points of these two incisions are connected on one side by an oblique incision
extending exteriorly and inferiorly along the side of the nose (Fig. 1123).
2. With the metacarpal saw the anterior nasal spine is detached hori-
zontally; and with the bone-cutting forceps the bony septum is divided in
the same direction for some distance.
3. The metacarpal saw is applied with its point in the nares at the lower
margin of the pyriform aperture, and the nasal process of the superior maxil-
lary bone, together with the anterior end of the inferior turbinated bone, is
sawed throiigJi, corresponding to the skin incision, as far as the nasal bone.
4. Both nasal bones are sawed off transversely in the nasofrontal suture ;
and the septum, if necessary, is divided, with bone-cutting forceps, partly
from the inferior and partly from the superior transverse incisions with two
incisions meeting posteriorly in the form of an obtuse angle.
5. By introducing an elevator into the upper end of the lateral incision,
the union of the nasal bone with the upper jaw of the other side is infracted,
and the whole nose is then turned over toward the opposite cheek.
A very satisfactory view of the interior of the nose as far as the posterior
pharyngeal wall is then obtained.
If it is desirable to maintain those parts for some time accessible for the
eye and the finger, the nose may remain in this dislocated '^o'&iXXon for several
zveeks (without injury to its nutrition). At the end of this period, of course,
a superficial vivification of the margins of the wound will be required on
account of their being then in a state of cicatrization.
If it is desirable to turn over only one-half of the nares, the transverse
skin incisions do not extend beyond the median line. The sawing of the
upper jaw is done as described above. The nasofrontal suture is sawed
through as far as the median line, and the union of the two nasal bones is
infracted in the median line by the use of the elevator.
TEMPORARY RESECTION OF THE NOSE
according to Gnssenbauer (Y'lg. 11 25), for exposing the frontal sinuses, the
ethmoid sinuses, the sphenoidal sinuses, and the orbits : —
1. Tamponing the nares.
2. External incision down to the bone from the inner half of the eyebrow
along the nasal process of the frontal bone and the superior maxilla down-
ward ; next, transversely across the bridge of the nose corresponding to the
borders of the nasal bones, and upward to the inner half of the other eyebrow.
5/6 SURGICAL TECHNIC
3. The nasal process of the upper jaw as far as the inferior edge of the
orbit ; the two nasal processes of the frontal bone, in connection with the
lachrymal bone ; the orbital plate of the ethmoid
bone ; and finally, the connection of the perpen-
dicular plate of the ethmoid bone and of the palate
bone (the vomer), are all divided with the chisel.
4. The flap of bone and soft parts is turned
in an upward direction, the tumor is removed, the
cavity of the wound is packed with iodoform gauze,
and the latter brought out of the nostrils ; the flap
Fig. 1 125. GussENPArER's jg turned down again, and sutured in its whole
Temporary Resection of ^ ^
THE Nose extent.
When tlic tuviors are attached to the wall of the
pharynx or the cenncal vetiebrcE, it may be easier, under certain circum-
stances, to reach the root of the polypus from the pharynx instead of from
the nose.
Mamie, and afterward Dieffenbach, divided longitudinally the zvhole soft
palate, together with the uvula, ifi the median Hue ; the two halves were then
drawn apart and subsequently closed again by staphylorrhaphy. Maison-
nenve used the same incision, but left the uvula intact {boutofuiiere palatine),
whereby the subsequent reunion of the soft parts was more easily obtained.
Bdckel divided the soft palate from the hard palate by a transverse incision.
Nelaton removed, from a T-incision, the posterior part of the hard palate ;
and Gussenbauer divided the mucoperiosteal membrane (" Uberzug") of the
palate in the median line, detached it toward both sides, and chiselled open
the bony roof of the palate. By this procedure the sphenoidal sinuses can
also be successfully exposed.
Chalot ajid Habs chiselled from the hard palate a kind of artificial fissure
palate, by dividing, with the wire saw, the vomer from an incision similar to
that of Fig. 1 121. From the cavities of the rapidly extracted canine teeth
they chiselled off the hard palate along the alveolar margin as far as the
insertion of the soft palate ; next they divided the alveolar process between
the alveoli of the canine teeth and the nares, and then turned down the
middle portion, adhering only to the soft palate like a trap-door. Partsch" s
procedure is easier, and without the considerable hemorrhage occurring
during this operation. From a similar incision of the soft parts extending
from the second molar tooth of one side to the second molar tooth of the
other, the soft parts are drawn forcibly upward, the bone is rapidly exposed
with the elevator, and with a broad chisel the upper jaw above the roots of
OPERATIONS INVOLVING THE FACIAL CAVITIES 577
the teeth, the mucous membrane of the base of the nose, and the mucous
membrane of the antrum of Highmore are divided horizontally as far as the
tuberosity of the superior maxilla until the whole palate under moderate
pressure can be turned downward like a visor. After the extirpation of
the tumor, the temporarily detached palate is replaced in its former position,
and fastened by superficial sutures. The reunion takes place very rapidly,
— beyond expectation, — and without any disturbance of function.
For exposing the base of the skull, according to Kocher, by turning up the
lower half of the two upper jaws, see page 484.
Finally, those tumors which spring from the pterygoid processes of the
spJienoid bone have their seat in the pterygopalatine fossa behind the upper
jaw, and which grow into the temporal fossa (retromaxillary tumors, iwn
Langenbeck), cannot be extirpated either from the mouth or from the nose,
and must be exposed by the osteoplastic resection of the upper jazu (see p. 474).
EXTIRPATION OF NASOPHARYNGEAL POLYPI,
to which access must be obtained in some way or other, is made according
to the nature of the tumor present and its degree of vascularity. Hard
tumors are removed with knife and scissors ; the base is thoroughly cleared
away with the sJiarp spoon and tJie raspatory. Sometimes it is possible with
these instruments to free the tumor "in toto " from its attachment. If
violent hemorrhage occurs, and if the tumor is soft in structure, the tJiernio-
cautery must be employed, with which even the last vestiges of the stump
of the tumor can be destroyed. These tumors have also been destroyed by
electrolytic treatment, and in some cases with a permanent result.
Whether the painting of the stump with LiigoV s solution protects from
recurrence is questionable; on the other hand, with advancing age, these
tumors often decrease or disappear of their own accord {Gosselin, Hueter^.
ADENOID VEGETATIONS IN THE NASOPHARYNGEAL CAVITY {Meyer)
Their presence is at once recognized /rf?;;^ the expression of the face and
the manner of speecJi of the patients (children). But concerning their extent
and nature reHable information is obtained only by the finger, introduced
behind the soft palate ior palpating th& pharyngeal space. The granulations
can be easily removed by scraping. The procedure is as follows : —
After the operator \\2.'& pointed, to about a right angle, the nails of both
his forefingers (the nails, of course, must be somewhat long), the child is
placed on a chair, to which his arms and his legs are strapped. The
2P
57'
SURGICAL TECHXIC
Fig. 1 126. Pointed In
strument for sup
PLYING Fingernail
surgeon, having under some pretext persuaded the unsuspecting child to
open his mouth, quickly introduces his finger protected by a metal sheath.
He now has free play. Standing at the side and behind the patient's head,
he first scrapes with the forefinger, which has been introduced behind the soft
palate, the corresponding side of the pharyngeal space ; next, he removes
the finger from the sheath, inserts the other forefinger, and performs the
same operation on the other side until smooth walls can be felt everywhere.
Above all, it is necessary to proceed as radically as possible during the
first operation ; for, a second time, it might not be easy to persuade the
child to consent to the operation.
During the operation the hemorrhage, though violent, is never alarming,
and is arrested by cold nasal douches. The patient is confined to his room
and his bed during the next few days, and receives cold
fluid nourishment, such as milk and eggs.
If the operator's nail is not long or hard enough,
instruments can be substituted {e.g. Fig. 1126), in which
case, of course, the control by the sense of touch is not
by any means as perfect.
This operation loses much of its barbarous character
if the patient is partially anaesthetized, so that, when requested, he coughs
out the blood flowing into the larynx ; the use of instruments is preferred
by some surgeons.
For the removal of these
vegetations, Meyer invented
his circular knife (Fig. 1127,
a). Lange and many others
modified it, and now there are
knives shaped even like a
plane. Meyer 's instrument
is introduced into the pharyn-
geal space from the lower
meatus of the nose ; the
instruments bent at an an-
gle are introduced from the
mouth. In all cases, the fin-
ger introduced by the side of
Fig. 1 128 the instrument should serve
Michael's Naso- . , a i. ^1
pharyngeal ^^ ^ guide. At the present
Forceps time, the favorite circular
Fig. II 27. CiRcrL.\R Knives
According to a, Meyer; b, Schoelz;
c, Lange; d, GoUstein
OPERATIONS INVOLVING THE FACIAL CAVITIES
579
knife is probably Gottstein s (Fig. 1127, d), a curette bent on the flat. It is
introduced from the mouth high into the pharyngeal space, and then bv
vigorous downward pressure the masses are scraped away, downward if
possible, in a connected piece, and the scraping is continued until the pal-
pating finger cannot detect any more diseased tissue.
Fig. 1 129. Brown's Pharyngeal Syringe
Granulations have also been cntshed with forceps (Fig. 11 28 ), or destroved
by the galvano-cautery.
Douching the nose with either the irrigator or the pharyngeal syringe
{Brozi'H, Fig. 1 129) may be used during the after treatment.
CONTRACTION OF THE NOSTRILS,
originating from plastic operations or from ulcerations, can be removed
permanently only by lining the enlarging incisions with skin.
The bloodless dilatation with dilating bougies is tedious ; tubes must be
worn for years.
If the nostril has contracted to a small fistulous opening, the skin dupli-
cation may be reached, to some extent, by an oblique T incision {DieffenbacJi ).
The upper line of the T incision extends along the margin of the ala, while
its base comes to lie in the comer between the septum and the upper lip.
The flaps thus formed are pushed into the nostril by a tube.
Fig. II 30 Fig. 1131
Dii„^TiNG Contracted Nostrils
Or the stricture is divided longitudinally in an tipzvard and downward
direction, corresponding to the shape of a normal nostril. At the middle of
the septum, a tension-relievijig incision is made, and the median flap, made
more movable thereby, is stitched on each side to the mucous membrane
(Figs. II 30, 113 1 ).
A small flap (Roser) (see page 527) may also be formed at the extremity of
the dilating incision. In serious cases, partial rhinoplasty must be made.
58o
SURGICAL TECHNIC
IN DEVIATIONS (SCOLIOSIS) OF THE SEPTUM OF THE NOSE,
originating from iuj/irics and from abno7-mal longitudinal grozuth of the
same (combined with catarrh of the nose, or producing it), various methods
have been tried to render the meatus (contracted by the convex side of
the septum) again free for the entrance of air.
Blandin, Riipprecht, and Roscr made an opening in the septum for the
admission of air into the other healthy meatus. Blandin perforated the
curved cartilage with an aivl, while Rupprccht a7id Roscr pujic/wd a hole in
the septum as large as a lentil with special punch or perforating forceps
similar to a conductor's punch.
Others resected the projecting cartilaginous portion, but avoided per-
foration.
DiejfenbacJi excised a correspondingly large oval piece. Cliassaignac
and Roser proceeded in a similar manner.
The most conservative procedure is the
SUBPERICHONDRIAL RESECTION OF THE SEPTUM {Petersen^
Under anaesthesia, with the nostril held widely open, with a narrow-
bladed knife, a I l-shaped flap with its base upward is circumscribed in
the Dincopcrichondi ial covering on the con-
vex side. This is dissected back carefully
in an upward direction with a fine ele-
vator, and the cartilage now exposed, corre-
sponding to the lower incision, is divided
transversely with the knife. From this in-
cision, always from the same nostril, the
operator penetrates with the elevator be-
tween the cartilage and the perichondrium
on the other side, and detaches the same
sufficiently. The portion of cartilage, now
freed on both sides, is cut out with the scis-
sors in the form of a Gothic window, jj.
The mucoperichondrial flap is tnrned doivn
and fastened by two sutures to the angles of
the wound.
This method is especially adapted to
deviations of the anterior portion of the septum, since the small size of the
field of operation, as well as the rather considerable hemorrhage, makes
operating at a greater depth impossible, since the surgeon cannot see what
Fig. 1 132
Adams' Rhino
I'LASTOS
Fig. II 33
JuRACz's Forceps
OPERATIONS INVOLVING THE FACIAL CAVITIES
581
he is doing. The bloodless straigJitening of the curved septum has also
been attempted with a special kind of forceps.
Adams, with his " I'hinoplastos" (Fig. 1132), straightened the septum by
pressure, and subsequently inserted for three to five days a compressor
consisting of two parallel plates. Jicracz improved the forceps in this man-
ner : the anterior part holding the plates can be removed after reposition
has been produced by closure of the blades, and remains in position as a
compressor (Fig. 1133).
D. IN THE ORAL CAVITY
FOR INSPECTING THE CAVITY OF THE MOUTH
a number of instruments are used, — the so-called oral specula.
Separate the lips with the fingers, or use the common lip-holder of metal
or wood {Lner), or blunt retractors {voji Langenbeck), or similar instruments.
The 7^ows of teeth, especially when they
are tightly compressed, either intentionally
or in anaesthesia, are forced apart by wedge-
shaped instruments (dilators). The simplest
of these is a zvedge of soft wood, which is
forced laterally between the molar teeth. It
has a coarse screw-thread, which is very prac-
tical (Fig. II 34). The introduction of this
screw wedge succeeds more gently and easily
by boring movements.
Heisters moiitJi gag consists of two steel
arms tapering anteriorly, which are forced
apart by screw power (Fig. 11 36).
Of similar construction is Koiiig-Rosers
mouth gag. Its arms (bent at an angle and
lined at their ends with plates of lead) are
forced apart by compressing the handle. When in posi-
tion and opened, the dilated mouth can be kept oi^oxv for any
leiigtJi of time.
When, after the patient opens his mouth of his own
accord, it is necessary to keep it open for sojne time, the
operator simply inserts between the rows of molar teeth a
cork ox Pit ha'' s month wedge, a piece of caoutchouc doubly
grooved and fastened to a thread. Weinlechner' s gag is
of similar construction, but it is provided with a handle.
Fig. 1 1 34
Screw Wedge
582
SURGICAL TECHNIC
Fu.. 1 136. Heister's
-Mui TH Gag
Excellent for inspecting the mouth and for keeping it open during
some operations (c.^. on the tongue, palate) is Whitehead' s oral speculum,
the two arms of which are kept apart by adjustable ser-
rated stops or bars; the part intended for the lower jaw
has also an adjustable tongue plate. (Figs. 1138, 1139
show the instrument closed, opened, and applied.)
The English speculum is built on a similar plan (Fig.
1 140), the arms of which can be screwed
apart by a spiral coil ( Tillmaiis).
Brims' s automatic moutJi gag consists
of two adjustable furrowed plates, which
come to lie upon the rows of teeth, and
which, by means of curved arms provided
with a spring, constantly provide an elas-
tic (springy) movement. Its closing is
prevented by a stop, which can be re-
moved by the pressure of the finger.
In some patients the tongue curves Fig. 1137. Pitha's
. 1 1 , , ^ r ^1 • Mouth Wedge
considerably, and, on account or this
great curvature, as well as on account of its movements, prevents a satis-
factory inspection of the pharynx. The tongue is depressed with the
finger, or better with a spatula or the handle of a spoon. The angular
spatula (Fig. 1 142), the arms of which can be opened only at a right angle,
is more convenient. The hand holding it does not shade the entrance to
the oral cavity. Tiirdcs tongue spatula must be mentioned here. Its
broad plate is affixed laterally at an angle to the handle. It was mentioned
in the discussion of posterior rhinoscopy for depressing the base of the
tongue.
In employing tongue depressors it is of especial importance not
to introduce them deeply enough to touch the pillars of the pharynx
and the base of the tongue, because choking sensations are produced
thereby.
Patients, especially children, who offer resistance, are forced to open the
mouth by introducing the finger between the rows of teeth, and by folding
at the same time the margin of the lower lip between them (Hueter), or by
introducing a gag in the aperture behind the molar teeth. Small children
open the mouth at once if the surgeon closes the nose with his fingers.
Moreover, in most cases, success is obtained more rapidly by kindness than
by force.
OPERATIONS INVOLVING THE FACIAL CAVITIES
583
Fig. 1 138. Front view when applied
Fig. 1 142. Tongue Spatula
Fig. 1 139. Whitehead's Oral Speculum
Closed and viewed from above
Fig. 1140. TiLLMANNs's English
Speculum
Fig. 1 143. Turck's Tongue
Spatula
Fig. 1141. Bruns's Automatic
Mouth Gag
Fig. 1 144. Tongue Spatula of Glass
584
SUR(iICAL TECHNIC
For the prevention of the entrance of blood into the trachea and the
oesophagus during operations in and on
the cavity of the mouth, Rose recom-
mends that the head of the patient
(lying flat on his back) should hang
downward over the end of the oper-
ating table (hanging head, Fig. 1145).
The blood flows then through the pos-
terior nares and out from the nos-
trils. The hemorrhage, however, on
account of the venous stasis in the
blood vessels of the neck, is consider-
ably greater.
It is better, according to Ricd, to
raise the whole operating table at its
lower end so that the whole body is in
the inchned position, the head being
Fig. 1 145. Roses Operation ^
(Head of patient hanging downward) most dependent.
EXTRACTION OF TEETH
Diseased teeth are extracted : —
{a) When tho. paiti and disease {cat-ies) has progressed so far {pnlpitis)
that by cauterization and by suitable filling of the cavity {p/onibage) no
permanent cure can be expected.
(/;) When they are the cause of alveolar abscesses (periostitis of the roots)
2Lndyistulas of the gums.
Sound teeth are extracted only : —
{a) When they are the probable cause of violent nenralgia.
(b) For faulty position when they interfere with the eruption of other
teeth and with speech.
{c) Preliminary to some operations.
A tooth can be extracted from its socket (alveolus), in which its roots
are firmly impacted, only after it has been somewhat separated from its
alveolar attachments or walls. Y ox forcing apart the alveolar zvalls, formerly
the tooth was inclined laterally, whereby mostly that side of the alveolus
toward which the tooth was turned broke off. The instruments used for
this purpose operated largely by leverage : the tootJi key, or key of Garengeot,
the " Uberwurf," the pelican, and the elevator, etc. (Figs. 1146, 1147).
OPERATIONS INVOLVING THE FACIAL CAVITIES
585
Tooth foTceps, acting more conservatively, are the instruments now
generally used. They grasp the neck of the tooth; and, since this is
variously shaped in the different teeth, owing to the shape and arrangement
of the roots, different forceps are used.
Fig. 1 146. Tooth Key
Fig. 1 147. Lecluse's Elevator
Fig. II
Alveoli of the Upper Jaw
I, 2, incisors
Fig. 1149
3, canine tooth;
4, 5, bicuspids;
6, 7, molars
Fig. II 50
Alveoli of the Lower
Jaw
8, wisdom tooth
The roots of the several teeth are arranged as follows : —
In the upper jaw : The incisor teeth and the catiine teeth have necks
nearly round ; they are grasped with straight forceps with smooth margins
(Fig. 1 1 51, 4
586
SURGICAL TECHNIC
The bicuspids have two roots (often grown together) outside and inside
respectively (labial and lingual). For their somewhat rectangular necks,
forceps have been made with smooth blades but bent a little on the flat
(Fig. 1151, '^)-
The molars have three roots, two externally (labial) and one internally
(lingual). The forceps which fit the neck of these teeth (tref oiled) have on
their external side two facets, separated by a projection ; on the inner side,
they are excavated ; they are bent on the fiat. Forceps specially adapted
for the right and the left side are used (Fig. 1 151, a and b).
a b c d
Fig. 1 151. Forceps for Teeth in the Ui'PER Jaw
a, right molars; b, bicuspids; c, incisors and canine teeth;
d, left molars
Fig. 1152. Forceps for Teeth in the Lower Jaw
a, right molars; /', molars of both sides; c, left molars
Fig. 1 153
Universal Forceps
For the zvisdovi tcctJi, the roots of which are almost grown together
(cone-shaped), forceps with smooth blades but well curved are adapted.
In the lower jaw : Incisor teeth and canine teeth have round necks, as in
the upper jaw ; hence, the same forceps are used, only they are bent more
conveniently on the edge. The same holds good for the bicuspids.
All molars, however, have two roots which lie in the axis of the jaw from
before backward (proximal and distal); the forceps fitted for the neck of
OPERA nONS INVOLVING THE FACIAL CAVITIES 587
these teeth have on both blades two grooves separated by a spine, and are
well curved on the edge and on the flat. With them, the operator can
extract luisdom teeth also (Fig. 1152^.
In order not to necessitate too large a number of forceps, the so-called
tiniz'ersal forceps (en-tont-cas) have been invented, the smooth margins and
slight curv^e of w^hich are approximately adapted to every neck of the
different teeth (Fig. 1153).
EXTRACTION
The patient is placed on a chair, firmly holding the seat with his hands ;
if the operator proceeds rapidly and energetically, it is hardly necessary to
have the head held by an assistant fin the upper jaw, slightly bent backward,
in the lower jaw, slightly bent forward;.
Nevertheless, if it appears necessary, the operator takes his position at
the right side of the patient, places his left arm around his head, while the
fingers of his left hand are free for opening the mouth, lips, etc. With his
right hand he manipulates the forceps. In this position, most teeth can be
extracted. But if it is more convenient, and if the forceps can be applied
more advantageously, the operator takes his position in fj-ojit, and at the
patient's left side, in which case, however, the holding of the head must be
omitted (this, moreover, can be prevented "a priori" from being drawn back
by pressing the head against the wall, the back of the chair, etc.). The
forceps are grasped with the w^hole hand. The thumb is applied on both
blades near the lock ; the fourth and fifth fingers enter between the arms
of the forceps and force them apart, guarding thus against a too forcible
pressure of the forceps.
The open forceps are introduced over the crown of the tooth, and are
applied close to the tooth under the gums (which are pushed aside by the
sharp margins of the forceps;. They are inserted as far as the neck of
the tooth and closed. By a few lateral movements outward and inward, the
alveolar walls are somewhat freed from the tooth, and the tooth is finally
extracted vertically ; the operation occupies from two to three seconds.