound and while warm and soft, molds it to (it the above named 
margins at which the assistant holds his (infers. This insures abso- 
lutely the retention of the pa ratlin within the limits of this mold, which 
when it cools becomes very hard. 

11. Interference inlli lln- <n-fi<nt <>] lln> niuxcle <>t tin' 1 or u'ntfi* 
of flic HOSI'. This is most likely to happen when a very low deformity 
of the nose is to be corrected. The author has found that the oppos- 
ing muscles of the constrictors of the a la 1 cannot act and the patient 
then complains of nasal obstruction like that due to paralysis of the 
dilating or lifting muscle of the wind's of the nose. In order to prevent 
the paraffin from coming down too far a finder should be inserted into 
the nostril during 1 the injection and the tip of the nose raised upward 
and outward, if a lateral injection is made. 

l'_!. /','xr(//>c of }>(U'(il)ui after injection can be avoided by thor- 
oughly molding the mass into the desired shape, although this should 
be done even while the needle is still within the tissues so as not to 
get the mass into one place. The needle should he moved about, almost 
withdrawn, and reintroduced, since the paraffin often sticks to the 
needle. The needle should be withdrawn only after no more parallin 
whatever is escaping from it. It escapes usually for a few moments 
even after the turning of the piston ceases on account of the pressure 
within the syringe. A line blunt pointed probe should be passed 
through the opening of the skin so as to be sure that no parallin is left 
in the skin puncture. A drop of collodion will further close the punc- 
ture and prevent the escape of any paraffin. Xasal motion or manipu- 
lation should be prevented. If liquid paraffin is employed under such 
circumstances cold applications for a few moments are advisable. 

1.'). Solidification of the i>nni1fin in the syringe, or more fre- 
quently within the needle, is a condition that complicates the technic 


very much, especially when paraffin of high melting ])oint is used. The 
injection must bo accomplished quickly, frequently necessitating the 
heating of the needle over a flame just before introduction a process 
which may be injurious to the skin. Again the sudden expulsion of the 
liquid paraffin into the tissues may cause it to pass into undesirable 
locations or too much paraffin may be injected at one time, causing all 
the complications of hyporinjoctions. The fact that semi-solid par- 
affins in the cold state are mainly employed now, makes this occurrence 
rare. It appears to the author that when the same syringe that is em- 
ployed for the semi-solid paraffin is used, however, with a very short 
and conical needle, the solidification of the paraffin is obviated. By 
rapidly screwing the piston down, the injection can be more readily 

14. Alixorption antl dix inter/ rat ion of the paraffin injected are of 
considerable interest and importance. Some authors believe that the 
injected mass becomes encapsulated by a fibrous capsule like a foreign 
body, while many others with histologically examined tissue as proof, 
believe that the mass is first surrounded with a connective tissue wall, 
and that fibrous bands traverse the mass and subdivide it. The par- 
affin finally becomes absorbed and all that is left is a new connective 
tissue mass of cartilage-like consistency to the touch. The ultimate 
absorption of the paraffin does not seem to have any effect on the gen- 
eral condition of the individual. The time required for the paraffin to 
become absorbed varies according to the kind of paraffin injected, the 
amount and location of the injection, and differs even in different indi- 
viduals. Some authors have found that after one month a good-sized 
mass was entirely replaced by connective tissue, while others have found 
paraffin as late as four months after injection. The harder the par- 
affin the longer will it remain and the less will it be traversed by con- 
ned ive tissue. In loose connective tissue areas absorption will be 
more rapid than in closely bound down areas. Small quantities in- 
jected at a time will be absorbed more rapidly than larger. It is of in- 
terest to note the action of the newly-formed connective tissue as to 
absorption and contraction on taking on nooplastic manifestations. 

I."). I)i Ijlcull K'S as /<> /l/c jit'oficr iiicllu/fi point of I lie jxira /Jin.-- 
In this regard widely different opinions are expressed. However the 
great number of operators believe that paraffins of lower degrees, 
molting point from !>7 to 11.") K., arc the best for the purpose. The 
author believes thai the formula recommended hv Kolle: 

I'araHin (plate sterile) 

Vaselin (white sterile).. 

PLASTIC snicKitv or 'I'liK NOSK AND KAI:. .'!4!> 

is the best to employ, (ilass tubes may he prepared sterile in advance 
and in these the para flin may he resterilized, tnhe and all, just het'orc 
the injection, hy washing with hichloi'id and alcohol. The injections 
should he made with this semi-solid paraffin in a cold state hecanse the 
complications and unpleasant results may thus he avoided. 

1(5. II t/ficrxi'itxif in'Hrxs of the skin plays a very small role in the 
objections or difficulties met with in the use of paraffin injections. I sn- 
ally for a short time only, twenty-four to forty-eight hours after the 
injection is made, is there any complaint of pain. More often patients 
complain of a sense of distension or of a drawn feeling. Late symp- 
toms rarely develop if cold paraffin is used in small amounts at a time 
and if some little time intervenes between the injections. Harmon 
Smith reports a sense of numbness following the injection and other 
authors have reported subsequent neuralgic pains from the sensory 
nerve filaments caught in the newly-formed connective tissue 
mass after the paraffin has become absorbed. If infections of the skin 
or subcutaneous tissue should take place following' the injection, there 
may be some tenderness or hypersensitive-ness of the area injected. 

17. Kcthn'x* of the skin is a pretty constant result of paraffin in- 
jections. It varies a great deal in decree, there being in some cases 
only a flush, while in others a very dee]) red color follows. Again it 
may simulate a grave acne rosacea, with distinct new blood vessel 
(capillary) formation. It may also appear at different times follow- 
in !> the injection. Sometimes immediately after the injection has been 
made, especially if hot liquid paraffin is employed, the nose becomes 
very red and it may continue so for a long time. Again, the redness 
and capillary formation may not occur until months later. This ap- 
pears to be due to hyperinjections especially of hot material. 

Redness is unquestionably due to pressure, on the venules such as 
one would obtain in Bier's hyperemia, and possibly to an active 
hyperemia, nature's part to assist in absorbing 1 the foreign body, 
paraffin. Again, late appearance of the redness is very likely due to 
cicatricial subcutaneous contractions from the new substitute connec- 
tive tissue mass. Whether the chemical action of the hydrocarbons lias 
anything to do with the redness of the skin has not yet been determined. 
The early evidence of redness may be relieved by ice cold applications, 
moist dressings of acetate of aluminum, ichthyol salve, ten per cent 
extract of ergotol, belladonna, and adrenalin internally. In later stages 
the same treatment plus the eventual severance of newly-formed blood 
vessels, puncturing of the skin very superficially, and electrolysis have 
all been suggested. Karlv cases when verv stormv and red. mav call 


for removal of some of the injected mass and older cases after all has 
been done, may require the dissection of some of the newly substituted 
mass of connective tissue. The author has found that a certain amount 
of redness follows these injections, but that it never lasts very long 
and eventually disappears. 

18. Secondary diffusion of the injected paraffin has occurred a 
number of times, especially into the loose tissues of the eyelids. The 
difficulty lies in the fact that the paraffin is injected in areas tightly 
bound down, as the root of the nose, and finding a lack of resistance at 
this place it migrates into the looser areas. Tn all such cases the use 
of cold paraffin in small quantities will avoid this difficulty; when once 
diffusion or migration has taken place, excision is about all that can 
lie done. 

19. // ypcr/tlaxia of the connective tissue following the organiza- 
tion of the injected matter has been observed a number of times, and 
the author had a very pronounced case come under his observation, 
which is here illustrated (see Fig. )>29). The specific cause of such new 
formation of connective tissue in this extensive form is not known, and 
most authors believe it to be due to a special predisposition on the part 
of the individual, such as is found in the tendency to develop keloids. 
When such a disfiguring condition develops there is only one procedure 
admissible the complete excision of the fibrous mass. If there should 
})e a recurrence, a second operation must be performed. 

'JO. Ycllou' appearance and thickening of the skin after these in- 
jections are observed in rare instances, and they are among the most 
difficult conditions to deal with satisfactorily. The cause is supposed 
to be the use of hard paraffin injected too close to the dermal layer in 
regions where there is not enough loose underlying tissue. The elec- 
trolytic treatment, by making a number of punctures at repeated sit- 
tings, is advised. This will bleach the area by secondary scar forma- 
tion and contraction. In case the result from such treatment is not 
satisfactory, it may be necessary to excise the pigmcnted portions. 

I'l. ttreakhlfl doint of tissue and resultant abscesses due to the 
pressure of the injected mass upon the adjacent tissue after the injec- 
tion has become organized have been observed generally in cases fol- 
lowing trauma. Abscess formation has been observed without thi- 
cause, and may be due to the increased pressure on the blood vessels, 
causinir their obliteration and the breaking down of the tissues. The 
treatment consists in making a small incision and draining the accumu- 
lated purulent material. \Vlicn all reaction symptoms disappear the 
parts are au'ain injected. 

Fig. :'.:>!'. 
Parattinoma with attempted removal. 



Technic of Paraffin Injections. Inslntnn-nts. About all that is 
required is a syringe which is strong and not too heavy, with a screw or 
ratchet arrangement for expressing the paraffin slowly, but which can 
also be made to expel its contents in heated liquid form in a continuous 
How. There are many varieties on the market, and those of Harmon 
Smith, Broeckaert, Eckstein, Kolle, Onodi, Walker Dowman and the 
author's are all satisfactory. The only difficulty with most of them is 
that they are arranged only for the use of semi-solid paraffin ex- 
pressed by the screw method, or for the liquefied hot paraffin in a 
continuous flow. The author's syringe (Fig. o.'JO) is so constructed that 
it may be adapted for either variety of paraffin. For the main ideas in 
the construction of this instrument, the author is indebted to V. Mueller, 
instrument maker, Chicago. 

The i>'reat advantage which the instrument of Broeckaert has over 

Fig. 330. 
Beck's paraffin syringe. 

others is that it can he managed by the operator with one hand while 
the other can he used to prevent the paraffin from escaping into the 
loose tissues. Moreover, when one is injecting intranasally the other 
hand is free to dilate the nostril. 

Various shaped needles will suggest themselves for use in differ- 
ent special localities. In injections about the nose a needle with too 
large a caliber should be avoided, since the opening will prevent heal- 
ing; in fact, there is greater liability to infection. Again, the bleeding- 
is greater from the skin, although it is never of any great consequence. 

Material. Paraffin which has a melting point of 110 F., with the 
following formula : sterile plate paraffin, 1.1, sterile white vaselin, 120, 
is made up and filled into glass tubes, open at both ends and having an 
inner diameter exactly equal to that of the tube in the syringe (0.5 
cm.). The ends are corked, and the cork-stopper is coated with a layer 


of paraffin. These tubes are always ready for refilling 1 the syringe, and 
all that is necessary is to wash them in biclilorid and alcohol before 

Fillni<i tl/<' Si/rh/f/c (icli'tle the needle /'* attached}. Tni'n the ring 
bar so that it can be slipped down, thus releasing the piston screw. 
Pull out the handle of the syringe, so that the paraffin chamber is 
opened. Then uncorking both ends of a prepared tube and holding one 
end right over the paraffin chamber of the syringe, the paraffin is 
pushed into it by means of the metal rod. It should be noted that the 
end where the needle is to be attached is to lie free from paraffin; other- 
wise the air thus included will prevent the paraffin from filling the en- 
tire chamber of the syringe, and on injecting, some air will enter the 
tissues. This may not do any harm, but may elevate the tissues and 
deceive the operator as to the amount of paraffin injected. 

If hot liquid paraffin is to be employed, then the ring bar is left 
down and the paraffin is drawn up through the needle. Instead of this 
procedure, the syringe may be filled first and the needle attached after- 
wards. The syringe should lie kept in very warm water until ready 
to be used. It may, however, become too hot and uncomfortable to hold, 
and for this reason the author employs heavy rubber gloves when 
using this method. 

Preparation f Field. Until two years ago, thorough scrubbing 
with soap and water, biclilorid, ether and alcohol, was the usual routine 
before injections, but since then the author simply has the Held 
scrubbed with alcohol, following which he applies the ten per cent alco- 
holic solution of tincture of iodin. 

sufficiently loose to enable one 1o raise it. If through contraction of scar 
tissue or otherwise Ibis is not possible, a small incision must first be 
made and the skin dissected loose. If the resulting incision is too large 
and there is danger of Ilie paraffin exuding, it is well 1o put in a stitch. 

Injeelioii. liaise the skin as in any subcutaneous injection over 
the site to be injected, and thrust the needle, apart from the syringe, 
through the skin. The direction of the needle is from the root of the 
nose downward. As a rule no blood comes back through the needle, 
but if this should occur, draw the needle slightly outward and pass in 
a somewhat different direction. In order to prevent the cavity filling 
with blood and forming a liematoma, it is best to compress the parts 
for a few moments, before injecting the paraffin. Xow attach the 
syringe by holding the needle steady, and then turn the handle while 
holding the barrel of the syringe by the crossbars. An assistant holds 
his fingers firmly over the root and side of the nose so as to prevent 


the paraffin from finding its way into the loose tissue or other places 
where no paraffin is desired. If cold paraffin is employed this is not 
very likely to happen. It is well repeatedly to draw the needle out- 
ward almost to the skin opening while injecting, in order to liberate it 
from the mass, and in that way the paraffin will he more uniformly 
distributed. Again, a certain amount of molding is possible while in- 
jecting, and this may be aided by irrigating the skin with very warm 
water or hot compresses. After having given a proper shape to the 
injected mass, ice applications will facilitate its solidification and the 
retention of its shape. The greatest care must be exercised, as alreadv 
pointed out, not to inject too much at one time; it is better to repeat 
the injection a number of times. 

dication is the absorption of cartilage by pressure, the result of a 
perichondritis or a hematoma, and this affords the best results although 
the defect may be very large. The paraffin mass, however, will never 
hold up the ear as cartilage did. The preparations are the same as in 
nasal injections. The liquid hot paraffin gives better results than the 
cold, since it gives greater consistency to the ear. 

After the two layers of the skin of the deformed ear are thor- 
oughly separated by dissection, the paraffin is tilled into the cavity as 
into a bag and allowed to solidify somewhat. Supports or splints made 
by taking two impressions of the other ear with dental compound 
(front and back) are employed. Then the ear is roughly shaped and 
the excess of paraffin is allowed to escape through the small incision 
that was made. Then apply a thin layer of cotton, the dental com- 
pound splints, strap with adhesive plaster, and bandage to the side of 
the head. This is left undisturbed for one week unless there should be 
much pain or fever. Subsequently a cotton support and bandage are 
worn for about three weeks, until organization lias taken place. In 
the subsequent treatment of a newly-made ear by plastic, an injection 
of paraffin between the skin layers may undoubtedly be beneficial to 
tlu i consistency and appearance of the ear. 

Paraffin Injections in Collapsed Alae. 

Mcnz<>l's Mt'fliod 

1. Pack the nose (vestibule) firmly with cotton. 

2. Pass the needle under the skin overlying the cartilage at the 
crease between the nose and cheek, forward and upward. 

I). Distribute the injected mass (equal parts of paraffin and vas- 
olin) over the ala so as to stiffen it, but not to any great degree, so that 
when the cotton is removed from the nose the inner surface will not 



approach the septum. Cotton packing is permitted to remain for twenty- 
four hours. 

VIII. Reduction Method. 

In order to diminish as a whole or in part the size of a nose enlarged 
by some pathologic condition, traumatism, or deformity of unknown 
origin, extranasal, intranasal or combined methods may be employed. 
Thus it is that resection of a portion of the nasal septum by the in- 

Fig. 331. 

Cd r t i <aj e 
oj Spt u YW 

Super/ o r 
rt a x i ( I a. 

Lower Latero.1 
C 4 rt 1 1 A Q 

Fi-. 332. Fig. 333. 

Joseph's operation 1'or reducing hump, length, \\iiltli of nose and largo nostrils. 

tranasal method will influence the shape of the nose, but alone will 
seldom straighten it. By intranasal methods, thai is through incision 
within the ahe, redundances may be removed or displaced so as to fill 
out deficiencies in the nose. A very largo nose, affected with chronic 
rosaceous hypertrophy, requires operation by external methods. Also 
many very lar.u'e hump and twisted noses are best attacked by external 
methods. The minor deformities, as large ahe or large nostrils or a verv 


ig- 334. Fig. ;. 35 . 

Kolle's operation for hump nose. 

Fig. 337. 

Beck's operation for hump nose. 


long hanging tip of the nose, arc as a rule best corrected by external 

Joseph's Operation for Reducing Hump, Length, Width of Nose and 
Large Nostrils. 

1. An A-shaped incision is made over the anterolateral por- 
tion of the nose, just above the tip. A corresponding incision is made 
above this, the distance depending on the amount of tissue that is to be 
removed. The ends of these incisions should reach to the margins of 
the ahr. (Fig. .TH.) 

2. .V wedge-shaped portion of the nose is now taken out, includ- 
ing the skin between the two incisions, the underlying connective tis- 
sue and cartilage. The hum]) or crest of the nose, containing bones 
and cartilage, is shaved off by means of the chisel and the knife. (Fig. 

.'I. The nose is shortened by excising a wedge-shaped portion of 
the cartilaginous septum, with its base at the dorsmn of the nose and 
the apex running backward as far as the bony portion of the septum. 
(Fig. 3:53.) 

4. Suturing the parts together, one dee]) suture should pass be- 
tween the upper and lower margin of the excised septum at the crest, 
so as to bring the point well up. The other sutures are superficial 

."). The dressing should be such as to hold the tip of the nose up- 

Kolle's Operation for Hump Nose. 

1. Make a longitudinal incision over the prominence of the hump 
(Fig. o.'U) and dissect off the skin and periosteum to cither side of it 
until it is completely exposed. ( Fig. .'>.'>.").) 

'2. By the aid of a chisel the hump is taken off, care being taken 
not to enter the interior of the nose or to tear away the mucous mem- 
brane. If there is a tear it should be sutured at once. 

'). If a broad bone defect is obtained by the removal of the hum]), 
then by the aid of a heavy forceps the margins may be pressed together 
to obtain a sharper ridge. 

4. ('lose defect by llalsted's snbcnt icular periostea! suture. 

Beck's Operation. 

I. Instead of the longitudinal incision, a transverse one curved 
upward, subsequently to be hidden by spectacles, is made across the 
bridge of the nose. The ends of this incision may go to some distance 
on the side of the nose and thus create a Hap which will easily expose 
t lie hump. ( Fig. .'!.'!(). ) 


'2. By means of a chisel take off the hum] >. ( Fi.u' 
.'!. ('lose in (lie same manner as in the preceding operation. 
Ballenger's Operation for Hump Nose (Intranasal). 

1. By means of scalpel feel the lower bonier of the nasal bones 
and pass through niueons membrane bclwccn the skin and nasal bones. 

Fig. 338. 
Ballenger's operation for hump nose 

FiR. 339. 
Ballenger's operation for Ions nose. 

J. Klevate the skin from the underlying anterior portion of the 
nasal bones by tho aid of a Freer ty]e elevator. 

.'5. Introduce^ the Balleiii> - ei' reverse chisel and with a downward 
and forward pull, parallel to the bridge of the nose, shave off the hump. 
(Fig. 338.) 
Ballenger's Operation for Long Nose. 

1. Make two incisions through mucous membrane and cartilage 
to the opposite iiiucoperichondriinn above the point of the nose close 


Fig. 340. 

Fig. 341. 

Fig. 342. 

Fig. 343. 

Fin. 344. 

line's operation for hump, twist and broad ala or large nostrils. 
(Illustrated by Heck.) 

to the dorsiim and carry downward and backward to meet at the floor 

of t lie nose. Dissect the llllico| >ericholldri 11 III free. ( Kin'. .'!.'>!(. ) 

'2. At the dorsnin of the nose the Imse of this cartilage Hap is sev- 
ered and the wed.u'e shaped piece removed. 

.'!. 'The nose is elevated by a sort of sl'm.u' bandage of adhesive 
plaster, and held thus for from four to ei.u'bt days. 

Roe's Operation for Hump, Twist and Broad Ala or Large Nostrils. 

1. Make an incision at the junction of the inner alar skin surface 
with the nasal mucous membrane, and pass below the skin over the 
cartilage and nasal bones. ( Fi,u - . .'140.) 

'2. Flevate the skin and subcutaneous connective tissue by means 
of elevators (the author prefers Mayo scissors, as by opening the 
blades the tissues are separated with the least t raiiinatism ) until the 
entire hump is exposed. ( Fiix. .'!41. ) 

.'!. By means of a small saw the hump made up of cartilage and 
bone is sawed off ( Fi.u 1 . l}4'2) and removed. If, as is frequently tin- 
case, the hump nose is at the same time twisted and depressed, the 
hum}) is sawed off partially, but is left attached above to the fibrous 
tissue as a sort of a pedicle and slid over into the depression. Here it 
is subsequently retained. ( Ki.u's. .'!4.'! and .'144.) This fibrous pedicle 
is not absolutely necessary, as the bone and cartilage chip will live any 
way. If the depression be i>Teater than the bone cartilage chip can 
fill out. small subcutaneous tissue Haps are turned back into the de- 
pression. These are as a rule taken from the tip of lateral portions of 
the a la 1 , which also are lari>v in many cases. 

4. Kither a soft metal or adhesive retention dressing is applied 
over the nose and the incision within the ala is sutured. 

Roe's Operation for Broad Alae and Large Nostrils. ( Fi,u\ .''>4.V) 

1. An incision is made within the nostrils closer to the exterior 
than in the preceding operation. 

'2. The cartilage is liberated and part of it is excised together 
with some of the subcutaneous tissue. ( Fiir. ->4(). ) 

.'!. Suture and insert two small rubber tubes. Kiir. .".47 -how- 
final results. 

Beck's Operation for Hump Nose. 

1. Lift up tip of the nose and make with a knife a small semi- 
circular incision in the anterolateral portion of the vestibule at the 
mucocutaneous junction of the cartilage and bone. 



Fig. 345. Fig. 846. Fig. 347. 

Roe's operation for broad ahv or large nostrils. (Illustrated by Beck.) 

'2. Dissect over the Immp with Mayo 's scissors as in Fi ( u;. .'US. With 
the same scissors en,<>;aii;e and sever the hump which is usually made up 
of eartilau'e. 

Fig. :', 
Heck's operation Tor hump nose. 

'!. Displace this fragment hy external manipulation and hy tin- 
aid of line forceps or the scissors in the eventually existing depression 
(it none exist reino\"e t he piece). 


4. It' the base from \vliicli the hump is removed, is very broad and 
sharp, the ed^es may he filed off with a straight rasp or shaved off with 
a chisel. 

."). The Mood expressed from the cavity is mopped away and an 


Fig. 351. 
Kolle's operation for long tip nose. 

adhesive plaster is drawn tightly over the bridge of the nose with no 
dressing between it and the skin. 

(>. One silk stitch is used to close the wound. 

Kolle's Operation for Long Tip Nose. 

1. Make an incision on either side through the entire thickness of 
the nose, including the septum, as shown in Fiu'. .''4!), beirinninu 1 at r, 


2. From c to //, in a natural curve line, all the tissues of the ahr 
are severed. 

3. A short upward cut is made through the entire thickness of 
the columella at c, from which point the septum is cut as shown in the 
dotted line fl , towards c. 

4. The tip b of the part <t is now cut off, leaving the nose as in 
Fig. 350. 

5. The front part a is now sutured to the remaining portions of 
the columella at b, and the cartilages of the ahr where they are pro- 
truding are excised to such an extent as to permit union of the skin 
over them, as shown in Fig. 351. 

IX. Prothetic or Artificial Noses. 

There are frequently anatomic, pathologic and social conditions 
that require the correction of the nasal deformity to be made by the 
aid of artificial devices. It can be said without question that so far as 
the appearance is concerned, at least if not too closely scrutinized, an 
artificial nose that is correctly made looks much better than one that 
results from the most of the best surgical procedures. (Figs. .'552-355. ) 

For instance, in cases of carcinoma which have been operated up- 
on to the extent of removing the greater part of the nose, there 
will naturally be some hesitation about performing a plastic opera- 
tion. In cases where the face is all scarred up it is much better to em- 
ploy an artificial nose. There are some people who have not the neces- 
sary time to have plastic work done on their noses by reason of the 
necessity of making a living and providing for their families. 

These artificial noses may be made to fit any kind of defect and 
are usually held in place by spectacles and adhesive (actors') paste. 
The making of these noses is left to a specialist in this line, but only 
under the direction of a physician, since the condition of the nose must 
be thoroughly examined before fitting an artificial nose. 

Artificial Supports. In noses in which the bony framework' is 
destroyed or absent one may introduce wire or rubber supports, made 
especially for each individual case. In cases of lues, in which t here exists 
a perforation in the hard palate, a sort of a horn may be vnlcani/ed 
upon a dental plate that will push the collapsed nose forward and thus 
support it. 

X. Orthopedic Method. 

By wearing certain forms of apparatus which usually must be 
specially made in each individual case, a deformity may be changed, 
especially in early life or when it follows a traumatism. It is also pos- 


Fig. xr>-2. 

Prothetie or artificial noses. 



sible to correct collapsed or saddle-back nose by special methods. (Fig. 

XI. Operations for Closing Perforating Septum. 

Goldstein's Operation. 

1. Freshen up the edges of the perforation and elevate the muco- 
perichondriuin from the cartilage for about one-half inch. 

L*. Remove a small rim of the cartilage all along the perforation 
by means of Ballenger's single-fined swivel knife. (Fig. .'!")().) 

.'). Outline a mucoperichondrial Hap on the most convenient por- 

Fig. 356. 

Fig. 357. 

Fig. 358. 
(loldstein's operation for perforation of septum. 

lion of the septum, \vitli the hinge pedicle at the margin of the per- 
foration. The author would suggest the use of the cautery in order to 
destroy the epithelium so that the flap may heal more easily. (Fig. 


4. Dissect this flap and bring it between the two layers of the 
mucoperiehondrium about the pert drat ion. 

.">. Suture through and through by a quilted suture with the aid 
of Yankaiier needle. ( Fiir. .'!.")*. ) 


Hazeltine's Operation for Perforation of Septum. 

1. Freshen ii) the margins c-c ( Fi,u'. .').")!)) and elevate the inuco- 
|M'ricliondriiim (as in the snbnmcons resection) \vliere the anterior 
Hap lies. 

'2. An incision through the mnco-perichoiidriniii about one half 

Fig. 35! 

Fig. :-!61. 
Hazeltine's operation for perforation of septum. 

to one inch anteriorly to perforation (l>-h, Fiiv. '!")!') is made, and the 
Hap, with pedicle above and below, is dissected as far as the perforation. 
.">. If the anterior Hap was made on the riidit side, then make 
the posterior Hap (r-r. Fiir. .">,")!)) on the left side, by a similar incision 
throuii'li the inncoperichondrinm about one-half to one inch back" of 


4. Approximate and suture anterior flap to posterior margin 
of perforation (/'-/', Fig. .'>()()) and slide the posterior flap of the op- 
posite side forward and suture to the anterior margins of perforation 
(d-d, Fig. .'561). Denuded areas (a-u} from the Ha]) heal by granulation. 

Goldsmith's Operation for Closure of Septal Perforations. 

1. Fxcise margin of perforation by the Ballenger's single-tine 
swivel knife. 

'2. Separate the mncoperichondrial flap on either side all around 
the perforation. 

.'). Take a piece of cartilage either from another case just oper- 
ated upon for deviation by the submucous method, or a piece of sheep's 
septal cartilage, which must be larger than the perforation. 

4. Slip this cartilage plate into the dissected flaps and replace 
carefully all around the perforation. 

."). Put in anterior nasal splints to retain the cartilage and niuco- 
perichondrium in place for forty-eight hours. 

6. Subsequent cauterization to assist in epitlielialization and 
application of scarlet red ointment constitute the after-treatment. 


Otoplasty is a subject that has received very little attention as 
compared with rhinoplasty, and most text-books contain very meager 
information on the subject. However, much better cosmetic results 
are obtained than in nasal plastics, especially in deformities or mal- 
positions. In the absence of the entire or a greater portion of the 
auricle, the results except with prothesis are very unsatisfactory. There 
is one comforting fact that in women deformities of the ear may be 
hidden by lonir hair. Far plastics are performed principally for cos- 
m<'1ic reasons, since the physiologic function is but slightly influenced 
unless it be in eases of congenital atresia, with presence of a good 
middle ear and auditory nerve apparatus. 

Classifications According to Kolle. 

, ,, ,. . I rnilateral. 

I. Preaiirieular deficiency - 

[ Bilateral. 

\ Cnilateral. 
II. I ostauriciilar denciencv 


General Classification. 

I. .Macrotia ( lar.uv car). 

II. Asymmetry of the two ears. 

TIL Ileterotopy (false position of the auricle). 

IV. Synechia of the posterior surface of the auricle. 

V. Projecting, roll or <lo,i>' ears. 

VI. Pointed ear (Darwinian tubercle). 

VII. Macacus ear. 

VI 1 1. \Vildermuth 's ear. 

I X. Absence of helix. 

X. Lobule deformities and abnormalities. 

X I. Synechia of lobule. 

XII. Shriveled ear following; perichondritis or infected liematonia 

or abscess. 

XIII. Traumatic destruction, complete or partial. 
XIV. Poliotia. 
XV. Microtia. 

Usual Operation for Macrotia. 

1. Ivxcise a V-shaped segment of the auricle, including all the 
structures at the upper and larger part. The base of the V is at the 

Fig. 362. 


Fig. 364. 



external border of the ear. (Fig. '}()- and .'>(>.'>.) The size of the wedge- 
sha])ed piece to be removed will depend on the size of the deformity 
to be corrected. 

'2. Excise a narrow wedge-shaped segment from the lower half 
of the auricle, the base of this wedge being at the incision, the apex 
directed towards the lobule. (Fig. o(>4.) This is necessary to make 
the upper and lower portions of the auricle fit for exact approximation 
of the helix. 

.'}. Suture the lower wedge first and then the large transverse 
defect after exact approximation. 

Fig. 365. Fig. :!66. 

Parkhill's operation 1'or inacrotia. 

Parkhill's Operation for Macrotia. 

1. Make an incision through all the structures in line with the 
curve of the antihelix. 

'2. From each extremity of this incision make a curvilinear in- 
cision towards the outer margins. 

.'!. A small tongue-shaped flap is further excised from this last 
incision towards the external border, in order to shorten the 1 011.11; 
diameter of the ear, and the crescentic excision will make the width 
of the ear smaller. This will make a crescent-shaped defect with a 
little longne. ( Fig. .'Hi.").) Suture defect. ( Fig. .'Hi*;.) 

Cheyne and Burghard's Operation for Macrotia. 

1. Excise a V-shaped piece of the auricle from the upper and 
outer part, the acute angle of the V being' carried almost into the 
concha. ( Fig. .'!<>7. ) 


'2. Corresponding to the upper border of the concha a semilunar 
incision is made through all the structures. 

3. From the hitter's extreme ends two short curved incisions arc? 
made to meet the V-shaped incision, removing the- two pieces thus 
formed. ( Fig. 307.) 

4. The parts are brought together and sutured on both sides of tin- 
auricle. (Fig. 36S.) 

Goldstein's Operation for Macrotia. 

1. Make a curvilinear incision down to the cartilage, with its 
convexity directed to the outer margin of the ear, on the posterior 
surface of the auricle. (Fig. 369.) 

Fig. 367. Fig. 

Cheyne and Burghard's operation for macrotia. 

'2. Dissect off this flap and lay over the mastoid region. 
(Fig. 370.) 

3. Cut through the cartilage in the perpendicular direction of 
the ear and curve the incision at each extremity for a short distance 
in order to make a sort of a cartilage flap. Great care must be exer- 
cised not to cut through the skin on the anterior surface of auricle, in 
other words, not to buttonhole it. (Fig. 370.) 

4. With a dissector, as employed in a submucoiis resection of the 
septum, the dermopericliondrium is dissected off from the cartilage, 
thus making the cartilage flap, and the dissection is continued a little 
beyond the necessary limits so as to enable one to slide the flap over 
with greater ease. 



Fig. 369. 

Pig. 370. 


Fig. 371. Fig. 372. 

Goldstein's operation for marrot ia. 


."). Dissect also the dermoperichoiidriinn anteriorly from the 
external portion of tin; exposed cartilage because the subsequent sutur- 
ing will liave to be done at tliat ]>,oint. 

(>. Pass a small sharp curved needle armed with fine chromici/cd 
catgut through the ii|>j)er part of the internal cartilage ilap ( which 
will become the overriding one). Then at the same place pass the 
needle tli rough the external cartilage Ilap, which will become the over- 
ridden one, and taking in a small Itit of cartilage come out through 
both (laps, completing one mattress suture. Another suture of the 
same type is made in the lower portion of the incision, and the parts 
are ready for suture. (Fig. .'57 1.) 

7. While the assistant holds the parts together so as to get 
an overriding of the internal flap, the sutures are tied. 

8. The posterior dcrmoperichoiidrium flap is brought back again 
and sutured. (Fig. 372.) 

Goldstein's Operation for Projecting Ear. 

1. Make two curvilinear incisions back of the auricle, one having 
its convex border towards the outer border of the ear, the other towards 
the occiput, thus creating an elliptical flap of skin. (Fig. 373.) 

'2. Dissect off this skin flap, exposing the perichondrium of the 
auricle and the periosteum of the mastoid. (Fig. 373.) 

3. Excise an elliptical portion of the cartilage of a size depend- 
ing upon the amount of projection present. (Fig. 374.) 

4. Draw the cartilage towards the mastoid region and suture to 
the periosteum at this point. (Fig. 375.) 

f). (Mose the skin defect by a few interrupted sutures. (Fig. 37(5.) 

Beck's Operation for Roll Ear or So-called Dog-ear. (Fig. 377.) 

1. Make an incision through the skin on the posterior part of 

the auricle in line with the usual site of the antihelix. 

_'. Dissect the skin freely on either side of the incision, but not 

the perichondrium. 

3. Fxcise a very thin sliver of cartilage the whole length of the 
skin incision in a curvilinear shape. (Fig. 378.) 

4. Bend back the helix and form an antihelix by doubling the 
cartilage upon itself. Hold the parts together on the anterior surface 
of the ear. 

5. Pass two mattress sutures of silkworm gut through the skin, 
perichondrium, cartilage, two layers of perichondrium, cartilage. 
perichondrium and skin. These are tied over pieces of rubber tissue 
in order not to cut into the skin. (Fig. 379.) 



Fig. 373. 

Fig. 374. 

Fig. 375. Fig. 376. 

Goldstein's operation for projecting ear. 

Fig. 377. Fig. 378. 

Heck's operation for roll ear or so-called dog ear. 


(i. Fxcisc small portions of excess skin on the posterior surface 
and make a subcuticular suture. 

r riiis same operation can lie adopted for the formation of an anti- 
helix in an ear that is not rolled. 

Szymanowski's Operation for Reconstructing an Auricle. 

1. Make an incision as outlined in Fig. .'{SO, hack of the rudi- 
mentary ear or external auditory meatiis, about the size of the pinna 
on the opposite side, taking in the skin and all subcutaneous tissue 
possible 1 . 

'2. Dissect the above outlined flap and fold at the constricted 
middle part so as to bring the ra\v surfaces in apposition. 

.'>. Suture along the margins above and below. 

4. Cover the denuded area of defect by skin grafts or slide a 
llap from the occipital region and support posteriorly by gauze pads. 

Subsequent ( 'nrrcction. 

5. Incise above and below as shown in Fig. .'181, placing small 
triangular (laps back of the auricle and bringing the latter forward 
into a more projecting shape. Also excise a small portion of the 
newly-formed auricle from the lower margin, to shape a lobule. 

Beck's Operation for Synechia of Auricle to the Mastoid Squama. 

1. Sever the adherent ear from the mastoid surface and place 
between the surfaces gauze or rubber tissue to prevent reunion and 
wait for granulation formation. 

'2. Make a correctly outlined flap to cover mastoid region as 
well as posterior surface of auricle, on the forearm, ou the side 
opposite to the synechia, since the subsequent immobilization is more 
comfortable in that way. Place rubber tissue below this tlap to 
prevent its reuniting and allow it to become thicker. 

Our Wrrl- Later. 

.'!. Freshen up the surfaces ou the mastoid region, turn the auricle 
forward and suture 1 into the forearm llap on the greater portion of 
the defect. (Fig. .".Sl'.) 

4. Apply regular plaster retention cast as in the 1 Italian plastic 
operation for the nose. 

To/ Dai/* Later. 

5. Sever pedicle from forearm and suture on all sides, special 
care being taken to make a natural fold at the insertion of the auricle. 
This is best accomplished by a spring wire like a spectacle frame over 


Fi. 380. 

Fitf. 381. 
S/vmano\vski's operation for reconstructing an auricle 


some light dressing, to he held hy the wearing of spectacles for the 
time being. 

(5. Suture defect in forearm. 

Instead of using the flap from the forearm one or two Wolfe 
grafts, or Thiersch grafting, may he employed 1o cover Ili<- defect. 
Again, the sliding ovei 1 of a flap from the lateral portion of the occiput, 

Fig. 381'. 
Beck's operation for synechia of auricle to mastoid. 

even though it contain hair, to cover the mastoid region, will aid a 
great deal and prevent the further formation of a synechia on the 
posterior surface of the auricle. The latter may he covered hy skin 

Roberts' Operation for Absence of Ear. 

This author's procedure is very much like the operation illustrated 
in Figs. )>8-')-,')8(), except that he employs only skin and subcutaneous 



Simple Operation for Colobomata. 

Excise the scar margins so as to obtain fresh dermal layers and 
suture anteriorly as well as posteriorly with special care at the tip 
cf the lobule, since keloid is liable to form. (Fig. 387 and 388.) 

Green's Operation for Colobomata. 

1. Kemove the cicatrized skin from the notch without cutting it 
away at the tip limits, but pull it down. (Fig. 389.) 

Fig. 38:: 

Robert's operation for absence of oar. 

'2. firing the denuded surfaces together and employ the little 
ribbon of skin to make a rounded margin of the tip. ( Fig. 3!)0.) 

Monk's Operation for Prominent Ear. 

1. Fxcise a strip of skin and subcutaneous tissue in the form 
illustrated in Fig. 3!H, making 1 he one incision all along the. attachment 
of the nnricle ;md the other corresponding to the degree of projection. 


X t 

The Hap is made cither broad on the top, middle or bottom, depending 
on the location of the prominence. 

-. Stitches are carefully applied so as to pucker the defect thor- 
oughly, and perfect approximation is imperative. 

Simple 1 operation for colobomata. 

Green's operation for eoloboniata. 

Kolle's Operation for Projecting Ear. 

1. Make an incision on the back of the auricle three-quarters of 
an inch from its outer margin, be.n'innin.u 1 above at the sulcus and 
curvinu' u])\vard and outward and then uTadually downward until 
the lower part of the sulcus is readied. The skin only is incised. 



12. Bleeding at once takes place and by turning the auricle over 
the mastoid and side of head, an outline in blood is made which 
corresponds to the incision to be made. 

3. This second incision when completed will outline a heart-shaped 
flap, which is removed. (Fig. 392.) 

4. An elliptical piece of cartilage is removed in extremely pro- 
jecting ears without going through the anterior skin. (Fig. 393. ) 

5. Suture the cartilage with catgut separately and then apply 
continuous sutures from above downward to the skin margins to 
close the defect and to bring the ear close to the side of the head. 

Fig. :i!il. 

Monk's operation for prominent 

f \\ 

Fig. 392. Fig. 393. 

Kolle's operation for projecting car. 

0. Place a pad over ear and use a bandage that is not too firm. 
7. Allow stitches to remain for nine days and do not disturb the 

Postauricular Deficiencies or Retroauricular Fistulae. 

These are as a rule the result of mastoid operations (radical) 
which formerly were performed by leaving a large retroauricular 
drainage for a long time; when healing took place, the cavity was 
lined by epithelium continuous with the outside skin. Some of the 
(rases, even when the posterior bony canal was taken away and the 
membranous canal was split in the usual plastic manner, remained 
open in the back of the car and then there was a cavitv which was 


lined by epidermis continuous with the skin of the external auditory 
canal and the skin on the posterior surface of the auricle. 

Trautmann's Operation for Closure of the Posterior Deficiencies. 

1. Incise the fistula, making two crescentic flaps with their ep- 
idermal layer looking towards the auditory canal. (Fig. 394.) (This 
is done only in those cases in which the usual plastic of external 
auditory ineatus in connection with the radical mastoid operation has 
heen performed.) 

2. Stitch these two Haps with catgut. (Fig. 39f>.) 

3. Dissect freely the skin and perichondriuin over the pinna 
and also the skin and periosteum over mastoid region. (Fig. 390.) 

4. Tnite these hy interrupted sutures over the two lower flaps. 
(Fig-. 397.) 

Von Mosetig-Moorhoff Operation. 

1. Make a tongue-shaped flap below the fistulous opening, leaving 
the hinged pedicle at the lower margin. (Fig. 398.) 

'2. Dissect loose, but not too close to the margin of the opening 
or else too little blood supply will remain to nourish the flap. (Fig. 

3. Freshen up the margin of the fistula and loosen the margin 
thoroughly for suture. 

4. Turn the flap with its dermal layer towards the inside (to- 
wards the auditory canal) and suture to margin of fistula. (Fig. 

5. Close newly-formed defect by first loosening its margin (Fig. 
401 ), subsequently either cover the turned-in flap with skin graft 
or allow it to granulate and cicatrize. It becomes necessary at times 
to make secondary corrections at the pedicle portion. 

Goldstein's Operation. 

1. Loosen the margins about the fistula freely on the cartilage as 
well as on the mastoid side, and freshen up the margins. 

'_'. Make lateral incisions to allow free coaptation of the margins 
of the fistula. (Fig. 40) 

3. Close by means of ^Michel's clips. (Fig. 403.) 

4. Allow the defects created by counter incisions for relaxation 
to granulate. 

Ear Prothesis. 

As in nasal deformities, there are times when the local as well 
as the general condition does not warrant an operation of magnitude; 
under such circumstances much better results are obtained by the 
use of a well-fitting artificial ear. 


Fig. 394. 

Fig. 395. 

Fig. :::);. Fig. 3<)7. 

'hf Trautniann op'^ratifjii for closure of posterior deficiencies. 



Fig. 399. 

Fig. 400. Fig;. 401. 

The von Mosetig-Moorhoff operation for postorior doficieneies. 



It is necessary at times to shape the stump remaining so that the 
artificial ear may fit and hold properly. Again there may be no 
external part at all, and then it may be necessary to construct from 

Fig. 4(iL'. Fig. 403. 

Goldstein's retro-auricular plastic-. 

Fig. 404. 
Celluloid artificial car 

tlio tis>ucs surround! 
tho attaHiiiionl of Un- 
cial oar. 

tlio aroa of tlio auditory moatus a plaoo for 
otliosis. Kiir. 404 illustrates a celluloid arlifi- 


Neuroplasty for Facial Paralysis. 

The various plastic operations on the facial nerve are performed 
for the purpose of reestablishing the function of the peripheral 
branches of the facial nerve after it has left the stylomastoid for- 
amen, by transplanting this distal end into another motor nerve or 
approximating it directly to the central or proximal portion of such 
a nerve. All branches of the facial nerve given off within the temporal 
bone are not influenced by anastomosing procedures. The direct repair 
of the severed facial nerve is not considered in this discussion of 
neuroplasty. The methods employed heretofore are: 

1. Facial-spinal accessory end to end anastomosis. 

'2. Facial-hypoglossaJ, end (facial nerve) to side (of hyperglos- 

3. Facial-hypoglossal, end to end. 

4. Facial-spinal accessory and descendens hypoglossi-spinal acces- 
sory anastomosis. 

f). Facial-glossopharyngeal anastomosis. 

The principles underlying neuroplastic surgery are: 
1. The approximating nerves must be under absolutely no ten- 

'2. The neural structures of one nerve should be in contact with 
the neural structures of the opposite nerve. (This is particularly 
necessary in the end to side methods.) 

3. Suturing must be done with the finest of material and under 
great care (not so many sutures being used as to endanger strangula- 

4. The anastomosed nerves should be surrounded with muscle 
tissue or Cargile membrane, to prevent too great a cicatricial forma- 
tion about them. 

5. Absolute asepsis is necessary to obtain a good result. 

(!. Adjunct treatment such as electricity, massage, tonics, etc., 
following the operation hastens recovery, the time depending on the 
degree of muscular atrophy which preceded the operation. 

7. Correct diagnosis before the operation as to the reaction to 
degeneration is very important, so as to be sure that if a perfect 
anastomosis operation is performed and union is absolutely perfect, 
a good result is possible; otherwise this excellent therapeutic pro- 
cedure would be discredited, as the muscle would not be susceptible 
of motion in spite of the unimpeded nerve stimulus. 



Spino-Facial and Periphero-Spinal to Descendens Hypoglossi 

Anastomosis. * 

1. Make a Y-shaped incision, one branch of the Y ending in front 
of the trains, the other back of the ear on the line with the tragus. 
The stalk of the Y is directed forward and downward, in front of the 
sternomastoid, for about three inches in length. This incision goes 
through skin and superficial fascia. (Fig. 405.) 

2. Dissect bluntly down to the muscles and expose the posterior 
border of the parotid gland. 

3. Ellevate the lobule of the ear, draw forward the parotid gland 
and dissect down into the narrow space between the anterior border 

Fig. 405. 
Incision for spino-facial anastomosis. 

of the mastoid and the posterior border of the rannis of the lower 
jaw. Here locate the facial nerve in its course from the stylomastoid 
foramen towards the posterior border and the under surface of the 
parotid gland. 

4. Place a ligature (but not tied) around it for subsequent identi- 
fication and leave this Held of operation for the time being for the 
location of the other nerves. (Fig. 406.) 

."). Find the spinal accessory nerve, which is on the line from the 
angle of the lower jaw backward, where it pierces the fascia of the 
sternomastoid muscles. 

o'. Place a suture about it for the same purpose as in the facial. 
(Fig. 40(J.) 

*C-.ntril.ut<Ml l,y W. W. (Irani, M. I).. Dt-nver. 


7. Expose the hypoglossal which lies in this region, just where 
the occipital artery is given off from the external carotid, about the 
central tendon of the digastric muscle. 

8. Out the digastric muscle posterior to its central tendon and 
reflect this posterior belly backward. 


Fig. 406. 
Spino-t'acial and periphero-spinal to descendens hypoglossi anastomosis. 

9. Locate the descendens hypoglossi at this point as it leaves 
the hypoglossal and passes downward on the sheath of the common 
carotid artery. Place a thread about this nerve also. (Fig. 406.) 


10. Go back to the facial nerve, draw it out so as to be able 
to reach the end that comes from the stylomastoid foramen and with 
a pair of slender scissors sever it close to this foramen and pull out 
this end of the nerve. 

11. Pull on the spinal accessory and sever it .just before it enters 
the sternomastoid muscle, making sure before 4 it is severed that a 
long enough segment may lie drawn to unite with the facial stump 
without occasioning any tension when their ends are united. 

ll'. Have an assistant hold both ends. Then cut off the spinal 
accessory and the peripheral end of the facial in close and exact 
approximation, the operator suturing them with tine linen thread, and 
using a small round needle. One suture is to be made at each side, 

Fig. 407. 
Beck's nerve tracing forceps. 

possibly including some nerve fibres, and another supporting suture 
through the neurilemna only on the under surface. The sutures are tied 
only moderately tight. 

1..'!. To prevent cicatricial constriction, place some Targile mem- 
brane at the point of nerve union about this anastomosis. 

14. Now sever the descendens hypoglossi by drawing on the 
thread fully three-fourths of an inch below where it leaves the hypo- 
glossal, and turn this cut end upward. 

].). Approximate this end of the descendens hypoglossi and the 
peripheral end of the spinal accessory with the same teclmic as was 
used on t he facial nerve. 

Hi. Reunite the digastric muscle and close the wound without 

Facial-Spinal Accessory Anastomosis. 

1. Make an incision through the skin facia from behind the ear 
forward and downward along the anterior border of sternomastoid 
He, to about the level of the thvroid cartilage. 


I 1 , Ketract and find the spinal accessory nerve as it pierces the 
sternomastoid muscle. 

-'!. Dissect and retract forward over the lower jaw, exposing the 
parotid gland (posterior l)order). 

4. Locate the facial nerve as it enters this gland. 

f). Follow it below the cartilaginous portion of the external 
auditory canal down between the posterior border of the ramus of 
the lower jaw and the anterior border of the mastoid process. 

(i. It may be necessary to divide the posterior belly of the 
digastric muscle. Ketract the stylohyoid muscle and pass about the 
nerve the author's nerve tracing forceps. (Fig. 407.) Follow the nerve 
to the stylo-mastoid foramen, which is behind the styloid process, 
and close on the nerve. 

7. Steadily pull the nerve out of the mastoid canal (stylomastoid 
foramen) and keep the forceps attached to the nerve. 

8. Withdraw as much of the spinal accessory nerve as is neces- 
sary to make an easy approximation with the dissected facial nerve. 

!). Trim the facial nerve end squarely to fit the spinal accessory 
and suture the two end to end. 

10. Three sutures are placed, going through the neurilemma and 
taking in a few of the axis cylinders. An additional supporting suture 
(continuous) takes in only the sheath of both the nerves. 

11. Make a slit or pocket into the posterior belly of the digastric 
muscle (if it is divided it should first be united), or place a layer of 
Cargile membrane about the anastomosis. 

ll?. Close wound. 

Facial-Hypoglossal End to Side Anastomosis. 

1. Incise the skin, fascia and platysma, beginning behind the ear 
and carrying the cut downward and then forward towards the thyroid 

'2. Retracing the tissues, the hypogiossal nerve is located by 
drawing up the digastric muscles posterior to the sternoniastoid 
where the sheaths of the great vessels lie. On the level of the thyroid 
cartilage, where the carotid artery divides into the external and 
internal branches, the hypogiossal nerve will be seen at the point of 
crossing of the occipital and the internal carotid arteries. Here it 
turns forward and lies on the mylohyoid muscle. 

3. Expose the hypogiossal nerve at the point closest to the facial 

4. Locate the facial nerve as in the facial-spinal accessory anas- 
tomosis, and draw it out in the manner described above from the stylo- 
mastoid foramen. 



f). Trim the facial stump in such a manner as to strip the major- 
ity of the axis cylinders of their sheaths for about three lines. 

(>. Place three sutures through this stump, thus getting it ready 
to join with the hypoglossal nerve. 

7. Make a small buttonhole in the exposed hypoglossal nerve at 
the point mentioned in division 3, parallel to the course of the nerve 
and on its upper border, to admit the prepared facial stump. It is 

nerve im 
planted end to 
Side in hypo- 

Kacial-li vno.ulossal end to side anastomosis 

Posterior belly 

well to enter this buttonhole slit with a fine pair of scissors and cut 
a few axis cylinders transversely within the sheath in order to get 
direct contact with the facial axis cylinders and thus obtain a more 
ra pid re^-em-rat ion. 

s. I'a>> the already prepares! sutures of the facial stump through 
the slit in the hypoglossal nerve Irom within, outward, one on each 
>ide and the third at one end. The tying should be done by the oper 


ator while the assistant keeps the slit open with a fine pair of forceps 
(spring) and holds the facial stump steady in the slit. Another sup- 
porting suture surrounds this anastomosis in the same manner as in 
the spinal accessory procedure. (Fig. 40H. ) 

1). The same procedure as in the, facial spinal accessory is fol- 
lowed in the prevention of cicatricial formation about the union, as 
is also in the closure of the external wound. 

Facial-Hypoglossal End to End Anastomosis. 

1. The same procedure as in the end to side operation up to the 

nerve ^n 

\\W65torao5ed end 
to end with hypo- 

Descendens - 

Facial-hypoglossal end to end anastomosis, 

point of union, except that the hypoglossal is not prepared so close 
to the facial nerve. (Fig-. 409.) 

'1. Follow the hypoglossal nerve nearer to the front as it enters 
the floor of the mouth. 

3. Sever the hypoglossal and turn it back to join it with the 
facial nerve which has also been prepared as in the other two previous 


4. The union and management of the anastomosis and the wound 
are subject to the same procedure as in the facial-spinal accessory 

Myeloplasty for Facial Paralysis. 

In cases of congenital facial paralysis, or in permanent paralysis 
in which the peripheral branches of the facial nerve are imbedded in 
cicatricial connective tissue, or when the paralyzed muscles of the face 
supplied by the seventh cranial nerve are completely atrophied and do 
not react to the electric currents, or finally if for any reason the hypo- 
glossal or accessory nerves are not accessible and the neuroplastic opera- 
ation cannot be performed for any other reason, the masseter muscles 
may be used to obtain a straighter face. The associated movements fol- 
lowing this operation are objectional. These, however, do not persist, 
for the patients re-educate that particular part of the masseter muscle 
\vhich causes facial expressions. 

Tcclniir. Under local or general anesthesia make an incision 
along the posterior border of the ramus of the lower jaw. The tissues 
are dissected forward until part of the masseter muscles is reached. 
These are now separated from their attachment to the ramus of the 
jaw and the lower border. A sort of a tunnel is now made with a 
pair of Alayo's scissors, spreading the tissues rather than cutting 
them, until one reaches the external angle of the mouth. It is impor- 
tant not to go too high in order not to wound the duct of the parotid 
gland. As the angle of the mouth is approached, care must be taken 
not to wound the facial artery. The facial vein must sometimes be 
ligated. (treat care is to be exercised not to penetrate through the 
mucous membrane of the mouth or the skin externally. The masseter 
muscles already severed are now armed on two silkworm gut sutures, 
with very short curved needles, one on each end of the thread so as to 
have four needles in all. One thread is now passed close to the upper 
lip, through the subcutaneous tissue and skin, while the second thread 
is placed close to the lower lip. These sutures are tied over a piece 
of gauxe to prevent their cutting in. The wound is closed completely 
without drainage. 

During the next three weeks the patient takes only liquid diet in 
order not to use the masseter muscles. The stitches holding them are 
removed at the end of ten davs, as are also those of the incision. 





Date Due 

PRINTED IN U.S.*. CAT NO. 24 161 


A 001 365 678 o 


LP25 o 

Loeb, Hanau W 

Or>erative surpery of the nose, 
throat , and ear... 

L825 o 

r ,oet>, Fanau W 

Operative surgery of the nose, throat, 
and ear. . .