second indication, operation for cosmetic reasons, was mentioned merely for pur poses of discussion, the author emphasizing the fact that he does not advocate resort to surgical procedure under these circumstances. A fair knowledge of the shape which the nose should have after correction is important, but in grave external deformities calling for plastic surgery, especially for the transplantation of flaps, results are, as a rule, anything but perfect. The principal methods employed are (1) intranasal or introvestibular, and (2) external. The intranasal and paraffin methods were omitted from the author's discussion of the subject and his attention confined to the principal methods for external correction, viz., (1) Indian methods, (2) Italian methods, (3) German or French methods, (4) miscellaneous methods. The technic of each was described in connection with illustrative cases, of which lantern-slide pictures before and after operation were presented. his remarks to the discussion of the subcutaneous method, which does not entail injury to the skin, except such as may be necessitated by the removal of unsightly scars. A careful study of the etiology and nature of the deformity, as well as of the condition of the tissues and anatomical structures involved, must be made before intelligent advice can be given as to the method to be employed and the results to be expected. All constitutional and local disturbances entering into the deformity should be corrected before plastic operative procedure is undertaken. The operation itself must then be carefully studied with reference to the condition and position of the tissues, the re lation of the different parts of the nose to that of the face, the last point being of particular importance from a cosmetic point of view. The surgeon must be governed in every instance by the peculiarities of the case under observation, but the general principles of subcutaneous plastic work upon the nose may be stated as follows: The first step in the operation is the careful raising of the skin, without injury to it, from the deformed portion, the incision being made from the inside of the nostril anterior to the deformity, and the redundant portion cut away or placed in the depressed portion, thus making the nose symmetrical and giving it the desired shape. It is rarely necessary or desirable to remove any portion of tissue, or even bone, there being generally a corresponding depression, for the filling of which the redundancy may be used. This applies particularly to deformities resulting from traumatism, where there is simply a displacement rather than a destruction of tissue. The technic was further detailed, and its results shown in the presentation of the histories, accompanied by photographs, of a series of cases operated upon by the subcutaneous method. 1 ་ The Correction of Nasal Dr. Harmon Smith Deformities by the Use of New York city. of Paraffin. An investigation of this subject was prompted by the adverse criticism so often expressed concerning the subcutaneous injection of paraffin and the enumeration of so many dangers as possible sequel to its use. In order to facilitate his investigation, the author sent a circular letter to all those engaged in this work, requesting information concerning the number of successful and unsuccessful cases treated, the probable causes of non-success, the number of cases of blindness due to embolism, the number of cases of sepsis resulting in ab scess and loss of paraffin, the number of cases in which paraffin lodged in undesirable location at the time of operation and the methods employed for preventing this occurrence, the number of cases in which it shifted after operation, the instrument used for injection, the kind of paraffin employed and the melting point, and conclusions as to whether the injection of paraffin is dangerous, undesirable, unwarrantable or practical. The 91 replies were summarized by the author as follows: Forty-one surgeons had made paraffin injections for the correction of nasal deformities in one or more cases; 40 had had no experience; 10 had had too little experience to express an opinion. In the author's own experience, not included in the above, he had had over 200 injections for the correction of nasal deformities, with only two unsatisfactory results. The total number of cases reported by the 41 surgeons who had employed the method was 1252. Of these, 1000 were reported as entirely successful, 104 as unsatisfactory; blindness resulted in two of the 104 cases: 55 of the 104 resulted in sepsis and extrusion of the paraffin; in 22 of this 104 lot the paraffin lodged in the wrong location, and in 7 of the same series the paraffin shifted after operation. The instruments used were ordinary hypodermic syringes-Killian's, Beck's, Pfau's, Broechhart's and Smith's. The paraffin injected varied in melting point from 103° F. to 136° F., 110° F. being the melting point of the paraffin used by the majority. Thirty-one of the forty-one consider the procedure practical under proper precautions; the other ten consider it dangerous, and in most cases unwarrantable. From a consideration of these statistics and of the literature of the subject, as well as from his own experience, the author concludes that the procedure is prac tical when performed by one of experience and under proper surgical precautions; that the proper paraffin is one with a melting point of 115° F., made of hard or soft paraffin, to be injected cold; that the injection must be made slowly and in small quantities at each sitting, ample time being given the tissues to regain their normal vitality before the second injection is made; that cold compresses after the injection favor the anchorage of the paraffin, while a collodion dressing over the entrance of the needle is a precaution against infection; that no syphilitic, diabetic or nephritic patient should be injected without due consideration, and that no attempt should be made to inject cold paraffin except with a screw syringe or with one of the ratchet injectors. prefaced his discussion of this subject by advocating that the repair of harelip and cleft palate be included in the practice of laryngology and rhinology, because no one is presumed to have a better knowledge of all the structures involved and of their functions than is the laryngologist and rhinologist, and because no one is better able than is he, trained as he is to work in deep cavities, to carry out the delicate technic necessary to success. The statistics of these conditions and the various theories as to their causation were briefly given, and the reasons for the accepted belief in the importance of early operation detailed. The operations for the two conditions could best be described separately. The plan of operation in any case of harelip must depend upon the nature and extent of the defect. Where only an incomplete notch is present Nelaton's method can be successfully employed. When a single fissure extends up to or into the nostril either a unilateral or bilateral tongue-shaped flap may be cut from the lip, the plan to be followed depending upon the amount of tissue which is missing. Ferguson's method is an excellent one, particularly as it is in accordance with the principle always to be followed of utilizing all the tissues that remain, in order to prevent as far as possible tension on the retention sutures. In case of double harelip with an intermaxillary projection, the latter must be dealt. with by a preliminary operation calling for the replacement of the projecting portion in a position corresponding to the normal alveolar arch. This should be done at least two weeks before the repair of the harelip. The author did not advocate the complete removal of the projecting intermaxillary portion. The failures resulting from repair of harelip are due to malnutrition of the patient, to improperly prepared or badly-adjusted flaps, and to too great tension on the sutures. The technic of operation for closure of cleft palate depends greatly upon the age of the patient at the time closure is undertaken. When the child is seen at birth or during the first three months of life the procedure advocated by Brophy is perhaps best. It furthermore substantiates Brophy's theory that the cleft in the palate is the result of a failure of the two sides to unite, and not of arrested development and consequent deficiency of tissues. In the event of the coexistence of harelip and cleft palate, the palate should be repaired first. After the patient has passed the age when it is possible to approximate the lateral halves of the superior maxilla by the Brophy method, the Davis-Colley op eration may be employed to advantage. This method the author described in detail. The benefits derived from successful repair of harelip and cleft palate are, first, marked change of feature, and second, improvement in voice and speech. The former is immediate, the latter becomes apparent as the child acquires a knowledge of spoken words. Speech is rarely improved to any great extent when operative procedure is delayed until adult life, particularly if the palatal muscles have been severed. Early operations and methods of procedure which do not interfere with muscular action are, therefore, to be advocated. The Cosmetic and Plas- Dr. Max A. Goldtic Surgery of the Ear. stein of St. Louis. The cosmetic and plastic surgery of the ear is classified by the author as follows: (1) The correction of defects and deformities of the external ear, including the many abnormalities and congenital stigmata; (2) the plastic technic following the radical mastoid operation, with special reference to the operative details. in the formation of the various flaps and a comparison of the special advantages of each of these plastics, and (3) the correction and closure of persistent retro-auricular openings following the radical operation. After briefly summarizing the embryology of the auricle, the author gives the most conspicuous of the anomalies as classified by Gradenigo, viz., (1) macrotia and assymetry of the auricle; (2) heterotopy (misplacement); (3) adhesion of the posterior surface of the auricle, in whole or in part, to the head; (4) projecting auricle; (5) the pointed ear (Darwin tubercule and Satyr point); (6) the macacus ear, in which the helix is flattened or imperfectly defined; (7) the Wildermuth ear (prominence of the antihelix); (8) absence of the helix; (9) absence or exaggerated development of the lobule; (10) adhesion of the lobule. After detailing the various surgical procedures for the correction of aural deformities the author concludes that if good judgment is exercised in the correction of these deformities the work of cosmetic surgery of the ear may be carried on with dignity and may afford many opportunities for the demonstration of originality and excellent technical ability. The plastic surgery of the ear as applied to the mastoid operation and to the management of retro-auricular wounds he believes to be a classic field, upon the development of which will largely depend future attainments in this important department of aural surgery. Treatment of Infective (The Oration in The author's observations are based upon upwards of 100 labyrinthine operations. In only two cases was the cochlea alone operated upon. In 23 cochlea and vestibule were opened, and in the remainder the vestibular apparatus was the seat of operation. Only five cases followed acute middle-ear suppuration. Among these cases 29 died. In 16 the operation was performed after purulent meningitis already existed. In three cases death ensued from brain complications. The author then classifies his cases and comments upon each class. According to Jansen, the labyrinth operation is not in itself a dangerous operation. The author then gives his technic. To quote: METHODS OF OPERATION. "In opening the vestibule I have for 15 years employed two methods, which I made public in various lectures in the years 1893-1900. One method attains the exposure of the vestibule, inside the temporal bone, by leading along the horizontal semi-circular canal; the other one by removing the posterior wall of the petrous bone from the posterior cranial fossa at the upper crus from the lower, and at the posterior crus from the upper canal, as well as at the posterior crus from the horizontal semi-circular canal. Injury to two organs must be avoided--to the facialis in front, which may happen in the first method; to the dura behind, which may occur in the second method. "With a high position of the jugular bulb and the fossa jugularis, a lesion of the bulbus is also possible, and if the fossa jugularis stretches very high up into the temporal bone the bulbus may, especially when the opening is made from behind, be very much in the way of the operation, even making is impossible. A lesion of the inner wall of the vestibule, with injury to the dura of the internal auditory canal, is almost impossible if the operation is properly performed. But caution is necessary, the wall in part being very thin. The injury to the dura in the meatus would have fatal results. We once saw death The opening of the internal auditory meatus is most easily possible, if one loses the direction and penetrates above or behind the vestibule into the petrous bone instead of forward and downward into the vestibule. ensue. from lesion. At the posterior crus I remove the whole canal and so keep away from the roof of the vestibule. I also remove the bone under this part of the horizontal canal in the direction sloping down to the back, taking the very greatest precautions with regard to the facialis, which lies in front. "The stapes plate reaches with its posterior margin about the lateral boundary of the vestibule and takes up a middle position between horizontal and vertical. By this and by the extension of the ampullar extremities of the horizontal and upper canal the upper portion of the vestibule leads toward the front. "If I penetrate in this way by the anterior crus in the direction of the canal, and above its lower wall towards the vestibule, and by the posterior crus close to its posterior and lower edge, I have selected a large portion of the lateral wall of the vestibule as the place of attack. "Thus it is easy to open the vestibule either in its posterior lower part or near the ampulla of the horizontal semi-circular canal. According to the pathological changes, the vestibule is to be opened here or there, in front, above or at the posterior orifice of the semi-circular canal; in cases without fistulæ, in the described way, along the horizontal semicircular canal, in the direction of the oval window, parallel with, behind and a little. below the facial bridge. Thus the facialis is surely protected from lesion. "The direction in which we have to seek the anterior wall of the vestibule is indicated not only by the anterior crus of the horizontal semi-circular canal, which might lead us astray by its long extended position, but also by the fenestra ovalis, which we can in any case precisely locate by the introduction of a hooked probe. In cases of narrowing of the vestibule by new formation of bone we must expose the front part, at the same time preserving the portion of bone which supports the lower wall of the anterior crus as a bridge. We penetrate behind and parallel with this bony ridge, inwards, downwards, forwards, in the direction of the fenestra ovalis. If the vestibule is found, the examination with a hooked probe will give a certain opinion as to the size, form and position of the cavity. The lateral wall may easily be felt with the probe, and then neatly removed with a narrow chisel or burr. "If one wishes to obtain information of the contents of the vestibular apparatus, the chisel is to be preferred. To prevent the anterior crus from snapping off, the burr is the better instrument. "By using necessary caution and by experience the facialis need not be exposed. "It is of the greatest importance to use the chisel as a plane and to plane off shaying after shaving. "It is of importance to reach the deepest point of the vestibule, to lay bare its floor, to smooth the way to it properly and to arrange that it may be seen at a glance. By exposing the lower orifice of the inferior semi-circular canal we enlarge the cavity of the vestibule downward, and by exposing the common orifice of the vertical semi-circular canals we enlarge it at the back. It is precisely for the enlargement of the vestibule towards the back, either the better to reach diseased bone lying behind the labyrinth or to create below more favorable conditions for wounds, either with or without exposure of the dura, that the burr is eminently suited. "Finally, I expose the ampulla from the upper vertical semi-circular canal, and then consider the operation completed. Only very rarely do I follow up all the canals, opening them in their full length. starting from the cavity of the wound. |