Professional Documents
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DNV-SOl^
THE LIBRARY
OF
THE UNIVERSITY
OF CALIFORNIA
LOS ANGELES
GIFT OF
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UNIVERSE
-UNIVER%
THE
SURGICAL ANATOMY
AND
OPERATIVE SURGERY OF
BY
A.
BROCA
TRANSLATED BY
MACLEOD YEARSLEY,
F.R.C.S.
LONDON
REBMAN, LIMITED
129,
Biomedieal
Library
INTRODUCTION
THE
subject of
the following
importance to the
otologist,
monograph
is
one of immense
of so
is of
especial value.
M. Broca's work
have endeavoured
to
render
same
Where
way
differed
when the
from that
MACLEOD YEAESLEY.
10,
18, 1901.
676784
CONTENTS
PAGE
I
SURGICAL ANATOMY
15
OPERATIVE PROCEDURES
18
18
25
in.
STACKE'S OPERATION
31
IV.
I.
II.
CRANIUM
V.
33
THE ATLAS
35
-
39
47
-
51
SURGICAL ANATOMY
purpose to give here a didactic and complete
middle ear and its adnexa, but to bring into
prominence the various landmarks thanks to which the surgeon
can attain certain success to lay stress upon the structure of
the mastoid and the arrangement of its cells and to state with
IT
is
not
my
description of the
operating,
wound the
let
What makes
Hence
know where to attack, but where to
know exactly what to avoid.
is
it
is
anatomical relations vary with the age of the subject, and consequently important operative deductions vary also (see figures).
External Form.
part
of
is
the
Behind
its
The bulk
of the
muscles inserted in
Surgical
other hand,
it
Anatomy
is
no mastoid process
it is
at thirteen years
it is
is
is
notch
white
line.
of the
different
It is
a level with, very rarely above, this floor so that if one attacks
the bone with the gouge resting below it, one is nearly certain
not to penetrate the cranial cavity unwittingly.
On the outer surface of the process another irregularity is seen,
which furnishes the surgeon with one of the best of landmarks,
;
meatum
nent plate,
situated
the
postero-superior
Surgical
Anatomy
cumference
more
of
anterior than
is
its
upper extremity
is
little
the inferior.
instrument as
all
on the other
often necessary
one wished to penetrate the postero-
if
It is
is
bounded
in front
by
of
In old
Further, comparative anatomy is conclusive.
38).
horses the tympanic ring is practically closed completely the
two extremities of the ring are, in regard to one another, not
;
separated by a millimetre
spot where the spine of
Henle
is
12
Anatomy
Surgical
The spine
of Henle,
when
it
exists,
is
a valuable operative
one count upon it?
landmark; but
found
it
the spine in one single instance, and even then the anomaly was
In twenty
unilateral, thus making one absence in 200 mastoids.
cases the spine was slightly marked, but yet recognisable by a
and finger.*
distinct conclusion
practised eye
The
this
is,
bony landmark
ing upon
child? To determine this question M. Lenoir has examined
fifteen crania (thirty mastoids) of children of different ages at
the Anthropological Museum he has at the same time studied
the distinctness of the supra-mastoid ridge and of the squamoso;
mastoid suture.
He
much
relied
upon
manner below
But
appearance
is to
be seen on
the surface of the bone over the cortex which hides the antrum.
of
Henle, as
have pointed
recent
which is discussed on p. 5 and Fig. 39, and the antrum is then covered
simply by a thin perforated lamina. These foramina have several connections
with the persistent petro-squamosal sinus. The displacement of the limitrophic cells, which become postero-external, is explained on p. 41.
* There is
certainly a difference of opinion regarding the constancy of the
supra-mastoid spine or spine of Henle. Probably the author is in the main
correct in giving it as nearly always present.
I have, however, met with a
good many cases, both in the dead and living subjects, in which it was but
very feebly marked. The fossa which accompanies it is, on the contrary,
always present, although it may at times be a mere dimple, and I have therefore always laid more stress upon the presence of this supra-mastoid
'fossa
than upon the spine as a guide to the antrum. Translator.
Surgical
Anatomy
the posterior part of the spine of Henle, and from that time the
These landmarks change, therefore,
spine becomes a landmark.
in proportion as the subject grows older, for they move below
and behind in a circumference concentric to the auditory
meatus.
thickness and of
hardness
are
very
considerable.
or rather,
it
is.
composed
of
is,
as I have
two parts
the
pneumatic (36'8
sclerosed, that
is
p.
100),
to
say,
unprovided with
cells
(20 p.
100).
And what
6
'
Surgical
sclerosis,' of
tions in the
These
the mastoid
is
Anatomy
tympanum.
inconstant
cells are
therefore I
commence by speaking
The mastoid
of the
secondary
cells.
surgical language
cells are
near the junction of the upper third with the lower two-thirds of
the meatus.
This is the group of special cells, and when these
cells are important, it is among them that the largest cavities
are found, as the cells in Figs. 53, 54, 55.
These figures show,
that
the
mastoid
and
further,
among
squamous cells is a perfect
The squamous
* It is
important to remember these cells in the zygoma in opening the
mastoid in children, as they may otherwise mislead one into
believing that
the antrum has been reached when it is still intact.
Translator.
Surgical
Anatomy
These
47, 48, 51), that these petrous cells are accurately seen.
sections show, further, the various relations which they may
lateral sinus, from which they are separated
a
compact plate, sometimes thick (Fig. 51), sometimes very
by
thin (Figs. 47, 48).
They also show that petrous cells can be
behind
the
antrum
for the length of the posterior surface
present
When
is
the primordial
cells,
and from
cell,
it
others.
In the
mastoid process does not exist in the newbut yet the antrum is found
scarcely present
foetus, the
born child
it
is
Surgical
them, prolonging the
in
attic
Anatomy
behind into the thickness of
adult.*
From
air cells,
tympanic
generally to be found.
'
barrier to the advance of the cells, which do not pass it until the
year has elapsed and, much later, the trace of this suture
first
which marks
it
is
order to determine
1.
cell in
its
surgical anatomy, in
Its depth.
2.
Its relations
3.
it
is
necessary to be careful.
1. The Depth of the Antrum.
and there
described.
Translator.
'
'
Surgical
Anatomy
the antrum was already 10 millimetres deep, and only 4'5 millimetres in a child of five (Fig. 46). On another occasion I have
found an antrum situated 11 millimetres from the surface in a
am
to stop
if
practical interest
chronic
otitis,
of
this
is
possibly
is
one should
soon.
The
discussion
when opening
(Schwartze,
is
to
first
it
is
antrum.
2. Position of the Antrum in Relation to External Landmarks.
The antrum really possesses in the previously-mentioned landmarks spongy spot in young children, supra-mastoid ridge,
When
this ceases to
This spot
is
difficult.
To begin with, we know that, whatever be the age of the subject, the antrum is situated beloiv the supra-mastoid ridge, above
and in front of the squamoso-mastoid suture. These two lines, I
know, are not always distinct, especially in the child but when
;
they are present it is the rule in the adult they are valuable
for the precise delimitation of the field of operation.
'
io
Surgical
Anatomy
(I)
(2)
when
formed by
the antrum
fixed, of 7 millimetres,
abridged
joins the
;
it
will be
completed when
come
figures
antrum.
of the
to the anterior
it is
and goes right across to the other end of the drum, the
of the Eustachian tube (Fig. 42). The deeper the antrum
culty,
orifice
tympanic ring
descends no more
adult
it
any
On
that
at
to say,
is
first
it
above the
even ascends a
little,
of
size.
the arch of
numerous small
cells
open.
more
or less
on the horizontal
* As I have
pointed out in a previous footnote, the supra-ineatal fossa is
always present when the spine of Henle is absent, although it may be but a
mere dimple.
Translator.
Anatomy
Surgical
1 1
of the
tympanum
the aditus
is
brain.
The
(2)
in operathe facial
is
It is
my
operations.
The facial
The
is
better pro-
internal.
of the mastoid,
fragile,
for
and
hollowed
by large
pneumatic
cells
(Fig. 49).
The
is
the nerve
is
Surgical
Anatomy
we
of
for us
will
at once
and quickly.
may
The
doubtless
appears
somewhat sweeping
to surgeons
who have
my
suffices that
it
may
be possible to
make
it
necessary to study
it
in detail.*
Tliis opinion is
Surgical
Certain authors
make
Anatomy
13
may
him
of the caries
in the
literature.
To suppose that in these observations no error of interpretation or of operative technique has entered
an objection which
is liable to occur in observations made on the living
subject
one can only conclude that the anatomical arrangement which
they have demonstrated is possible, but by no means frequent.
Frequency can only be established by the anatomical study of a
numerous
'series.
Now, Hartmann, in 100 preparations, only
found two in which trephining would touch the sinus in his
memoir, so exact from an anatomical point of view, Eicard says
that he has only met, in horizontal section of the petrous,
with one single case where such danger existed, and yet he adds,
in this extreme case, a distance of 12 millimetres still separated
;
'
the
sinus
of
meatus.'
fossa.
is
found.
It is
of this scale,
behind the
pyramid, that the lateral sinus descends, below its elbow, the
bend corresponding to the asterion, that is to say at the junction
the occipital, the parietal and the mastoid, and encroaching
more or less on the postero-inferior angle of the parietal. There
of
of mastoids,
(1)
14
Surgical
Anatomy
it is the rule not to find any cells, but a diploic plate between
two compact laminae, as in the rest of the cranial vault. If the
sinus was invariably to be found in this region, it would always
be very far from the process properly speaking, but it is enough
more
know
that the
bend is
and
more
or
not
less high
less forward,
only in one
and the rule is
subject and another, but on one or other side
that the lateral groove is larger and deeper on the right side
than the left.
Suppose now a very large and very deep groove, and we
understand perfectly how in horizontal and transverse projection
groove for the lateral sinus is
its
more or
can be very
it
of
it
little
at this level.
was not in
its
place ?
it
pyramid.
very evident that if a probe were driven in at the spot where
we should describe the antrum, it would directly puncture the
it is
antrum
that
is
and with care, would meet with a cavity, and from that
time would be prepared, if he remembered it, for the possible
election
presence of the sinus the deep wall of this cavity ought not to
be attacked save with great caution and under special indications
;
(vide p. 47).
to
sinus
it is still
demands the
cally
it
live subject
Now,
antrum
Surgical
Anatomy
and
subject.
of view.
'
the
quote the phrase so clearty expressed by Eicard that
half
of
the
mastoid
is
on
account
'of
its
dangerous
posterior
to
the
lateral
but
the
in
diminishes
sinus,
vicinity
danger
proportion as one leaves the base to approach the summit of the
In reality
it is
pus
it.
constant, that
is to
of chronic
it is
tympanum and
following
difficulty
cadaver the sinus has always been found very hollowed (Fig. 51)
or nearly level.
For the child the sections 20-23 and 27-30
should be consulted.
Surgical
Anatomy
But
mastoid
This
exit.
is
Stacke's operation,
and
to
understand
it, it
'
'
It is
bone, between the external meatus and the internal ear.
raised
whose
a
two
it
to
to
drum,
slightly
compare
customary
bases
It is
interest
from
altogether other-
which
is
membrane,
it
must be acknow-
ledged that this opening does not occupy the whole surface of the
In
placed at a considerable distance from the ceiling.
at
the
membrane
is
seen
the
bottom
of
when
the
other terms,
lintel is
which
is,
'
The
tympanum
situated above
an
of the
malleus enclosed
which
better
ossicles (le
The
mur
Anatomy
Surgical
17
that is to say, the head and neck of the malleus, the short process
and the body of the incus.
The internal wall of the attic (part of the labyrinthine wall
situated above the
by
its
f enestra ovale)
only possesses surgical interest
relations with the transverse semicircular canal and the
which
there projecting
is
orifice of
This tegmen tympani separates the middle ear from the middle
More or less marked according to the subject,
the petro-squamous suture can be seen there, sometimes large
cerebral fossa.
enough
to constitute a perfect
'
dehiscence
'
of the roof.
Then
between the squamous part of the temporal and the petrous, the
former serving, in short, as a cover, above and outside, to the
cavities of the middle ear.
Fig. 18, particularly, shows that in
these
two bones can be isolated from one
a young enough subject
another without fracture.
The mode of union between these two bones at the cerebral
when
Operative Procedures
II
OPERATIVE PROCEDURES
I
3.
by opening the
mastoid.
4.
fossae of
the cranium.
Choice of Operation.
Very various methods have been described
mastoid.
From the preceding anatomical facts
the
opening
for
it
follows that our choice should be guided by the following con(1) the first task should be to look for the antrum
siderations
should be
made by
search
antrum and
all
insists
and
my
possible to do so.
2. It is again fear of the sinus that has influenced the surgeons
who have proposed and practised opening the antrum by the
statistics
prove that
it is
but
if,
by
The
is
reached nearly at
its
centre, but
on
Operative Procedures
account of the
facial,
19
made by
self that
is
difficult,
and
probe.
3. None of these objections hold in the case of the
postauricular route, in which the sole danger is the wounding of the
But
sinus.
this injury
skilled operator,
of a
is
to
reject
which
Trace
it
is
this incision,
The
cellular
system
is
to create, consequently,
let
Operative Technique.
is practised on the cadaver, or on the living subject when
the skin, subcutaneous tissues, and bony cortex are healthy.
which
The
22
2O
Operative Procedures
have been
freed.
and
mastoid
seconds,
view, there
Hps
this
point
is
For several
thus brought to
operation
every facility for using the pressure forceps on the
of the incision.
Beyond
weight, so
the field of operation.
This done, the bone
Henle,
if
the subject
is
the
antrum
may
be
found with
certainty.
Operative Procedures
meatus marked by the spine
ference of the meatus, with
upper pole of the meatus.
of
its
21
With the
chisel
it is
is
the
made dangerous
side
by the
lateral
^^^
sinus,
chisel
the
area,
the
must no longer
be held perpendicular
to the bone, but suffi-
ciently
about
and
oblique
45
at
degrees
in several strokes,
j-.m+r.
FIG.
1.
Often,
the
of
especially if
cavities are full
The area
spine
mastoid
(c.s.m.)
and
mastoido
squamous
by rarefying osteitis,
the antrum will be
But often, also, it is necessary
quickly found under the square
to go deeper.
This is done with care, always with the chisel
and mallet, millimetre by millimetre, pushing the work equally
on all sides of the square in depth, but not making it wider.
From the depth of about 1 centimetre one becomes more and
* The
raising of this square of cortex in this position would, I think, be
taken exception to by most otologists in this country as being too far back.
Most English surgeons prefer to commence their excavation nearer to the
spine of Henle (or supra-meatal fossa).
Personally, the square area of
operation in which I commence my opening of the mastoid is one which,
similar to that of Broca in its dimensions, is placed higher and more anterior,
including the spine of Henle within it, its anterior face being formed by the
Translator.
posterior-superior boundary of the meatus.
22
more
Operative Procedures
cautious, because of
fifteen
method
is
employed as
in
should be
attack
millimetres
only 5
and
square
neither
the
spine
of
2.
The same
forward.
that this
young
is
child
SO,
it
for in the
may
be the
in size, but
caution,
by very
is
easy
to penetrate.
This contingency
is,
It is
true, altogether exceptional.
child (the cortex being very thin and
it
is
Operative Procedures
bottom
at the
23
point,
normal or diseased,
perfectly
attack
is
(2)
rigor-
(3)
part
cutting
The
precise
spot
has
always
shown
me,
in
young
the
the
child,
seat
of
election
At a
the antrum.
later
date
it
important to
it
3.
The
not
is
FIG.
of
is
know
where
an operation is done after the formation of an abscess or a fistula.
It would seem at first sight that one ought always to enter at
the point, friable or perforated, of diseased bone, and, as one
progresses, to allow one's self to be conducted to the antrum by
this in cases
It
is
to
the
is
exposed to operative
Often
especially.
sinus
complications,
perforation
enough, as a matter of fact, the pathological opening is very
much back as regards the sinus ; and, on the other hand, one
does not
know whether
Operative Procedures
The absolute
to primarily
bone, or fistula
iv ell-conducted operation
should begin with the discovery oj the antrum at the seat of election.
The rest of the time is occupied in laying lare all the secondary
cells, without leaving any cul-de-sac where pus can collect.
every
the
symptoms
have
to
tion.
do a
The
to persist,
and
to
secondary operais
practice
ordinarily
Pav
cells
thin septa.
toid
and
exists,
also,
when no
appre-
ciable cell
twice
The
antrum
being opened,
with the chisel
enlarged
it
is
TTI
These
anatomical
and
an account of the Way
in which a surseon should act
refer him to
it seems best to
held to give
'
seen.
55
in previous figures.
th
th
'
(Figs. 40-56)
Old
types of niastoids at various ages.
eburnaotorrhosas, which are often accompanied by consecutive
But it must
tion of the mastoid, are always to be mistrusted.
the cells of various
not be forgotten
the figures
bear
testimony
that, without
An
The beak
of
the instrument
towards the
tip,
is
Operative Procedures
and on this beak, which prevents all violent
;
penetration
into the deep parts, towards the sinus or towards the
facial, the
sinus
When
chisel.
touches
curette
bone,
cavity,
limiting a
on the wall
of
on
everywhere
smooth
single
the
protector
or
the
of
no
the probe
exit
of
The bony
be examined
fectly free
is
when
it is
from blood.
easy to attain
if
per-
This
at first
stoppage of the
bleeding of the soft parts
complete
is
of
FIG.
5.
opened.
ing,
II.
This
operation
the
following
steps
(1)
Skin
(2) exposure
(3) finding the antrum and
excavation of the mastoid
(4) opening of the aditus and attic.
1. The skin incision is the same as in the preceding case, with
incision
of the
bone
it is
If
Operative Procedures
26
purulent pocket at
its
broadest part.
inserted, with
is
separated, inferior
and
cutaneous tube
against the
is
cut,
brought down entire. Auricle and meatus are then turned forward, held in place by forceps covered by an aseptic compress,
and from that time the whole bony part of the region is seen
mastoid, bony meatus, and tympanic frame, with what remains
membrane.
Such operation
of the
or largely destroyed.
To obtain a clear view
it is first
the meatus.
in the
made with
packing
is
exactly as has been said above, at the seat of election, which will
be the seat of appreciable external lesions.
It is in the actual
case especially that I would insist upon this precept, for it is in
chronic mastoidites and otites, to which alone the complete
operation
is
These lesions are not the only ones. The mastoid undergoes,
under these conditions, more or less profound alterations but
;
found.
The
caries
of
the
attic,
the
posterior wall of the meatus, and the curette soon finds proof of
several small friable bony spots.
of
more
or less size.
Operative Procedures
27
the
The
latter.
following
is
Stacke's protector
exit is seen in the
is
antrum, above, in
front,
tector is
tion.
young
child,
when
or
the
Pav.-f-
re-
duced
making
it
Ordinarily, the
the antrum.
Cond
and
it
is
having enlarged
is
is
only
it
by
FIG.
6.
is
In
part of its passage will become possible.
is
these positions the plate of the protector
applied against
the inner wall of the aditus that is to say that it protects the
semicircular canal, and, below, its lower border guarantees the
that the
first
using the
instrument with roughness, and keeping any weight on the
it should be kept
handle, or injury to the nerve may result
facial
against
accident.
against
in place
by
its
own
weight.*
Then, by
Operative Procedures
28
From
definite position, the beak entering the tympanum (Fig. 7)
this time the aditus and attic can be attacked. At first the chisel
.
is
applied, perfectly
the
If
thin
not be broken
other
hand,
little
danger
middle
The
fossa
is
far
away,
and
risks,
if
there
to
is
fear.
cerebral
enough
one only
it
breaks
the
baring
dura mater to a slight
extent, from which I
quickly,
By
If
so
penetration is
dreaded, the wall of the
attic
can
be
worked
shall
describe
Stacke's operation,
for
and
the aditus, after the beak of the protector has been exposed.
The upper track finished, the lower one is completed, and it
is here the facial is found.
The chisel must be applied at
the junction of the upper one-third with the lower two-thirds
of the meatus, mostly at mid-height of the meatus, and it must
make
a trapezoid breach,
using the chisel with care, and keeping it well under control, the bridge of
bone which forms the outer wall of the aditus can be removed over the plug
Translator.
of sponge without risk of injuring the nerve.
Operative Procedures
29
so that the piece removed from the wall of the meatus has a
base as high as the half of the meatus at most, and in the depth
chisel-cuts at the upper part being always perfectly perpendicular to the bone, the lower ones being, on the
contrary, more
of the breach
especially
little,
At
operation
it is
neces-
for
which
limetre
.Ad.
must be used.
Cell.
dry antiseptic, or
gives
much
help.
FlG 8
tightlv
*
*V
1-1
chisel
point of the
with an ordinary tampon, fluid is sponged from the surface. The
tampon is lifted out by a sharp blow with the left hand, which
should never leave the mallet, or it may be lifted out by using
;
the chisel as a curette, and then for a short time the cavity
can be seen distinctly, so that the chisel can be applied with
when
it is
are sufficiently large.
a
has
condensing
not rare to find that the bone
undergone
osteitis which chokes up the cell system, making it nearly nil,
when a narrow aditus is found with a microscopic antrum.
Operative Procedures
30
In these conditions the operation can nearly always be conducted by the method which I shall describe, if one keeps
above and within, distinctly towards the aditus, breaking away
true, under the supra-mastoid
on
sometimes to a great depth to
ridge.
steadily
reach a rudimentary antrum surrounded by particularly hard
bone. With skill and practice this can be done, but it is not
necessary to be excessively persevering, and when the work becomes too assiduous the cells can only be entered by the
as
is
it is
One must go
tympanum
is
to say,
by Stacke's
operation.
When
that can be found are rounded off with the chisel over the prowhich guards against accidents
cholesteatomatous
tector,
;
To
finish,
the concha
some surgeons
meatus towards
also
rhage.*
The
wound,
is
to the
bottom
of the
* Save in
exceptional circumstances, I think it better to attain this end by
careful packing, via the meatus only, the post -auricular wound being sutured
This ensures union by first intention and a consequently
throughout.
unnoticeable scar. Subsequent packing is carried out through the meatus,
Translator.
and, if carefully done, there need be no anxiety as to the result.
Operative Procedures
tympanum and
auricular wound.
I shall not here describe the after-treatment of these patients.
I would only insist upon the fact that, to obtain a good result, it
is
or
ear, as
has been
said.
The
skin incision
is
way
of the
tion.
hind
speaking, leaving
The pinna
as
turned forward, so
separate completely the
to
is
canal.
aseptic
if
it
still
-ProL
menced.
The
his
model
is
made
where
its
beak has
Operative Procedures
32
direct
should
be placed
boldly in the meatus from the
ting
blade
first,
breaks
sufficiently
away
deeply,
and
bony
wall
the
much
practice
Cozd,
FIG. 10.
The wall
with.
mallet,
one piece.
The
attic is
organ
is
in
any danger
is
no
not approached,
After the ablation of the outer attic wall, the tympanum and
are widely opened at the bottom of the meatus.
The-
attic
malleus,
if
tympanum.
it still exists,
With a
fill
the
is
extracted,
aditus
Then
is
carried
Operative Procedures
oat,
the
facial
and
33
breach
is
slightly enlarged
and outwards
(Fig. 10), to
make
it
enter the
antrum
and the
aditus, then the antrum, then the various cells, are opened,
exactly as has been described in the preceding operation, but in
wound
is
meatus.
After Stackers operation, completed by retrograde opening, one
acts exactly as in the complete opening previously described.
Tympanum and
the Cranium.
Choice of Methods.
Before entering into the detail of operative
technique several pathological facts are indispensable, for upon
their recognition depends the choice of method.
to
number
themselves,
four
often
justify
surgical
interference.
They
localized
if
opened
4.
Operative Procedures
34
their origin
modern
to these
surgical
anatomical
auricular focus.
Another anatomico-pathological
fact to
be well remembered
is
is
equally frequent.
FIG. 11.
my
'
of the
Complete opening
Consequently, it should always be remembered that, if sometimes the symptomatology is sufficiently clear to allow of a precise
diagnosis, it is by no means usually so. An intracranial complication is recognised, some one in particular being suspected yet to
consider it to be an abscess is to willingly be deceived, and, as a
;
it is not possible to
specify
dural, cerebral, or cerebellar.
rule,
if
is
extra-
the
maximum
of rapidity
making
easily
of damage,
and quickly
for the
all
the
Operative Procedures
35
And
that
osteitis,
we are
intracranial
tympanum, one
sinus, of
it is
enters just
also seen that
is
ordinarily
is
when
it is
32
not
Operative Procedures
36
thrombosed
a similar continuity
is less
abscesses.
2.
Opening
the
Just at the
Temporal Fossa.
summit
of the
two extremities
by two short
vertical
and
FIG. 12.
chisel is
abandoned from
this time,
is
and
if it is
wished to enlarge
temporal fossa.
shows with great distinctness what point of the base
the cranium is reached, just below the temporal lobe that
tympanum, gouge-forceps
Fig. 13
of
is
Opening
the
Cerebellar
Fossa.
We
have here
to
reach
best
Operative Procedures
37
in
relation to the
antrum
is
aditus.
showing the
petro-mastoid excavation).
It is in Fig. 15, behind the superior border of the petrous, that
the entrance of this opening into the cerebellar fossa is seen
;
Opening
it
Operative Procedures
is
sinus.
'-:'!
',
"'<-
^f^ ^^fcs^MSi^?-!
FIG. 14.
'
FIG. 15.
Entrance into the cranium both towards the cerebrum and cerebellum.
The
Atlas
39
is to
without danger.
It is at the level of the posterior surface of the aditus and the
tympanum that the work ought then to be finished, being careful
to direct the instruments rather above than below
for below one
:
is
not far from the jugular foramen at its junction with the sinus.
practised operator can directly attack this region.
THE ATLAS.
This atlas
is
composed
pupils and
by my
Both have taken upon themselves the task
direction
of collecting
variations of the relations of the cavities of the middle ear from
to
show,
The
Millet
1897-1898).
The second part
In
the
horizontal plane.
A new
section
5 millimetres lower.
This
The
Atlas
alone is visible,
the track of the section passing at the level of the mastoid below
the floor of the antrum (Figs. 20-23).
2.
tympanum
to
the
outer
FICJ. 16.
One month.
FIG. 17.
Sixteen months.
Thus the
relations of
the facial with the aditus and the posterior wall of the meatus
In these two figures the
(Figs. 34 and 35) can be made plain.
direction of the descending portion of the facial
is
indicated by a
black line.
A second
made more
tinuously
3.
The
Atlas
middle
of the
out by
The outer
temporal wall.
itself
table of
cells.
appeared
entire.
The
FIG. 18.
of the
Fifteen days.
with age are not limited to the development of the mastoid alone,
but also extend to that of the auditory meatus, subordinate itself
to that of the cranial cavity
which the
which originally take no part
become
This
horizontal and participate in the formation of the base.
is' seen in
According as the child gets older,
Figs. 16, 17, 19.
the inner plate of the squamous becomes incurved, so that its
lower part, becoming horizontal, takes part in the formation of
the middle cerebral fossa.
the upper border of the longitudinal root of the zygomatic
process (linea temporalis] which corresponds externally to the
junction of the vault with the base of the cranium.
It is
From
The
Atlas
external part,
lobe
during the
first
FIG. 19.
of the
antrum,
of the aditus,
Fourteen years.
and
surface.
One month.
FIG. 20.
fossa,
passes
tympanum.
FIG
21.
One
year.
middle
of the
bony meatus.
The
Atlas
43
become closer.
The adjoining figures (20-23) represent horizontal
fossa
sections
is
produced.
In a subject of one month (Fig. 20) this section shows the
antrum badly this cavity is, as a matter of fact, at this age on
;
the
first,
front
the' pos-
This
from the
lateral sinus.
At its
occipito-mastoid suture.
external extremity still, this posterior surface of the petrous,
formed by the inner table of the temporal and the direction of
prolonged right up to the
which
wards,
is
is
oblique from before backwards and from within outslightly inflected to unite with the outer table, the
direction of
occipital
which
is
such that
it
(Fig. 20).
of the cerebellar fossa.
development
The
44
At the
expense
Atlas
FIG. 23.
minimum, undergoes
To the cartilaginous
in
Thirteen years.
tissue interposed
FIG. 24.
Three years.
The
Atlas
45
a bony
making part
fossa,
surface
of this wall is
formed
progressively,
a true
mastoid
in
wall.
enlarging,
But,
the
goes
movement
inflection
of
analogous
wall
between
of
bone,
which the
antrum
is
FlG 25 -~ Ei gh t years,
-
portion of
It
results
the
from
this
its
movement
internal
tympanic opening,
which
primarily
and
was
inis
antero-posterior,
flected, carried forward,
FIG. 26.
Fourteen years.
made
The
46
Atlas
inferior;
latter
contributes,
and rounded
and which
sibly rectilinear
covers.
It is to
it
partly
the
FIG. 27.
half.
mi
>
the
level of
posterior wall
the child in
the
meatus
carried for-
its
oblique in
first
loses
years,
progres-
and
obliquity
become perpendi-
this
sively
tends
is
So that,
ward.
to
cranium.
Two
between
years.
,,
the
formation
the
,,
of
,,
the
of
,
lateral
groove
sinus and the posterior wall of the meatus, in Fig. 24 the relations of the sinus marked on the external table, with the spine
of
Further
The
on
Atlas
importance
47
of
child
is
Thirteen years.
FIG. 29.
Or
cells.
of
the
the spine of
it
is
Henle,
necessary to prepare sections passing through
20-27) the
At
birth
antrum.
the
(Figs.
opening
clearly
centimetres
descending portion of the lateral sinus, about
i.e.,
The
48
Atlas
long,
By
a horizontal
antrum,
it
is
and
highest
part,
orifice of the
tachian
tube
lowest
the
Eusthe
but,
part
by successive sec;
made above
tions
make
these re-
lations plain. If in
a section passing
FIG. 80.
Fourteen vears.
posterior extremity of
through the
floor
antrum the
the antrum be limited by a line drawn
of the
at
of
the sinus, or
The antrum
slightly in front of
it.
any
is situated.
of
The
Atlas
49
upper part
of the
tympanic
opening.
movement
of
rotation
its
posterior extremity
is
carried out-
the antrum occupies the superficial plane and the sinus the deep
plane, it is the reverse which becomes the rule (Figs. 27-29).
When
the
more or less
more or less
cell
'
system
is
procident,' that
in front,
it
is
two tables
of the temporal.
The
The
50
Atlas
maximum
size, and even among the diploic, the lateral sinus is located far
from the posterior wall of the auditory meatus ; it approaches it,
FIG. 31.
Ten months.
that
FIG. 32.
is
to
say the
Three years.
The
Atlas
51
millimetre,
16-19), especially at
second to the petrous, and that in relation to the antrum the one
is anterior, superior and external, whilst the other is inferior,
and
if
When
and 35.
The outer wall
Figs. 34
of
measure
But
it
is
the arrangement of the middle ear and from the high position of
the aditus, that the surgeon must attack not the posterior wall of
42
The
52
Atlas
FIG. 33
must not
Thirteen
interfere
neighbourhood
of the
3 ears.
with
the upper
FIG. 34.
half
years.
the immediate
FIG. 36?
FIG. 35.
in
Two
inter-
Twelve years.
The
Atlas
53
is,
we
the nerve
that
it
is
the rule to
is
see,
the nerve
cut in
is
It is
after
more
tympanum
that
never complete.
On
the contrary,
when
the nerve
is
its
it is
and
outside.
projection, the
infundibulum
At
this
level
more appreciable
of
The
curette, after
having
infundibulum and
catches the projection of the canal. And this projection corresponds to the point where the wall of the nerve is very thin and
at times even incomplete.
object of the succeeding figures is to show well what is,
according to the age, the operative topography of the parts
The
Henle, which
(see
is seen to be independent
photograph 24, taken in the child).
at
of the
is
the spine of
tympanic ring
The
54
Atlas
.O.L
FIG. 37.
Lettering as in the preceding figures.
.O.L.
FIG. 38.
FIG. 39.
The
The
Atlas
FIG. 40.
Foetus of eight and a half months (left side). The antrum is opened, a probe is in the aditus, which the
Note their inclination,
chisels are ready to open.
which avoids cutting both the middle portion and
1
elbow of the facial. 2 ., tympanic ring. Other lettering as in the preceding figures.
FIG. 41.
55
The
Atlas
FIG. 42.
ing figures.
FIG. 43.
The
e'
respectively.
of danger.
Two pins,
of the base of the skull
The
Atlas
57
O.L.
FIG. 44.
Made
to show,
from the
e'
c,
of Figs.
FIG. 45.
of three years (left side).
Simple uncovera depth of
ing of the antrum, which is at
10 millimetres. No mastoid cells, correctly
millimetres thick.
speaking. Outer table 1'5
Boy
Very compact
diploiic
Of all the
the one in which
tissue.
two
auditory
43
The
Atlas
FIG. 46.
Boy
of
the
deep.
Simple opening
antrum, which is 4'5 millimetres
External table 1 millimetre thick.
Lettering as
.02.
\AJ>..
FIG. 48.
FIG. 47.
Man
of twenty-five years.
Horizontal
section passing through the antrum, of
which the inferior wall is seen, and
through the
be seen with
can
lying in
canal of the sinus
very marked one can always, from the
surface of the mastoid, attack well
behind and reach the antrum without
wounding the sinus.
the
aditus.
Bony
The
Atlas
59
FIG. 49.
The
frequent arrangement).
canal F is only separated from
the fossa G by several pneumatic cells in a very thin plate.
The
FIG. 50.
Man
of
Sclerosed
seventy-five years (left side).
mastoid. Antrum 27 millimetres deep. In consequence of the thickness of the outer table, the
mastoid cells, properly speaking, can only be
reached by the hole P. hollowed out towards the
antrum.
P, cells in the tip; C, petrous cells,
Other lettering as in the preceding figures.
jugular fossa.
The
6o
Atlas
FIG. 52.
Man
Sclerosed mastoid
of seventy-five years (right side).
External table
in the mastoid part, properly speaking.
4 to 5 millimetres thick ; antrum 27 millimetres deep ;
numerous petrous and squamous cells. It is seen how
Atticotomy
FIG. 53.
Woman
cells,
The
Atlas
61
.O.L.
FIG. 54.
Woman
the aditus
is
destroyed.
FIG. 55.
Woman
On this side atticotomy comother side, the mastoid is pneumatic, the antrum 25 millimetres deep. AD., aditus ad antrum
Ad., external aditus L., lateral sinus.
of sixty years (right side).
As on the
pletes antrectomy.
The
62
Atlas
FIG. 56.
Woman
The
AD,
aditus ad
the
same
danger.
antrum
F,
facial.
THE END
13JKY
vvaii TI/ av
UFO%
UNIVERSITY OF CALIFORNIA LIBRARY
Los Angeles
This book
fB
is
1 3 1961
7J
V
Form L9-100m-9,'52(A3105)444
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