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Transcriber’s notes:

Italic text is denoted by _underscores_ and bold text by =equal signs=.
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original text, e.g. a_{1} (seen mainly in illustration captions).

The table of contents contains a mix of italicised and non-italicised
entries that generally correspond to different heading levels in the
body of the text, but the correspondence is inaccurate and not all
headings are listed. No attempt has been made to correct these
anomalies.

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unit of weight, and ‘℥’ representing the ounce unit of weight (8 drachms
= 1 ounce). The third symbol does not have an exact computer
equivalent and has been represented in this transcription by the
character ‘ɱ’, which can signify ‘minim’ (a measure of volume
equal to 1/60th of a fluid drachm), ‘drop’, or ‘part by volume’. Roman
numerals x, v, i and j (i and j both represent 1) indicate the
quantities associated with these symbols.

Various inconsistencies of spelling and hyphenation occur throughout the
text; some are simple typographical errors but most are probably
variations attributable to the book's multiple authorship. Words with
variable spellings that occur with similar frequency (e.g. _trocar_ /
_trochar_, _aneurism_ / _aneurysm_) have not been changed, but most
other spelling inconsistencies have been ‘corrected’ to the predominant
form (e.g. _Caesarian_ --> _Caesarean_, _turbinate_ --> _turbinal_).
Omitted letters have been corrected by inserting the missing letters in
square brackets (e.g. sella turc[ic]a). Simple typos such as _uretha_
(_urethra_) and _polpyus_ (_polypus_) have been corrected silently, and
likewise with missing punctuation such as commas omitted from the index
and the table of contents. An apostrophe is used inconsistently with the
proper noun _Bruening_ / _Bruenings_.

Inconsistencies of spacing and hyphenation have been treated similarly.
For example, spaces have been removed from the abbreviations _i.e._
_e.g._ and from percentage values. Compound nouns that occur equally
often with/without hyphens, have not been changed, e.g. _bone forceps_ /
_bone-forceps_, _attic wall_ / _attic-wall_, whereas those that are more
frequently either hyphenated or not hyphenated, have been standardised
accordingly, e.g. _punch forceps_ --> _punch-forceps_, _heart-failure_
--> _heart failure_.




[Illustration: Cover]




                  OXFORD MEDICAL PUBLICATIONS

                         A SYSTEM OF
                      OPERATIVE SURGERY

                     OXFORD: HORACE HART
                  PRINTER TO THE UNIVERSITY


                 OXFORD MEDICAL PUBLICATIONS

                              A
                            SYSTEM
                              OF
                      OPERATIVE SURGERY

                      BY VARIOUS AUTHORS

                          EDITED BY
         F. F. BURGHARD, M.S. (Lond.), F.R.C.S. (Eng.)
    TEACHER OF OPERATIVE SURGERY IN KING’S COLLEGE, LONDON
               SURGEON TO KING’S COLLEGE HOSPITAL
  SENIOR SURGEON TO THE CHILDREN’S HOSPITAL, PADDINGTON GREEN

                       IN FOUR VOLUMES

                           VOL. IV

           OPERATIONS UPON THE FEMALE GENITAL ORGANS
                    OPHTHALMIC OPERATIONS
                   OPERATIONS UPON THE EAR
            OPERATIONS UPON THE LARYNX AND TRACHEA
      OPERATIONS UPON THE NOSE AND ITS ACCESSORY CAVITIES

                            LONDON

          HENRY FROWDE                 HODDER & STOUGHTON
     Oxford University Press          Warwick Square, E.C.

                             1909




EDITOR’S PREFACE


Great as have been the advances made in Surgery during the last fifteen
years, there is no direction in which they have been more noticeable
than in the elaboration of those comparatively small but important
details of operative technique which do so much to ensure a low
mortality and a successful result.

These improvements have been developed simultaneously throughout the
whole of the vast field covered by modern Surgery, and it has become
increasingly difficult for any single writer to deal with such an
important subject as Operative Surgery in an authoritative and efficient
manner. The scope of the subject is so wide that it is difficult to
ensure that the work when published shall be thoroughly up to date,
while a second and even greater difficulty is for any one, however great
his ability and experience, to deal equally exhaustively and
authoritatively with all of the many branches of which he would have to
treat.

To avoid both of these difficulties and thus to make sure that the work
shall reflect faithfully the present position of British Operative
Surgery, the plan has been adopted of securing the co-operation of a
number of prominent British Surgeons. Each writer deals with a branch of
the subject in which he has had special experience, and upon which,
therefore, he is entitled to speak with authority.

Besides the two important points just referred to, a third equally
important one has been kept in view throughout. Particular care has been
taken to make the work of as much practical utility to the reader as
possible. Not only are the various operations described in the fullest
detail and with special reference to the difficulties and dangers and
the best methods of overcoming and avoiding them, but the indications
for the individual operations are described at length, and the
after-treatment and results receive adequate notice.

It is therefore hoped that the work will be useful alike to those who
are about to operate for the first time, and to those surgeons of
experience who desire to keep themselves informed as to the progress
that has been made in the various branches of Operative Surgery.

The division of the work into a number of sections each written by a
different author, necessarily involves some overlapping of subjects and
some diversity of opinion upon points of technique. Efforts have been
made to prevent overlapping of subjects as far as possible by care in
their distribution and by conference between the authors concerned, but
no attempt has been made to harmonize conflicting views. Each author
supports his individual opinions by the weight of his authority, and any
discrepancies may be taken to represent the absence of unanimity on
various minor points that is well known to exist among surgeons of all
countries.

The task of editing a work contributed to by so many writers might well
appear to be an onerous one, but, owing to the promptitude, courtesy,
and forbearance of all concerned, it has been a source of great
pleasure, and the Editor’s most cordial thanks are tendered to all those
who have devoted so much time and trouble to the work.




PREFACE TO VOLUME IV


Every effort has been made to keep this volume strictly within the
definition of a work upon Operative Surgery--a somewhat difficult task
in the case of certain of the special subjects with which it deals. In
some cases methods of examination or manipulation have been described
that are not strictly operative in nature, but their inclusion has been
justified upon the ground that many of them are essential in operations
upon the regions concerned, and all require special manipulative skill
and dexterity.

The Index to this volume has been arranged in five parts, one part for
each Section comprised in it. In this way it has been possible to
economize space and, it is hoped, to render the task of reference
easier.

In the Section on Vaginal Gynæcological Operations, instrument blocks
have been kindly supplied by Messrs. Montague, Down Bros., and Griffin.
The remaining illustrations are from original sketches by the author.

In the Section on Ophthalmic Operations, Messrs. Weiss have kindly
supplied the instrument blocks. The remainder of the illustrations are
original. Mr. Mayou desires to thank Mr. W. H. McMullen for valuable
help in reading the proof sheets.

In the Section on Operations upon the Ear, all the illustrations, with
the exception of the instrument blocks kindly supplied by Messrs. Mayer
and Meltzer and a few illustrations from Tod’s _Manual of Diseases of
the Ear_, are original.

In the Section on Operations upon the Nose, the instrument blocks have
been supplied by Messrs. Mayer and Meltzer, who have also furnished them
in the Section on Operations upon the Throat. Mr. F. A. Rose has kindly
read the proof sheets of the latter Section, for which Mr. Harmer
desires to thank him.




CONTRIBUTORS TO THIS VOLUME


JOHN BLAND-SUTTON, F.R.C.S. (Eng.)

_Surgeon to the Middlesex Hospital, and Senior Surgeon to the Chelsea
Hospital for Women, London_

Abdominal Gynæcological Operations


JOHN PHILLIPS, M.A., M.D. (Cantab.), F.R.C.P.

_Professor of Obstetric Medicine, King’s College, London; Obstetric
Physician and Gynæcologist to King’s College Hospital_

Vaginal Gynæcological Operations


M. S. MAYOU, F.R.C.S. (Eng.)

_Assistant Surgeon to the Central London Ophthalmic Hospital; Ophthalmic
Surgeon to the Children’s Hospital, Paddington Green_

Ophthalmic Operations


HUNTER F. TOD, M.A., M.D. (Cantab.), F.R.C.S. (Eng.)

_Aural Surgeon to the London Hospital_

Operations upon the Ear


W. DOUGLAS HARMER, M.C. (Cantab.), F.R.C.S. (Eng.)

_Surgeon to the Throat and Nose Department, St. Bartholomew’s Hospital_

Operations upon the Larynx and Trachea


StCLAIR THOMSON, M.D., F.R.C.P. (Lond.), F.R.C.S. (Eng.)

_Professor of Laryngology and Physician for Diseases of the Throat,
King’s College Hospital, London_

Operations upon the Nose and its Accessory Cavities




CONTENTS


SECTION I

OPERATIONS UPON THE FEMALE GENITAL ORGANS


PART I

ABDOMINAL GYNÆCOLOGICAL OPERATIONS

By JOHN BLAND-SUTTON, F.R.C.S. (Eng.)

Surgeon to the Middlesex Hospital and Senior Surgeon to the Chelsea
Hospital for Women, London.

                                                                  PAGES

CHAPTER I

CŒLIOTOMY

  Preparation of Patient, 3. Basins, Dishes, and Instruments, 4.
    Suture and Ligature Material, 5. Dabs, 5. Gloves, Operating
    Table, Anæsthesia, 6. The Incision, 7. Misplaced Viscera, 8.
    Closure of Wound, 8                                             3-9

CHAPTER II

OVARIOTOMY

  The Operation, 10. Cysts of the Broad Ligaments, 14. Spurious
    Capsules, 15. For Carcinoma of Ovary, 15. Incomplete
    Ovariotomy, 16. Anomalous Ovariotomy, 16. Ovariotomy followed
    by Hysterectomy, 17. Repeated Ovariotomy, 17. Pregnancy after
    Bilateral Ovariotomy, 17. Ovariotomy at Extremes of Life, 18.
    Ovariotomy in Old Age, 19. Mortality, 19                      10-20

CHAPTER III

OÖPHORECTOMY

  Operation, 22. Abdominal Hysterectomy after Bilateral
    Oöphorectomy and Ovariotomy, 25. Mortality, 25. Operation for
    Primary Cancer of the Fallopian Tube, 26                      21-28

CHAPTER IV

OPERATIONS FOR EXTRA-UTERINE GESTATION

  Indications, 29. Operation, 29. Concurrent Intra- and
    Extra-uterine Pregnancy, 33. Results of Operative Treatment,
    34                                                            29-35

CHAPTER V

HYSTERECTOMY AND MYOMECTOMY

  Indications, 36. Subtotal Hysterectomy, 36. Total Hysterectomy,
    40. Mortality, 44. Risks of Abdominal Hysterectomy, 45.
    Abdominal Myomectomy, 46                                      36-49

CHAPTER VI

ON THE RELATIVE VALUE OF TOTAL AND SUBTOTAL HYSTERECTOMY

  Cancer of the Body of the Uterus and Fibroids, 52. Sarcoma, 53.
    Cancer of the Uterus after Bilateral Ovariotomy, 55.
    Adenomyoma of the Uterus, 56. Fate and Value of Belated
    Ovaries, 56                                                   50-60

CHAPTER VII

HYSTERECTOMY FOR PRIMARY CARCINOMA OF THE UTERUS

  For Cancer of the Cervix, 61. For Cancer of the Body of the
    Uterus, 63                                                    61-65

CHAPTER VIII

OPERATIONS FOR DISPLACEMENT OF THE UTERUS

  Ventro-suspension for Retroflexion of the Uterus, 66.
    Ventro-fixation for Prolapse of the Uterus, 67                66-68

CHAPTER IX

OPERATIONS UPON THE UTERUS DURING PREGNANCY, PARTURIENCY, AND PUERPERY

  Cæsarean Section, 69; _Immediately after the Death of the
    Mother_, 72. Ovariotomy and Hysterectomy during Pregnancy and
    in Labour, 73. Ovariotomy during the Puerperium, 76. Fibroids
    and Pregnancy, 77. Pregnancy with Cancer of the Cervix, 82.
    Concurrent Uterine and Tubal Pregnancy, 82. Pregnancy with
    Tumours growing from the Pelvic Walls, 83. Operations for
    Puerperal Sepsis, 83                                          69-85

CHAPTER X

OPERATIONS FOR INJURIES OF THE UTERUS

  Gynæcological, 86. Obstetric, 87; to the Pregnant Uterus, 89; to
    the Gravid Uterus in the course of an Abdominal Operation, 89.
    Bullet Wounds of the Pregnant Uterus, 90. Stab-wounds of the
    Pregnant Uterus, 91                                           86-92

CHAPTER XI

THE AFTER-TREATMENT, RISKS, AND SEQUELÆ OF ABDOMINAL GYNÆCOLOGICAL
OPERATIONS

  After-treatment of Abdominal Operations, 93. Complications of
    Abdominal Gynæcological Operations--_Metrostaxis_, 95;
    _Bed-sores_, 95; _Post-anæsthetic Paralysis_, 95; _Giving way
    of the Wound_, 96; _Hæmorrhage_, 97; _Intrapelvic Hæmorrhage_,
    98; _Pneumonia_, 99; _Parotitis_, 99; _Thrombosis_, 101;
    _Pulmonary Embolism_, 101; _Foreign Bodies left in the
    Abdomen_, 105; _Tetanus_, 107; _Injury to the Intestines_,
    109; _Intestinal Obstruction_, 110; _Perforating Ulcer of the
    Stomach and Small Intestine_, 111; _Injuries to the Bladder_,
    111; _to the Ureter_, 112. The fate of Ligatures, 117.
    Post-operative Kraurosis, 120. The Cicatrix, 120             93-122


PART II

VAGINAL GYNÆCOLOGICAL OPERATIONS

By JOHN PHILLIPS, M.A., M.D. (Cantab.), F.R.C.P.

Professor of Obstetric Medicine, King’s College, London; Obstetric
Physician and Gynæcologist to King’s College Hospital.

CHAPTER XII

PREPARATION OF THE PATIENT FOR PERINEAL AND VAGINAL OPERATIONS:
OPERATIONS FOR INJURIES TO THE PERINEUM AND PELVIC FLOOR

  Preparation of the Patient, 125. Operations for Repair of a
    Complete Laceration of the Perineum, 127. Operation for
    Laceration of the Pelvic Floor, 132                         125-133

CHAPTER XIII

OPERATIONS UPON THE URETHRA AND BLADDER

  Extirpation of a Urethral Caruncle, 134. Operations for
    Incontinence following Labour, 134; for Vesico-vaginal
    Fistula, 135; for Recto-vaginal Fistula, 139; for Cystocele,
    140                                                         134-141

CHAPTER XIV

OPERATIONS UPON THE VULVA AND VAGINA

  Operations upon Bartholin’s Glands, 142. Operations for Atresia
    of the Hymen and the Vagina, 143. Dilatation of the Vulval
    Orifice, 143. Colpotomy, 144; _Anterior_, 145; _Posterior_,
    147; _Lateral_, 148                                         142-148

CHAPTER XV

OPERATIONS UPON THE UTERUS

  Passage of the Uterine Sound, 149. Reposition of a Chronic
    Uterine Inversion, 151. Curetting the Uterus, 152. Dilatation
    of the Cervix, 156--_Rapid Dilatation_, 157; _Gradual
    Dilatation_, 159. Operations for Hypertrophy of the Cervix,
    160. Trachelorrhaphy, 161. Vaginal Fixation, 164            149-164

CHAPTER XVI

OPERATIONS FOR NEW GROWTHS OF THE UTERUS

  For Uterine Fibro-myomata, 165--_for Pedunculated Tumours_, 165;
    _for Sessile Tumours_, 166; _for Interstitial Tumours_, 167.
    Vaginal Hysterectomy, 167--_for Carcinoma_, 168; _for
    Fibroids_, 173                                              165-173


SECTION II

OPHTHALMIC OPERATIONS By M. S. MAYOU, F.R.C.S. (Eng.)

Assistant Surgeon to the Central London Ophthalmic Hospital; Ophthalmic
Surgeon to the Children’s Hospital, Paddington Green.

CHAPTER I

GENERAL CONSIDERATIONS APPLICABLE TO OPERATIONS UPON THE EYE

  General Preliminaries to an Operation, 177. Local Preparation of
    the Patient, 80. Making and Healing of Wounds in the Globe,
    182--_Purification of Hands_, 182; _of Instruments_, 183;
    _Direction of Incision_, 183; _Position of Incision_, 184;
    _Dressings_, 186; _Bandaging_, 186                          177-186

CHAPTER II

OPERATIONS UPON THE LENS

  Surgical Anatomy, 187. Discission or Needling, 189--_for
    Cataract_, 189; _for High Myopia_, 190. Capsulotomy, 192.
    Evacuation, 194. Evulsion of the Capsule, 195. Extraction of
    the Lens, 195. Modifications, 201; _Delivery of the Lens by
    Irrigation_, 203; _Extraction of the Lens in its Capsule_,
    204; _Subconjunctival Extraction_, 204. Couching, 209       187-210

CHAPTER III

OPERATIONS UPON THE IRIS

  Iridotomy, 211. Alternative Methods--_Kuhnt’s Operation_, 212;
    _Ziegler’s_, 213. Iridectomy--Optical Iridectomy, 214;
    Glaucoma Iridectomy, 217--for small Growths of the Iris, 225;
    for Prolapse of the Iris, 225. Transfixion of the Iris, 226.
    Division of Anterior Synechiæ, 227                          211-227

CHAPTER IV

OPERATIONS UPON THE SCLEROTIC

  Anterior Sclerotomy, 228. Cyclo-dialysis, 229. Sclerectomy, 231.
    Posterior Sclerotomy, 232. Paracentesis of the Anterior
    Chamber, 233. For Penetrating Wounds of the Globe, 234.
    Electro-magnet Operations--_with Small Magnet_, 237; _with
    Giant Magnet_, 238                                          228-239

CHAPTER V

OPERATIONS UPON THE CORNEA AND CONJUNCTIVA

  Removal of a Foreign Body from the Cornea, 240. Cauterization of
    the Cornea, 240. Operations for Conical Cornea, 241. Removal
    of Tumours involving the Cornea, 243. Tattooing the Cornea,
    243. Scraping Calcareous Films, 243. Operations upon the
    Conjunctiva--_Removal of Foreign Bodies_, 244; _for
    Pterygium_, 244; _Expression_, 245; _Conjunctivoplasty_, 245;
    _Removal of Tarsal Cysts_, 246                              240-246

CHAPTER VI

OPERATIONS UPON THE EXTRA-OCULAR MUSCLES

  Squint Operations, 247. Tenotomy, 248. Advancement, 251       247-254

CHAPTER VII

ENUCLEATION OF THE GLOBE AND ALLIED OPERATIONS

  Enucleation, 255. Evisceration, 257. Mules’s Operation, 259.
    Frost’s Operation, 259. Operations upon the Socket after
    Removal of the Eye--_Paraffin Injection_, 260. Operations for
    Restoration of a Contracted Socket--_Skin-grafting_, 261;
    _Inclusion of Flaps_ (_Maxwell’s Operation_), 261           255-262

CHAPTER VIII

OPERATIONS UPON THE EYELIDS

  Surgical Anatomy, 263. Suture of Wounds of the Eyelids, 263.
    Operations for Ankyloblepharon, 264; for Symblepharon, 264.
    Upon the Palpebral Aperture, 265--_Canthoplasty_, 265;
    _Canthotomy_, 265; _Canthorrhaphy_, 265; _Tarsorrhaphy_, 266.
    Ptosis Operations, 267; _Shortening the Eyelid by Excision of
    a portion of the Tarsal Plate_, 267. _Attachment of the Lid to
    the Occipito-frontalis Muscle_, 268. Advancement of the
    Levator Palpebræ Muscle, 272. Grafting a portion of the
    Superior Rectus into the Lid, 273                           263-274

CHAPTER IX

OPERATIONS FOR ENTROPION, REPAIR OF THE EYELIDS, TRICHIASIS, AND
ECTROPION

  Electrolysis, 275. Skin and Muscle Operation, 275. Rectification
    of a Faulty Curvature of the Tarsus--_Burow’s Operation_, 276;
    _Streatfield’s Operation_, 277. Transplantation of the
    Lash-bearing Area--Arlt’s Operation, 278. Ectropion
    Operations, 279--for Passive Ectropion, 280; _Snellen’s Suture
    Method_, 280; _Fergus’s Operation_, 281; _Kuhnt’s Operation_,
    281; _Argyll Robertson’s Operation_, 282. For the Active or
    Cicatricial Form, 284; _VY Operation_, 284; _Denonvillier’s
    Operation_, 285; _Fricke’s Operation_, 285; _Thiersch’s
    Skin-grafting_, 287. Repair of large Losses of Substance from
    the Eyelids, 287; _De Vincentiis’ Operation_, 287;
    _Dieffenbach’s Operation_, 288                              275-289

CHAPTER X

OPERATIONS UPON THE LACHRYMAL APPARATUS

  For the Relief of Lachrymal Obstruction, 290--_Dilatation of the
    Canaliculus_, 290; _Slitting the Canaliculus_, 291; _Syringing
    the Lachrymal Duct_, 292; _Probing the Lachrymal Duct_, 292;
    _the Insertion of Styles_, 293. For Obliteration of the
    Canals, 294; _Obliteration of the Canaliculi_, 294; _Excision
    of the Lachrymal Sac_, 294. Opening a Lachrymal Abscess, 297.
    Operations upon the Lachrymal Gland--_Removal of the Palpebral
    Portion_, 298; _Removal of the Orbital Portion_, 299.
    Operations upon the Orbit--Exploration of the Orbit
    (Krönlein’s Method), 299; Evisceration of the Orbit, 301;
    Opening an Orbital Abscess, 301                             290-301


SECTION III

OPERATIONS UPON THE EAR

By HUNTER F. TOD, M.A., M.D. (Cantab.), F.R.C.S. (Eng.)

Aural Surgeon to the London Hospital.

CHAPTER I

EXAMINATION OF THE EAR: GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS

  Examination of the Ear, 305--_Sources of Illumination_, 305;
    _Technique of Examination_, 306; _Method of cleansing the
    Ear_, 307. General Considerations with regard to
    Operations--_Preliminary Surgical Toilet_, 309; _Anæsthesia_,
    310. Position of Patient and Surgeon, 313                   305-313

CHAPTER II

OPERATIONS UPON THE EXTERNAL AUDITORY CANAL

  Operations for Furunculosis, 314. Removal of Exostoses from the
    External Meatus, 316. Removal of Foreign Bodies--_by
    Syringing_, 322; _by Instruments_, 323; _by Post-aural
    Incision_, 326; _by Operation upon the Mastoid_, 327.
    Operations for Stenosis of the External Meatus, 328.
    Operations for Atresia, 330; for Aural Polypus, 331         314-334

CHAPTER III

OPERATIONS UPON THE TYMPANIC MEMBRANE AND WITHIN THE TYMPANIC CAVITY

  Surgical Anatomy of the Tympanum, 335. Paracentesis, 336.
    Artificial Perforation of the Tympanic Membrane, 340. Division
    of the Anterior Ligament, 341. Division of the Posterior Fold,
    341. Intratympanic Operations, 342; _Division of Adhesions_,
    342; _Tenotomy of the Tensor Tympani_, 346; _Tenotomy of the
    Stapedius_, 347. Removal of Granulations from the Tympanic
    Cavity, 348. Operations upon the Ossicles--_Direct
    Mobilization_, 349; _Removal of the Ossicles_, 351          335-363

CHAPTER IV

OPERATIONS UPON THE EUSTACHIAN TUBE

  Catheterization, 364. Passing of the Eustachian Bougie, 369.
    Washing out the Tympanic Cavity through the Eustachian Tube,
    372                                                         364-372

CHAPTER V

OPERATIONS UPON THE MASTOID PROCESS: WILDE’S INCISION AND SCHWARTZE’S
OPERATION

  Surgical Anatomy, 373. History of the Mastoid Operation, 375.
    Wilde’s Incision, 377. Schwartze’s Operation, 378. Treatment
    of Special Conditions--_in an Infant_, 389; _Subperiosteal
    Abscess_, 389; _Bezold’s Mastoid Abscess_, 389; _Necrosis_,
    390; _Osteomyelitis_, 390                                   373-390

CHAPTER VI

THE COMPLETE MASTOID OPERATION

  Methods of Operation, 392; _Küster-Bergmann (Schwartze-Stacke)
    Operation_, 393; _Wolf’s Operation_, 396; _Stacke’s
    Operation_, 397; _Preservation of the Ossicles and Tympanic
    Membrane_, 399. The Formation of Post-meatal Skin Flaps, 401.
    Closure of the Wound, 404. Skin-grafting after the Mastoid
    Operation, 405. After-treatment of the Case, 410. Difficulties
    and Dangers of the Operation, 412. Results, 415             391-416

CHAPTER VII

OPERATIONS UPON THE LABYRINTH

  General Considerations, 417. Indications, 417. Surgical Anatomy,
    420. Methods of Operating, 421; _Curetting a Localized Lesion
    of Wall_, 421; _Opening the Vestibule_, 422; _Removal of the
    Cochlea_, 424; _Extirpation of the Labyrinth_, 425          417-428

CHAPTER VIII

OPERATIONS FOR EXTRA-DURAL ABSCESS AND MENINGITIS OF OTITIC ORIGIN

  On Intracranial Complications in General, 429. Operations for
    Extra-dural Abscess, 430. Operations for Meningitis of Otitic
    Origin, 433                                                 429-438

CHAPTER IX

OPERATIONS FOR LATERAL SINUS THROMBOSIS OF OTITIC ORIGIN

  General Considerations, 439. Exposure of the Lateral Sinus, 440.
    Opening of the Lateral Sinus, 442. Ligature of the Jugular
    Vein, 446. Exposure of the Jugular Bulb, 454                439-458

CHAPTER X

OPERATIONS FOR INTRACRANIAL ABSCESS OF OTITIC ORIGIN

  Indications, 459. Operation, 460. After-treatment, 469.
    Complications, 469. Prognosis and subsequent Progress, 470.
    Recurrence of Symptoms, 471                                 459-471


SECTION IV

OPERATIONS UPON THE LARYNX AND TRACHEA

By W. DOUGLAS HARMER, M.C. (Cantab.), F.R.C.S. (Eng.)

Surgeon to the Throat and Nose Department, St. Bartholomew’s Hospital.

CHAPTER I

ENDOLARYNGEAL OPERATIONS

  Indications, 475. Operation by Indirect Laryngoscopy, 477.
    Operation by Direct Laryngoscopy, 479                       475-486

CHAPTER II

EXTRA-LARYNGEAL OPERATIONS

  Thyrotomy, 487. Hemi-laryngectomy, 495. Anatomy of the Laryngeal
    Lymphatics, 496. Total Laryngectomy, 498. Comparative Results
    of Extra-laryngeal Operations, 502. Infrathyreoid Laryngotomy,
    510                                                         487-516

CHAPTER III

OPERATIONS UPON THE TRACHEA

  Tracheotomy, 517; _in Diphtheria_, 526; _in Conditions other
    than Diphtheria_, 544. Tracheo-fissure and Resection of the
    Trachea, 546                                                517-548

CHAPTER IV

INTUBATION OF THE LARYNX

  Intubation v. Tracheotomy in Diphtheria, 549. Indications, 552.
    Operation, 553. Difficulties, 555. After-treatment, 556.
    Complications, 557                                          549-558

CHAPTER V

TRACHEOSCOPY AND BRONCHOSCOPY

  Indications, 559. Tracheoscopy, 560. Upper Bronchoscopy, 562.
    Lower Bronchoscopy, 562. Complications, 563. Results, 566
                                                                559-566


SECTION V

OPERATIONS UPON THE NOSE AND ITS ACCESSORY CAVITIES

By StCLAIR THOMSON, M.D., F.R.C.P. (Lond.), F.R.C.S. (Eng.)

Professor of Laryngology and Physician for Diseases of the Throat,
King’s College Hospital, London.

CHAPTER I

GENERAL CONSIDERATIONS IN REGARD TO OPERATIONS UPON THE NOSE AND
NASO-PHARYNX

  Sources of Illumination, 569. Local Anæsthesia, 572. Local
    Ischæmia, 573. Bleeding and its Control, 574. The Protection
    of the Lower Air-passages from the Descent of Blood, 576.
    Shock, 577. Sepsis and other Complications, 577. Asepsis, 578.
    After-treatment, 578. Cleansing the Nose, 579. After-results,
    580                                                         569-580

CHAPTER II

OPERATIONS FOR INJURIES, DEFORMITIES, FOREIGN BODIES, AND RHINOLITHS:
OPERATIONS UPON THE TURBINALS: OPERATIONS IN SYPHILIS AND LUPUS

  Operations for Injuries to the Nose--Fractures of the Nasal
    Bones and Septum, 581. For Congenital Occlusion of the
    Nostrils, 582. Removal of Foreign Bodies, 584; of Rhinoliths,
    586. Operations upon the Turbinals, 586; _upon the Inferior
    Turbinal_, 587; _upon the Middle Turbinal_, 592. For the
    Results of Syphilis--_Sequestrotomy_, 594; _Post-syphilitic
    Adhesions of the Velum_, 595. For Tuberculosis, 596         581-596

CHAPTER III

OPERATIONS UPON THE NASAL SEPTUM

  For Deformities--_Removal of Spurs_, 597; _Perforating the
    Septum_, 598. For Simple Deviation, 598; _Gleason-Watson
    Operation_, 599; _Asch’s Operation_, 599; _Moure’s Operation_,
    599. For Combined Bony and Cartilaginous Deformity--Submucous
    Resection, 601. Complementary Operations, 610. For Perforation
    of the Nasal Septum, 611. For Abscess, 612. For Hæmatoma, 612
                                                                597-612

CHAPTER IV

OPERATIONS FOR REMOVAL OF NASAL GROWTHS THROUGH THE NOSTRILS: OPERATIONS
FOR OBTAINING DIRECT ACCESS TO THE NASAL CAVITIES AND NASO-PHARYNX

  Removal by the Snare, 613. Removal by Forceps and Curettes, 615.
    Lateral Rhinotomy (Moure’s Operation), 618. Rouge’s Operation,
    622. Combination of Moure’s and Rouge’s Operations, 625.
    Extension of Rouge’s Operation to allow of Access to the
    Maxillary Antrum, 625. Other Methods, 625                   613-625

CHAPTER V

OPERATIONS UPON THE ACCESSORY NASAL SINUSES

  Operations upon the Maxillary Sinus--_Catheterizing the
    Maxillary Sinus_, 626; _Puncturing from the Nose_, 626; _from
    the Alveolar Margin_, 628. _Operation through the Canine Fossa
    only_, 631; _the Caldwell-Luc Radical Operation_, 631;
    _Drainage through the Nasal Wall only_, 637. Operations upon
    the Frontal Sinus--_Catheterizing and Washing out the Frontal
    Sinus_, 638; _Opening the Frontal Sinus in Acute Suppuration_,
    642; _Killian’s Operation_, 642; _the Ogston-Luc Operation_,
    651; _Kuhnt’s Operation_, 653. Operations upon the Sphenoidal
    Sinus, 653; _Sounding and Washing out_, 653; _Opening the
    Sphenoidal Sinus_, 656. Operation in Multiple Sinus
    Suppuration, 659                                            626-660

CHAPTER VI

OPERATIONS INVOLVING THE NASO-PHARYNX: OPERATIONS FOR RETROPHARYNGEAL
ABSCESS: OPERATIONS FOR NASO-PHARYNGEAL ADENOIDS

  Methods of obtaining Access to the Naso-pharynx through the
    Nose, 661; through the Mouth, 662. Retropharyngeal Abscess,
    664. Removal of Naso-pharyngeal Adenoids, 665               661-672




LIST OF ILLUSTRATIONS


    FIG.                                                           PAGE

    1. Secondary Cancer of the Ovary                                 15

    2. Secondary Cancer of the Ovary in Section                      16

    3. An Infected Fallopian Tube                                    22

    4. A Tuberculous Fallopian Tube and Ovary: Entire and in Section 23

    5. Primary Cancer of the Fallopian Tube                          27

    6. A Section of Primary Cancer of the Fallopian Tube             27

    7. A Gravid Fallopian Tube                                       30

    8. A Gravid Fallopian Tube, containing Twins                     31

    9. A Diagram to show the Arterial Supply of the Uterus           37

   10. A Fibroid growing near the Right Uterine Cornu                38

   11. The Mattress Suture                                           39

   12. The Stump after Subtotal Hysterectomy                         39

   13. A Bicornate Uterus                                            42

   14. A Bicornate Uterus shortly after Delivery                     43

   15. Villous Disease of the Uterus                                 45

   16. An Adenomyomatous Uterus                                      54

   17. An Adenomyomatous and Tuberculous Uterus                      55

   18. Uterus with the Decidua _in situ_                             58

   19. Cancer of the Uterus                                          64

   20. The Fundus of a Uterus                                        68

   21. Portion of Ovary and Fallopian Tube                           71

   22. A Uterus distorted by Fibroids                                76

   23. A Gravid Uterus in Sagittal Section                           79

   24. Diagram representing a Gunshot Injury of the Uterus           90

   25. The Pulmonary Artery and Adjacent Part of the Lung and
        Trachea                                                     103

   26. A Pair of Pressure Forceps                                   106

   27. The Relation of Parts after Ricard’s Operation of
       Uretero-cysto-neostomy                                       114

   28. A Uterus in Sagittal Section                                 119

   29. Patient prepared for Operation                               126

   30. Complete Laceration of the Perineum                          128

   31. Long-handled Sharp-pointed Scissors curved on the flat       129

   32. Complete Laceration of the Perineum                          129

   33. Complete Laceration of the Perineum                          130

   34. Laceration of the Pelvic Floor                               131

   35. Repair of a Lacerated Perineum, with Non-union of the
       Sphincter Ani, before a Plastic Operation                    132

   36. Repair of a Laceration of the Perineum after a Plastic
       Operation                                                    133

   37. Auvard’s Self-retaining Speculum                             135

   38. Knives for freshening the Edges of a Vesico-vaginal Fistula  135

   39. Toothed Forceps for use in Vesico-vaginal Fistula            135

   40. Emmett’s Hook                                                136

   41. Sims’s Operation for the Repair of a Vesico-vaginal Fistula  136

   42. Simon’s Operation for the Repair of a Vesico-vaginal Fistula 137

   43. Repair of a Vesico-vaginal Fistula by _Dédoublement_         138

   44. Repair of a Vesico-vaginal Fistula. Sims’s Operation         139

   45. Stoltz’s Operation for Cystocele                             141

   46. Sims’s Vaginal Rest                                          144

   47. Pozzi’s Retractors                                           145

   48. Anterior Colpotomy                                           146

   49. Martin’s Trochar for Pelvic Abscess                          147

   50. The Passage of the Uterine Sound. _Introduction of the point
       into the external os uteri_                                  149

   51. The Passage of the Uterine Sound. _Commencement of the tour
       de maître_                                                   149

   52. The Passage of the Uterine Sound. _Completion of the tour de
       maître_                                                      150

   53. The Passage of the Uterine Sound. _Entry of the sound into
       the uterine cavity_                                          150

   54. Chronic Uterine Inversion                                    151

   55. Volsella for fixing the Cervix                               153

   56. Hegar’s Dilators (three sizes) for dilatation of the Cervix
       Uteri                                                        153

   57. Metal Bougies for dilatation of the Cervix                   154

   58. Bozemann’s Double-channelled Tube                            155

   59. Budin’s Celluloid Catheter                                   155

   60. Murray’s Flushing Curette; Blunt Curette                     155

   61. Dilatation of the Cervix                                     157

   62. Marckwald’s Operation for Congenital Hypertrophy of the
       Cervix                                                       161

   63. Hegar’s Operation for Supravaginal Elongation of Cervix      161

   64. Emmett’s Scissors (left) for Trachelorrhaphy                 162

   65. Trachelorrhaphy                                              163

   66. Pedunculated Fibroid Polypi in various Stages of Extrusion   165

   67. Wire Écraseur                                                166

   68. Submucous Fibro-myomata, capable of Treatment by
       _Morcellement_                                               167

   69. Galabin’s Broad-ligament Needle (right)                      169

   70. Jessett’s Broad-ligament Needle                              169

   71. Vaginal Hysterectomy                                         170

   72. Vaginal Hysterectomy. _Final stage_                          171

   73. Schauta’s Needle-holder                                      172

   74. Window of the Operating Theatre, King’s College Hospital     178

   75. Bull’s-eye Electric Hand-lamp                                179

   76. Lang’s Eye Speculum                                          181

   77. Undine for washing out the Conjunctival Sac                  182

   78. Cataract Extraction                                          183

   79. Sympathetic Ophthalmia                                       184

   80. Cystoid Scar after Glaucoma Iridectomy                       184

   81. An Eye Bandage                                               185

   82. A Pressure Bandage                                           185

   83. A Lens Three Weeks after Needling                            187

   84. Anatomy of the Anterior Segment of the Eye                   188

   85. Eye Speculum                                                 190

   86. Fixation Forceps                                             190

   87. Secondary Cataract                                           192

   88. Capsulotomy. _The method of incising the capsule_            193

   89. Capsulotomy. _The method of dividing a dense band_           193

   90. Iris Forceps                                                 196

   91. Iris Scissors                                                196

   92. A Vectis                                                     196

   93. Pagenstecher’s Spoon                                         196

   94. Lens Extraction                                              197

   95. The Knife entering the Anterior Chamber in Cataract
       Extraction                                                   198

   96. Making the Counter-puncture in Cataract Extraction           198

   97. Incision and Iridectomy in Cataract Extraction               199

   98. Opening the Capsule with Forceps in Cataract Extraction      200

   99. Cataract Extraction                                          201

  100. McKeown’s Irrigation Apparatus for washing out the Anterior
       Chamber                                                      202

  101. Subconjunctival Extraction                                   205

  102. Iridotomy                                                    212

  103. Iridotomy                                                    212

  104. Iridotomy by Ziegler’s Method                                213

  105. Iridotomy by Ziegler’s Method                                214

  106. Iridotomy by Ziegler’s Method                                214

  107. Optical Iridectomy                                           215

  108. Optical Iridectomy                                           216

  109. Optical Iridectomy                                           217

  110. The Normal Angle of the Anterior Chamber                     218

  111. The Angle of the Anterior Chamber from a Case of Recent
       Glaucoma                                                     219

  112. The Angle of the Chamber in a Case of Chronic Glaucoma       220

  113. Iridectomy for Glaucoma                                      221

  114. Iridectomy for Glaucoma                                      222

  115. Iridectomy for Glaucoma                                      222

  116. Iridectomy for Glaucoma                                      223

  117. Glaucoma Iridectomy                                          224

  118. Prolapse of the Iris through a Punctured Wound of the Cornea 226

  119. Cyclo-dialysis Operation                                     229

  120. Cyclo-dialysis Operation                                     230

  121. Lagrange Operation for the Production of a Cystoid Scar in
       Chronic Glaucoma                                             232

  122. Lagrange Operation for Chronic Glaucoma                      232

  123. Hollow Needle used for Paracentesis of the Anterior Chamber  234

  124. Author’s Chair for the Localization of Foreign Bodies in the
       Eye by the X-rays                                            236

  125. Small Electro-magnet for extracting Pieces of Steel from the
       Eye                                                          238

  126. Large Electro-magnet                                         239

  127. Electro-cautery                                              241

  128. Tattooing Needles                                            243

  129. Graddy’s Forceps                                             245

  130. Tenotomy                                                     249

  131. Tenotomy by the Open Method                                  250

  132. Prince’s Forceps for Advancement                             252

  133. Advancement by the Three-stitch Method                       253

  134. Enucleation                                                  256

  135. Mules’s Operation. _First step_                              258

  136. Mules’s Operation.                                           258

  137. Maxwell’s Operation for Contracted Socket. _First step_      262

  138. Maxwell’s Operation. _Final step_                            262

  139. Canthorrhaphy                                                266

  140. Harman’s Operation for Ptosis                                270

  141. Ptosis Operation. Panas’                                     271

  142. Ptosis Operation. Advancement of the Levator Palpebræ        272

  143. Ptosis Operation. Advancement of the Levator Palpebræ        273

  144. Treacher Collins’s Entropion Forceps                         276

  145. Lid Clamp                                                    277

  146. Streatfield’s Entropion Operation                            277

  147. Arlt’s Operation for Trichiasis                              278

  148. Snellen’s Sutures                                            280

  149. Fergus’s Operation for Slight Ectropion of the Lower Lid     281

  150. Modified Kuhnt’s Operation for Severe Ectropion. _Second
       step_                                                        282

  151. Modified Kuhnt’s Operation. _Fourth step_                    282

  152. Argyll Robertson’s Operation for Ectropion. _Second step_    283

  153. Argyll Robertson’s Operation for Ectropion. _Final step_     283

  154. VY Operation for Ectropion of the Lower Lid due to a Scar.
       _First step_                                                 284

  155. VY Operation for Ectropion. _Final step_                     284

  156. Denonvillier’s Operation for Ectropion of the Lower Lid.
       _First step_                                                 285

  157. Denonvillier’s Operation for Ectropion                       285

  158. Fricke’s Operation                                           286

  159. De Vincentiis’ Operation to replace the Loss of the Inner
       Portion of the Lower Lid                                     288

  160. De Vincentiis’ Operation completed                           288

  161. Modified Dieffenbach’s Operation to replace the Loss of the
       whole Lower Lid. _First step_                                289

  162. Modified Dieffenbach’s Operation. _Third step_               289

  163. Canaliculus Dilator                                          291

  164. Canaliculus Knife                                            291

  165. Lachrymal Syringe                                            292

  166. Muller’s Retractor for Excision of the Lachrymal Sac         295

  167. Axenfeld’s Retractor for Excision of the Lachrymal Sac       295

  168. Excision of the Lachrymal Sac                                296

  169. Excision of the Lachrymal Sac                                296

  170. Excision of the Palpebral Portion of the Lachrymal Gland     298

  171. Clar’s Lamp                                                  305

  172. Gruber’s Aural Speculum                                      306

  173. Angular Spring Forceps                                       306

  174. Examination of the Ear                                       307

  175. Aural Forceps holding Cotton-wool                            307

  176. Milligan’s Intratympanic Syringe                             308

  177. Neumann’s Syringe for Subcutaneous Injection                 311

  178. Burkhardt-Merian’s Aural Instrument                          315

  179. Crocodile Forceps                                            324

  180. Imray’s Scoop for extracting a Foreign Body                  325

  181. Aural Probe                                                  332

  182. Wilde’s Aural Snare                                          332

  183. Wilde’s Snare being passed round an Aural Polypus            333

  184. Wilde’s Snare gripping the Neck of Polypus                   334

  185. Polypus arising from the Attic Region                        334

  186. Anatomical Preparation of the Middle Ear                     336

  187. Paracentesis Knife held in position in the Hand              338

  188. Tympanic Membrane showing Incision in Acute Suppuration of
       the Middle Ear                                               339

  189. Line of Incision in Acute Suppuration of the Attic           339

  190. Lines of Incisions in Intratympanic Operations               341

  191. Cutting through Intratympanic Adhesions                      343

  192. Free Edge of Tympanic Membrane cut through                   344

  193. Sexton’s Instrument                                          345

  194. Method of using Siegle’s Speculum                            345

  195. Division of Intratympanic Adhesion with Excision of Handle
       of Malleus                                                   346

  196. Schwartze’s Tenotomy Knife                                   347

  197. Lucae’s Probe                                                350

  198. To show Sites of Perforation in Attic Suppuration and Caries
       of the Ossicles                                              351

  199. Removal of the Malleus by Wilde’s Snare. _First position_    354

  200. Removal of the Malleus by Wilde’s Snare. _Second position_   354

  201. Delstanche’s Ring-knife                                      354

  202. Removal of Malleus by Delstanche’s Ring-knife                355

  203. Ludwig’s Incus Hook                                          356

  204. Zeroni’s Incus Hook                                          356

  205. Removal of Incus by Zeroni’s Hook                            356

  206. Pfau’s Attic Punch-forceps                                   357

  207. Removal of the Outer Attic-wall with Forceps                 358

  208. Diagrammatic Section to show Correct and Wrong Positions of
       Incus Hook                                                   360

  209. Eustachian Catheter                                          365

  210. Passing the Eustachian Catheter                              366

  211. Passing the Eustachian Catheter                              366

  212. Passing the Eustachian Catheter                              367

  213. Passing the Eustachian Catheter                              367

  214. Author’s Graduated Eustachian Bougie                         370

  215. Left Temporal Bone, showing Anatomy of the Middle Ear and
       Mastoid Process                                              374

  216. Diagram showing Position of Sink Incisions in Post-aural
       Operations                                                   380

  217. Schwartze’s Operation                                        381

  218. Schwartze’s Operation                                        383

  219. Schwartz’s Seeker                                            384

  220. Schwartze’s Operation completed                              385

  221. The ‘Radical’ Mastoid Operation                              393

  222. Stacke’s Protector                                           394

  223. The ‘Radical’ Mastoid Operation                              395

  224. Pfau’s Curette for the Eustachian Tube                       396

  225. The ‘Radical’ Mastoid Operation completed                    397

  226. Wolf’s Operation                                             398

  227. Stacke’s Operation                                           399

  228. Post-meatal Skin Flaps                                       400

  229. Post-meatal Skin Flaps                                       401

  230. Closure of Wound after ‘Radical’ Mastoid Operation           402

  231. Körner’s Post-meatal Flap                                    403

  232. Panse’s Post-meatal Flap                                     403

  233. Stacke’s Post-meatal Flap                                    403

  234. Skin-grafting of Mastoid Wound Cavity after Operation        407

  235. Ballance’s ‘Stopper’ for pushing in the Graft                407

  236. Pipette for sucking Air and Fluid from beneath the Graft     408

  237. Skin-grafting of Mastoid Wound Cavity after Operation        408

  238. Skin-grafting of Mastoid Wound Cavity after Operation        409

  239. Posterior Portion of Skin Graft covering Outer Surface of
       Wound Cavity                                                 409

  240. Diagram to show Exposure of the Semicircular Canals          423

  241. Operation upon the Labyrinth                                 424

  242. Extirpation of the Labyrinth                                 425

  243. Method of Removal of Bone by the Forceps                     435

  244. Diagram to show the usual Points at which the Lateral Sinus
       is primarily infected                                        443

  245. The Lateral Sinus exposed and opened                         445

  246. Incision for Exposure of the Internal Jugular Vein           448

  247. Exposure of the Internal Jugular Vein high up                449

  248. Ligature of the Internal Jugular Vein low down in the Neck   451

  249. Free Exposure of the Lateral Sinus, which has been incised,
       with Ligature of the Internal Jugular Vein                   452

  250. Method of suturing the Open End of the Internal Jugular Vein
       in the Neck                                                  453

  251. Topography of the Auditory Region of the Skull               462

  252. Exploration for a Temporo-sphenoidal Abscess                 463

  253. Exploration for a Cerebellar Abscess                         467

  254. Skiagram showing a Tumour of the Larynx                      476

  255. Horsford’s Instrument for transfixing the Epiglottis         478

  256. Multiple Papillomata of the Larynx                           480

  257. Tube-spatulæ used for Laryngoscopy                           481

  258. Removal of Multiple Papillomata by Direct Laryngoscopy       483

  259. Intrinsic Tumour of the Larynx                               488

  260. Extrinsic Tumour of the Larynx                               488

  261. Thyrotomy                                                    491

  262. Total Laryngectomy                                           499

  263. Total Laryngectomy. Gluck’s Method                           501

  264. Infrathyreoid Laryngotomy                                    510

  265. Instruments for Laryngotomy                                  512

  266. Laryngotomy Canula fitted with Inner Tube                    513

  267. Skiagram showing an Angular Tracheotomy Tube in the Trachea  518

  268. Anatomy of the Larynx and Trachea and the Position of
       Incisions for the Operations in this Region                  524

  269. Tubes for Tracheotomy                                        527

  270. Trachea showing Ulceration caused by a Badly Fitting Tube    537

  271. Stenosis following Tracheotomy                               539

  272. Tubes used in the Treatment of Stenosis of the Larynx        540

  273. Trachea showing Ulceration into the Innominate Artery after
       Tracheotomy                                                  541

  274. Aneurism of the Aorta perforating the Trachea                542

  275. Sarcoma of the Trachea                                       547

  276. Instruments for Intubation of the Larynx                     553

  277. Instruments for Bronchoscopy                                 561

  278. Instruments for Bronchoscopy                                 562

  279. Upper Bronchoscopy with the Patient in the Dorsal Position   564

  280. Lower Bronchoscopy with the Patient in the Dorsal Position   565

  281. Laryngoscope Lamp                                            570

  282. Clar’s Electric Light                                        571

  283. Frontal Search-light                                         571

  284. Meyer’s hollow Vulcanite Nasal Splint                        582

  285. Krause’s Trochar and Canula                                  583

  286. Nasal Punch-forceps                                          583

  287. Post-nasal Forceps                                           584

  288. Nasal Dressing Forceps                                       585

  289. First Step in removing the Anterior End of the Inferior
       Turbinal, which is seen to have undergone Polypoid
       Degeneration                                                 587

  290. Nasal Scissors                                               588

  291. Amputation of the Posterior End of the Inferior Turbinal     590

  292. Nasal Spokeshave                                             591

  293. First Step in the Removal of the Anterior End of the Middle
       Turbinal                                                     593

  294. Second Step in the Removal of the Anterior End of the Middle
       Turbinal                                                     593

  295. Cresswell Baber’s Nasal Saw                                  597

  296. The Gleason-Watson Operation for Deformity of the Septum     599

  297. Asch’s Cutting Scissors                                      600

  298. Lake’s Rubber Splint                                         600

  299. Bayonet Knife                                                604

  300. Incision for Submucous Resection of the Septum               604

  301. Making the Incision from the Convex Side in Submucous
       Resection of the Septum                                      605

  302. Dull-edged Detacher                                          605

  303. Denudation of the Septum in Submucous Resection              606

  304. Complete Denudation of the Deviated Septum                   606

  305. Ballenger’s Swivel Septum Knife                              607

  306. The Method of employing Ballenger’s Swivel Septum Knife      607

  307. Submucous Resection of the Septum                            608

  308. Submucous Resection of the Septum                            609

  309. Submucous Resection of the Septum                            609

  310. Semi-diagrammatic Transverse Section of the Nose             610

  311. Operation for Perforation of the Septum                      611

  312. Nasal Snare                                                  613

  313. Luc’s Nasal Forceps                                          616

  314. Tongue Clip                                                  617

  315. Incisions for Lateral Rhinotomy (Moure’s Operation)          619

  316. The Area of Bone removed in Lateral Rhinotomy                620

  317. Lateral Rhinotomy                                            621

  318. Rouge’s Operation. _First stage_                             623

  319. Rouge’s Operation. _Second stage_                            624

  320. Catheterizing the Maxillary Sinus                            626

  321. Lichtwitz’s and Moritz Schmidt’s Antrum Needles              627

  322. Puncturing the Maxillary Sinus                               627

  323. Antrum Drills                                                628

  324. Solid Rubber Obturators                                      628

  325. Antrum Nozzle                                                628

  326. Washing out the Maxillary Sinus from an Alveolar Opening     629

  327. The Incision in the Caldwell-Luc Operation upon the
       Maxillary Sinus                                              631

  328. The Caldwell-Luc Operation upon the Maxillary Sinus          632

  329. Opening the Maxillary Sinus from the Nose                    633

  330. Carwardine’s Punch-forceps                                   634

  331. The Opening into the Maxillary Sinus from the Inferior
       Meatus of the Nose                                           635

  332. Denker’s Operation                                           636

  333. Catheterizing the Frontal Sinus                              639

  334. Radiograph to show the Value of the Röntgen Rays             640

  335. Radiograph showing Canula in the Frontal Sinus               641

  336. Killian’s Operation upon the Frontal Sinus                   643

  337. Killian’s Operation upon the Frontal Sinus                   644

  338. Periosteal Elevators                                         645

  339. Killian’s Triangular Curved Chisel                           645

  340. Citelli’s Bone-forceps                                       646

  341. Hajek’s Bone-forceps                                         646

  342. Killian’s Operation upon the Frontal Sinus                   647

  343. Radiograph of the Sphenoidal Sinus                           654

  344. Radiograph of the Sphenoidal Sinus                           655

  345. Catheterizing the Sphenoidal Sinus                           656

  346. Killian’s Long Nasal Speculum                                657

  347. Radiograph showing a Probe in the Sphenoidal Sinus           658

  348. Sphenoidal Punch-forceps                                     659

  349. Adenoid Curette                                              668

  350. The Removal of Naso-pharyngeal Adenoids                      668

  351. Removal of Naso-pharyngeal Adenoids                          669




                              SECTION I

                      OPERATIONS UPON THE FEMALE
                            GENITAL ORGANS


                                PART I

                  ABDOMINAL GYNÆCOLOGICAL OPERATIONS

                                  BY

                  JOHN BLAND-SUTTON, F.R.C.S. (Eng.)

  Surgeon to the Middlesex Hospital and Senior Surgeon to the Chelsea
                      Hospital for Women, London




CHAPTER I

CŒLIOTOMY


When the abdomen is opened for the purpose of removing a diseased
viscus, the operation receives a specific name, such as nephrectomy,
gastrectomy, splenectomy, and so forth. In many instances the abdomen is
occupied by a tumour which defies the skill of the surgeon to localize
to any particular organ until it is exposed to view through an incision;
it is usual to apply the term cœliotomy to an operation of this kind,
and it merely implies that the belly is opened by a cut. Cœliotomy is a
useful expression, because many abnormal conditions arise in the abdomen
which require treatment through an incision in its walls which do not
lend themselves to an expressive term, for example, the removal of
omental cysts, the evacuation of pus, blood, or the removal of foreign
bodies, &c. It is true that a cœliotomy performed on an uncertain
diagnosis may become a colectomy, ovariotomy, hysterectomy, &c., and the
preliminary step to the performance of the operations to be described in
this section is an abdominal incision, or cœliotomy. For whatever
purpose a cœliotomy is required in the treatment of diseases of the
female pelvic organs, the preparation of the patient and the initial
steps are alike; it will therefore be convenient to describe the manner
of carrying them out.

=The preparation of the patient.= It rarely happens that an operation is
so urgent as to leave little time for a thorough preparation of the
patient. It is desirable that the preliminaries should occupy two days
at least. During this time the patient is kept in bed and the bowels are
freely evacuated, either by calomel at night, with a saline draught in
the morning, or by an ounce of castor oil.

On the morning of the operation the large bowel is thoroughly emptied by
a soap and water enema, care being taken to use soft soap, to avoid
producing a pimply eruption known as the ‘enema rash’.

It is well known that injuries to the abdominal organs, whether by
accident or in the course of a surgical operation, are liable to be
followed by septic parotitis. Recent writers attribute this complication
to microbic infection of the ducts of the salivary glands (see p. 99);
its occurrence may be avoided by including careful cleaning of the teeth
among the preliminaries advisable for an abdominal operation. It is such
a simple and comfortable ordinance that there is no reason for not
following it.

The preparation of the skin needs to be very thoroughly carried out.
After a warm bath the hair is shaved from the abdomen, pubes and vulva,
and the skin is well washed with warm soapy water and swathed in gauze
compresses wrung out of a solution of perchloride of mercury, 1 in
5,000. These compresses remain for twelve hours. The abdomen is again
washed, and a second compress is applied which remains on until the
operation.

Occasionally patients object to have the abdomen and pubes shaved. In
such cases the hair can be easily removed by a depilatory. I have found
a powder prepared according to the following formula useful:--

Sodium monosulphide, 1 part; calcium oxide, 1 part; starch, 2 parts;
sufficient water is added to make a stiff paste, which is spread over
the parts. After five minutes it is washed off by means of a dab of
cotton-wool and the skin freely washed with warm water. This preparation
is only efficacious when freshly prepared.

The washing and application of compresses require care on the part of
the nurse, for some patients have skin so tender that it is easily
blistered, and a crop of small pustules is a source of inconvenience,
and leads to stitch-abscesses. In certain cases over-preparation may be
worse than no preparation.

When patients are advanced in years it is extremely necessary to protect
them from being chilled by undue exposure. It is well to clothe their
lower limbs in warm flannel garments or drawers made out of Gamgee
tissue. No open doors or windows should be permitted; though in summer
this is comfortable to the surgeon it may be disastrous to the patient.
In winter the temperature of an operating-room should not be below 65°F.
In this way ether pneumonia is best avoided.

In operations, such as oöphorectomy, ovariotomy and hysterectomy, it is
the rule not to operate during menstruation; experience has taught me
that operations performed during this period are not followed by evil or
untoward consequences, and for many years I have disregarded it.

Immediately before the patient is placed on the table the bladder should
be emptied naturally, or by means of a sterilized glass catheter.

In all pelvic operations it is a great advantage to employ nurses who
have had a special training in ‘abdominal nursing’.

=Basins and dishes.= All receptacles such as basins, pots, instrument
dishes and the like should be boiled. Mere rinsing or washing in warm
water is insufficient.

=Instruments.= These should be constructed of metal throughout, as this
enables them to be thoroughly sterilized by boiling. Needles and
scalpels may be enclosed in perforated metal boxes. Forceps and the
handles of scalpels are nickelled, and this keeps them bright. The
following instruments are necessary: Scalpel, twelve hæmostatic
forceps, dissecting forceps, two fenestrated forceps which are also
useful as sponge-holders, a volsella, six curved needles of various
sizes, two straight needles, silks of various thickness, and six dabs.

The surgeon should make a practice of employing a definite number of
instruments and dabs for all occasions, as it will save him much anxiety
in counting them at the end of the operation.

During the operation the instruments and silks are immersed straight
from the sterilizer in warm sterilized water.

=Suture and ligature material.= The most useful material at present
employed in pelvic surgery is silk. This material has a wide range of
usefulness, as it is employed to secure pedicles, for the ligature of
blood-vessels, and for sutures; it can be obtained of any thickness, and
is easily sterilized by boiling without impairing its strength. In
abdominal surgery there are four useful sizes, No. 1, 2, 4, and 6, of
the plaited variety of silk. The thread is wound on a glass spool and
boiled for one hour immediately before use. If any silk is left over
from the operation it may be reboiled once or twice without impairing
its strength. (The fate of silk ligatures is discussed on p. 117.) Many
surgeons employ catgut and hold it in high esteem. I regard it as an
unsatisfactory and dangerous material; moreover it cannot be boiled,
which is the simplest and safest method of making ligatures sterile.

=Dabs.= Nothing is so convenient for removing blood from a wound as
sponges; their absorbent property and softness are excellent, but they
are difficult to sterilize; therefore they are highly dangerous, and on
this account should be banished from surgery. An excellent substitute is
absorbent cotton-wool enclosed in gauze (Gamgee tissue). This material
can be cut to any size or folded into any shape, and is easily
sterilized by heat, or by boiling, without damage to its absorbent
properties.

For a cœliotomy six dabs are prepared of various sizes, according to the
nature of the case. These are boiled for one hour and then immersed in
sterilized warm water and washed from time to time in the course of the
operation.

I always employ six dabs, then there is no difficulty at the end of the
operation concerning their number. The dabs at the completion of the
operation are destroyed.

Many serious consequences have arisen from dabs and instruments
accidentally left in the peritoneal cavity after pelvic operations. This
subject is considered on p. 105.

The operator should remember that his responsibility in this matter is
determined by a decision in a Court of Law.

The employment of dry gauze dabs in abdominal operations is
objectionable because it is harsh and irritating to the peritoneum and
leads to the formation of adhesions.

=Gloves.= Increasing experience proves that gloves are most valuable in
securing freedom from sepsis. It is a very important matter that the
surgeon, the assistant, and the nurses who help at the operation should
wear rubber gloves boiled immediately before the operation for ten
minutes.

The wearing of gloves diminishes the mortality of the operation, and
minimizes its unpleasant and often dangerous sequelæ, such as
suppuration around sutures, septic emboli, tympanites, and the like.
Care must be taken to impress upon all who take part in an operation
that it is as essential to thoroughly wash and disinfect the hands
before inserting them in gloves as when no gloves are worn. It is also
necessary to warn nurses that the smallest hole in a glove renders it
useless.

To the operator thorough disinfection of the hands is of the highest
importance, for he may puncture or tear the gloves during the operation;
or a difficulty may arise in the course of it which will render it
advantageous for him to remove one or both gloves to overcome it. It is
with me a rule that if in the course of an operation it is necessary to
remove the gloves, I resume them for the final stages, and particularly
for the insertion of the sutures. The use of rubber gloves marks a most
important advance in operative surgery.

=The operating table.= In many cases of cœliotomy a table such as is
employed for the ordinary operations of surgery answers very well, but
for hysterectomy, oöphorectomy, and similar procedures it is a great
convenience to use a table on which the patient can be placed in the
Trendelenburg position, that is, with the pelvis raised, and the head
and shoulders lowered: this allows the intestines to fall towards the
diaphragm and leave the pelvis unencumbered. There are many varieties of
tables employed for this purpose. As these tables are made of metal, it
is necessary before the table is tilted to fix the patient’s arms
parallel with her trunk, otherwise they fall across the edge of the
table, and in some instances a troublesome paralysis of the muscles of
the upper limb has been the consequence.

It is worth while pointing out that most of the examples have happened
in the course of long operations (see Post-anæsthetic paralysis, p. 95).

=Anæsthesia.= The majority of surgeons employ a general anæsthetic, such
as ether, chloroform, or a mixture of chloroform and ether, in pelvic
operations. The most usual practice in London is to render the patient
unconscious with nitrous oxide gas and maintain the anæsthesia with
ether. It is a method which has given me the greatest satisfaction. As
a rule, it is wise whenever possible to employ an experienced
anæsthetist and trust to his judgment in regard to the selection of the
anæsthetic.

In exceptional cases pelvic operations such as ovariotomy and
hysteropexy have been successfully performed with the aid of intradural
injections of a solution of eucaine, novocaine, or stovaine.

=The incision.= The operation-area is isolated by sterilized towels and
the pelvis well tilted and so arranged as to face a good light. When the
patient is completely unconscious, the operator (standing usually on the
right side with the assistant opposite him) freely incises the wall of
the abdomen in the middle line between the umbilicus and the pubes (this
incision is conveniently termed the median subumbilical incision; its
length varies with the necessities of the case, but is usually 7 to 10
centimetres). The first cut generally exposes the aponeurotic sheath of
the rectus; any vessels that bleed freely require seizing with
hæmostatic forceps. The linea alba is then divided, but as it is very
narrow in this situation, the sheath of the right or left rectus muscle
is usually opened. Keeping in the middle line, the posterior layer of
the sheath is divided and the subperitoneal fat (which sometimes
resembles omentum) is reached; in thin subjects this is so small in
amount that it is scarcely recognizable, and the peritoneum is at once
exposed, and, as a rule, the urachus comes into view. In order to incise
the peritoneum without damaging the tumour, cyst, or intestine, a fold
of the membrane is picked up with forceps and cautiously pricked with
the point of a scalpel; air rushes in, destroys the vacuum, and
generally produces a space between the cyst (or intestines) and the
belly-wall; the surgeon then introduces his finger, and divides the
peritoneum to an extent equal to the incision in the skin.

It is important to remember that the bladder is sometimes pushed upward
by tumours, and lies in the subperitoneal tissue above the pubes; it is
then liable to be cut.

On entering the peritoneal cavity, the surgeon introduces his hand, and
proceeds to ascertain the nature of any morbid condition that he sees or
feels, or he evacuates any free fluid, blood, or pus which may be
present. Occasionally he finds that attempts to remove a tumour would be
futile or end in immediate disaster to the patient; then he desists and
closes the wound, and the procedure is classed as an exploratory
cœliotomy. Should a removable tumour, such as an ovarian cyst, an
echinococcus colony in the omentum, or the like be found, it is removed.

Before suturing the incision, the surgeon usually spreads the omentum
over the small intestine; occasionally he will be surprised to find this
structure, even in well-nourished women, represented by a mere fringe of
fatty tissue attached to the lower border of the transverse colon.

The recesses of the pelvis are then carefully mopped in order to remove
fluid, blood, or pus; the dabs and instruments are counted, and
preparations made to suture the incision.

=Misplaced viscera.= In addition to tumours and normal enlargement of
the uterus due to pregnancy, or an overfull bladder, there are certain
malformations as well as displacements of normal viscera the surgeon may
encounter in the pelvis which will, in some cases, cause him a certain
amount of embarrassment, such, for example, as a bifid uterus or a
spleen which has elongated its pedicle, or even twisted it, and, falling
so low in the abdomen as to occupy the pelvis, may even cause prolapse
of the uterus. In some of these cases it drags the tail of the pancreas
with it. The cæcum and the vermiform appendix often occupy the true
pelvis; in middle-aged and elderly women the transverse colon sometimes
forms a loop (the omega-loop), the extreme convexity of which often
reaches to the pelvis. I have seen the right lobe of the liver extend
into the pelvis, and come in contact with the unimpregnated uterus. It
is important to remember that a kidney sometimes occupies the hollow of
the sacrum; such a misplaced kidney has been removed under the
impression that it was a tumour. When a kidney occupies the pelvis it
lies behind the peritoneum as when it occupies its normal position in
the loin. A horseshoe kidney is a fertile source of divergent opinion in
diagnosis. A very large hydronephrosis simulates very closely an ovarian
cyst until exposed through an abdominal incision; in such a contingency
the operator performs nephrectomy; when the kidney is large enough to
resemble an ovarian cyst it can easily be removed through the median
incision.

A very distended stomach will reach the hypogastrium and has many times
been mistaken for an ovarian cyst; such a distended stomach has received
a thrust from an ovariotomy trocar and the operator has been astonished
to see food issue through the opening.

Tumours of the pelvic organs are often complicated with abnormal and
diseased conditions of the intestines, large and small; it is therefore
necessary for any one undertaking gynæcological abdominal operations to
be prepared to perform resections of the colon, enterorrhaphy,
gastro-jejunostomy, and the like when necessary.

Transposition of the viscera is a rare anomaly to encounter in the
course of an abdominal operation. I met with it once in 3,000
cœliotomies; the condition was recognized before operation.

=Closure of the wound.= There are about fifty methods known and
advocated for the closure of the median subumbilical incision, and the
following is a list of materials used by surgeons for this purpose:
silk, silkworm-gut, catgut, linen thread, and horsehair; silver, iron,
aluminium, bronze, and platinum wire, and Michel’s metal clips. The
object of these various methods and materials is to obtain a firm scar.

The first requisite for securing an unyielding scar is perfect asepsis;
but even the most perfectly healed abdominal scar may yield. Nature in
her great operation of uniting the lateral halves of the belly-wall in a
median cicatrix, the linea alba, cannot secure a non-yielding scar, it
is therefore presumptuous of the surgeon to think he can always ensure
it.

The method which has given me the best results is a simple one. The
peritoneum, sheath of the rectus, and rectus muscle are carefully
approximated by interrupted sutures of No. 4 silk carefully sterilized
and inserted with the hands covered with rubber gloves. The sutures are
inserted at intervals of rather less than 2 centimetres apart. Care must
be taken to include the peritoneum in these sutures. The skin is then
brought together by a continuous suture of No. 2 silk. When the
operation has been undertaken for a septic condition, such as pelvic
peritonitis, suppuration of an ovarian cyst, an acute pyosalpinx, or the
like, then it is useless to introduce buried sutures for the muscular
and aponeurotic layers, as they will quickly become infected. In such
conditions the abdominal walls are brought together by interrupted
sutures involving all the layers.

Those who are curious in regard to the various methods of closing median
cœliotomy wounds should consult a brochure published in 1904 on _The
Closure of Laparotomy Wounds as practised in Germany and Austria_, by
Walter H. Swaffield. This little book contains the detailed methods and
views communicated to him by more than fifty leading surgeons.

In Great Britain there is plenty of variety in the methods and material
employed for the closure of the incisions in abdominal operations, but
at the present time there is a marked tendency to return to the older
and simpler methods. The most dangerous and unreliable suture material
for the abdominal incision is catgut (see p. 96).

In studying the details of such operations as ovariotomy and
hysterectomy from books, it should be remembered that it is merely the
principles that can be explained. There are so many details in every
operation that can only be learned from watching, or, what is far
better, assisting a skilful and experienced surgeon in their
performance. This is true of all forms of surgical procedure. No man can
become a navigator without going to sea, however thoroughly he masters
the principles of seamanship from books, so no surgeon can acquire the
art of operating from merely reading descriptions of surgical
operations. If a surgeon can bring to bear upon abdominal gynæcological
operations, in addition to mere surgical dexterity, a competent
knowledge of the pathology of the organs, he will find it of the
greatest assistance. I would warn him particularly to take little heed
of the sneers of those eminently practical surgeons who affect to
despise pathology.




CHAPTER II

OVARIOTOMY


_Ovariotomy signifies the removal through an abdominal incision of
cystic and solid tumours of the ovary, and parovarian cysts._

The history of this operation is of great interest to surgeons because
it was the forerunner, so to speak, of all abdominal gynæcological
operations; they followed as a natural consequence on the establishment
of ovariotomy, and operations on the abdominal viscera generally are to
be regarded as an extension of pelvic surgery.

It is usual to state that ovariotomy was first performed by Ephraim
McDowell, of Kentucky, 1809: this is of historical interest only, for it
had no effect whatever in drawing attention to the feasibility of
removing ovarian cysts: it was in fact a still-born operation. The
pioneers of this operation were undoubtedly Baker Brown and Spencer
Wells in London, Thomas Keith in Edinburgh, and Clay in Manchester.
These surgeons brought the operation out of a ‘slough of despond’ and
placed it on firm ground. Spencer Wells and Keith were fortunate later
in their work in receiving guidance from Lord Lister’s discovery of
antisepsis: this, combined with the introduction of the short ligature,
firmly established the operation.

The improvement in securing the pedicle has played an important part in
the development of ovariotomy. McDowell tied the pedicle, but left the
ligature hanging out of the wound. Doran, who has written an excellent
review of this matter, ascribes the intraperitoneal method of dealing
with the pedicle to the systematic advocacy of Tyler Smith. The method
has been followed by brilliant results.

Baker Brown used to sear the pedicle with a cautery, and this method was
adopted with great success by Thomas Keith. The method of ligature is so
simple and safe that the cautery for this purpose has been long
abandoned.

=The operation.= The preliminary preparation of the patient and the
necessary instruments are described on p. 5. The Trendelenburg position
is not so necessary for the removal of large ovarian tumours as the
smaller examples which are apt to be firmly adherent to the floor of the
pelvis. In cases where the abdomen contains free fluid, ascitic or due
to the bursting of a cyst, or pus, it is a wise precaution to conduct
the early stages of the operation with the patient in the horizontal
position, otherwise the tilting will cause the fluid to gravitate
towards the diaphragm. As soon as the fluid has been removed the pelvis
may be raised if it be likely to facilitate the operation.

In the early days of ovariotomy it was the custom to tap the cyst, or,
in the case of multilocular tumours, to force the hand into the mass and
break down the septa of contiguous loculi and allow the viscid material
to escape. These devices were recommended because it was regarded as a
method making for safety to extract the cyst through a small abdominal
incision. Occasionally it is possible to extract the wall of a large
single-chambered parovarian cyst, after tapping, through an incision 7
centimetres in length. When the tumour is multilocular, or malignant, or
full of grease or pus, it is difficult and extremely dangerous to tap
it, as the material may infect the peritoneum either with septic matter
or with malignant particles, and end disastrously.

Cases have been reported in which, after traumatic rupture, or tapping,
of a dermoid, the epithelial contents escaped into the belly.
Subsequently the peritoneum was found dotted over with minute nodules
furnished with tufts of hair growing among the visceral adhesions. When
a woman with an ovarian cyst contracts typhoid fever, the cyst may
become filled with pus which contains the _bacillus typhosus_. Such a
case occurred in my practice in 1907.

For many years I have abandoned the use of clumsy trocars of all kinds
and remove the tumour entire, although it may require an incision from
the ensiform cartilage to the pubes. These large incisions heal quickly,
and are no more prone to hernia than the short incisions. This is the
only way of ensuring the safety of the peritoneum from being
contaminated by the harmful, dirty, and often malignant contents of the
cysts. In dealing with burst cysts a free incision enables the surgeon
to thoroughly and gently clean the peritoneal cavity.

The abdominal cavity is opened by a median subumbilical incision (see p.
7). Occasionally a difficulty may be encountered on reaching the
peritoneum, for, if the cyst has been infected, the peritoneum and cyst
wall may be so intimately adherent that they cannot be separated. In
these circumstances it is a wise plan to extend the incision upwards and
enter the abdominal cavity above the tumour. It is also to be borne in
mind that when the tumour adheres to the abdominal wall it is extremely
probable that a coil of intestine may be adherent also. When a tumour is
impacted in the pelvis it may push the bladder high in the abdomen; in
such an event this viscus is apt to be opened in making the incision. If
the surgeon has any doubt concerning the position of the bladder, he
should instruct an assistant to introduce a sound into it through the
urethra.

In a typical case, when the peritoneum is opened the surgeon at once
recognizes the bluish-grey glistening surface of the ovarian cyst, and
gently sweeps his hand over it in order to ascertain its relations and
to learn whether the cyst wall be free from adhesions. It is of the
utmost importance to be satisfied as to the nature of the tumour,
especially when the operator follows the unsatisfactory practice of
tapping, for if he plunge a trocar into a uterine tumour, or into a
pregnant uterus, he will involve himself in anxious difficulty.
Decomposing fluid, tenacious mucus, or blood-stained fluid may obscure
the parts, and should be sponged away: they indicate a ruptured cyst, a
malignant tumour, or a twisted pedicle. Much free blood may be due to
the bursting, or abortion, of a gravid tube. When the surgeon has
satisfied himself that the cyst or tumour is free to be removed he lifts
it out of the abdominal cavity, and if in this process the wall be so
thin that it is likely to burst, or actually leaks, the weak spot may be
freely incised with a knife over a convenient receptacle.

_Adhesions._ Although the surgeon may have had reasons to suspect the
presence of adhesions, frequently he finds none, and on other occasions
when he least expects them there are many. The most frequent adhesions
are omental, and fortunately they are the least important: they should
be detached and tied with thin silk. Adherent epiploic appendages
require the same treatment. Intestinal adhesions require care and
patience. When the intestines are adherent by strands and bands, these
may be cautiously snipped with scissors; when the adhesions are sessile
and soft the gut may be gently detached by means of a moist dab; but if
very firm it may be necessary to dissect off a piece of cyst wall and
leave it on the gut. The vermiform appendix requires especial care, for
it may be mistaken for an adhesion and divided. When intestines are
accidentally opened in the course of an ovariotomy they require the most
careful attention. Wounds in the colon may be safely sutured. Holes in
adherent small intestine may sometimes be sutured, but if the gut has
been extensively involved it may be necessary, and often judicious, to
resect a few centimetres and join the cut ends by a circular
enterorrhaphy.

Adhesions to the parietal peritoneum are as a rule easily detached with
the finger. The most serious adhesions are those which occur in the
depths of the pelvis, involving the uterus, bladder, or rectum, and the
separation of these may involve such accidents as wounds opening the
rectum or bladder, and injury to the ureters and iliac veins. The
treatment of such misfortunes will be considered later.

_The pedicle._ When the tumour is withdrawn from the belly the pedicle
is easily recognized: the Fallopian tube serves as an excellent guide to
it. The pedicle consists of the Fallopian tube and adjacent parts of the
mesometrium containing the ovarian artery, pampiniform plexus of veins,
lymphatics, nerves, and the ovarian ligament. When the constituents of
the pedicle are unobscured by adhesions, the round ligament of the
uterus is easily seen and need not be included in the ligature.

In transfixing the pedicle the aim should be to pierce the mesometrium
at a spot where there are no large veins, and tie the structures in two
bundles, so that the inner contains the Fallopian tube, a fold of the
mesometrium, and occasionally the round ligament of the uterus; whilst
the outer consists of the ovarian ligament, veins, the ovarian artery,
and a larger fold of peritoneum than the inner half.

Pedicles differ greatly; they may be long and thin, or short and broad.
Long thin pedicles are easily managed. The assistant gently supports the
tumour, whilst the operator spreads the tissues with his thumb and
forefinger, and transfixes them with the pedicle needle armed with a
long piece of silk doubled on itself. The loop of silk is seized on the
opposite side and the needle withdrawn. During the transfixion care must
be taken not to prick the bowel with the needle. The loop of silk is cut
so that two pieces of silk thread lie in the pedicle. The proper ends of
the thread are now secured, and each is firmly tied in a reef-knot; for
greater security the whole pedicle may be encircled by an independent
ligature, taking care that it embraces the pedicle below the point of
transfixion. (I use No. 4 plaited silk for transfixing the pedicle, and
a piece of No. 6 silk for surrounding it.)

After the operator has gained some experience in this simple mode of
tying the pedicle, he may, if he thinks it desirable, practise other
methods.

After securely applying the ligature the tumour is removed by snipping
through the tissues on the distal side of the ligature with scissors.
Care must be taken not to cut too near the silk, or the stump will slip
through the ligature; on the other hand, too much tissue should not be
left behind. The stump is seized on each side by pressure forceps, and
examined to see that the vessels in it are secure; it is then allowed to
retreat into the abdomen. Should it begin to bleed it must be caught
with forceps, drawn up, retransfixed, and tied below the original
ligature.

Occasionally a pedicle will be so broad that it is unsafe to trust to
this simple form of ligature. Broad pedicles will require three or more
ligatures. When several ligatures are required it is important to
remember that the ovarian artery lies in the outer fold of the pedicle
and the uterine artery at the inner end, and it is often possible to
secure these vessels separately with a thin piece of silk. The pedicle
can then be secured with a series of interlocking ligatures.

When an ovarian tumour has undergone axial rotation and has tightly
twisted its pedicle, the ligature should be applied to the torsioned
area: a single ligature is then sufficient.

It is impossible to frame absolute rules for ligaturing the pedicle. In
this, as in all departments of surgery, common sense must be exercised,
and at the present day, when ovariotomy is practised so widely, no one
would think of performing this operation without assisting at, or
watching its actual performance by an experienced surgeon.

Having satisfied himself that the pedicle is secure, the surgeon
examines the opposite ovary, and if obviously diseased it should be
removed.

The operator then sponges up any blood or fluid which may have collected
in the recesses of the pelvis. Whilst employed in this way he gives
instructions to have the dabs and instruments counted.

When the operator limits the number of dabs to six he can easily have
them displayed before him. The incision is sutured in the manner
described on p. 9.

=Cysts of the broad ligaments.= Occasionally the surgeon on opening the
abdomen finds that the cyst or tumour is situated between the layers of
the broad ligament. Sessile cysts of this kind are removed by what is
known as enucleation. The peritoneum overlying the cyst is cautiously
torn through with forceps until the cyst wall is exposed; then by means
of the forefinger the surgeon proceeds to shell the cyst out of its bed,
taking care not to tear the capsule or any large vein in its wall; it is
also necessary to exercise the greatest care to avoid injury to the
ureter. It is not uncommon, after enucleating a cyst in this way, to
find the ureter lying at the bottom of the recess. (For treatment of an
injured ureter see p. 112.)

When the enucleation is completed the walls of the capsule are carefully
examined for oozing vessels which require ligature. The capsule can
often be closed in such a way as to bring its walls into apposition and
thus obliterate its cavity; it then requires no further attention. When
there is much oozing the capsule is treated on the plan known as
marsupialization. The edges of the capsule are brought to the lower
angle of the abdominal wound and secured with sutures, and a drain,
either of gauze or a rubber tube, is introduced, and the remainder of
the wound closed in the usual manner.

Enucleation is usually accompanied by more loss of blood than simple
ovariotomy; this, and the prolonged manipulation, is often responsible
for severe shock.

=Spurious capsules.= It is necessary for the surgeon to remember that an
ovarian cyst, and especially an ovarian dermoid, is sometimes invested
by a spurious capsule. It is now well known that slow effusions of
blood, tuberculous exudations (Fig. 4), hydatid cysts, and ovarian cysts
become enclosed by capsules of fibrous tissue formed by the organization
of the peritoneal exudation which their presence excites. These capsules
are often so firm, and so completely encyst the fluid exuded into the
pelvis in cases of tubal tuberculosis, that such encapsuled collections
of fluid resemble, and are often mistaken for, ovarian cysts. It is also
necessary to mention that true ovarian cysts project from, but never
invade the layers of the broad ligament. From time to time cases are
reported in which ovarian cysts, especially dermoids, have been found
between the layers of the broad ligament: such are in all probability
instances in which a false capsule has formed around the cyst, and the
surgeon committed an error of observation in regarding it as a layer of
the broad ligament.

[Illustration: FIG. 1. SECONDARY CANCER OF THE OVARY. An ovary converted
into a solid mass of cancer secondary to a focus in the sigmoid flexure
of the colon: it weighed 5 lb. Two-fifths size.]

=Ovariotomy in carcinoma of the ovary.= When an operation is undertaken
for the removal of solid or semi-solid tumours of the ovary, and
especially when bilateral and accompanied by vomiting, it is incumbent
on the surgeon to make a careful examination of the gastro-intestinal
tract, for in many of these cases cancer will be found either at the
pylorus, or in the cæcum, or the colon, and particularly in the sigmoid
flexure. In such circumstances the ovarian masses are secondary to the
cancerous focus in the gastro-intestinal tract.

Bilateral malignant tumours of the ovaries are sometimes secondary to
primary cancer of the gall-bladder and the breast. Some of these
secondary cancerous tumours of the ovaries form masses as big as the
patient’s head.

In such conditions the ovaries and sometimes the uterus should be
removed even for the purpose of making the patient comfortable. When
the primary disease is in the cæcum, colon, or sigmoid flexure, and is
operable, the growth should be resected and the cut ends of the bowel
united by circular enterorrhaphy. In one instance, where the cancer
occupied the ileo-cæcal valve, I succeeded in making a lateral
anastomosis between the ileum and ascending colon, after performing
bilateral ovariotomy. The woman survived the operation two years.

=Incomplete ovariotomy.= The surgeon may start on an operation and,
after opening the abdomen, may find many adhesions, yet he feels that
the removal of the tumour is possible. He sets to work and overcomes
many of the difficulties, but finds at last such extensive pelvic
adhesions that it is imprudent to proceed further. In such cases he
evacuates the contents of the cyst and stitches the edges of the opening
in the cyst to the margins of the abdominal wound, and drains the
cavity. This mode of dealing with a cyst is usually termed ‘incomplete
ovariotomy’.

[Illustration: FIG. 2. SECONDARY CANCER OF THE OVARY IN SECTION. This is
a section of the ovary represented in the preceding figure. Half size.]

An incomplete ovariotomy is a very different condition to an
enucleation. The cavity left after enucleation closes completely, but
when the wall of an ovarian cyst or adenoma is left the tumour gradually
grows again, or it may suppurate so profusely that the patient slowly
dies exhausted. There are few things sadder in surgery than the slow,
miserable ending of an individual who has been subjected to an
incomplete ovariotomy.

=Anomalous ovariotomy.= In a few instances, generally under an erroneous
diagnosis, surgeons have removed ovarian tumours through an opening
other than the classical one known as the median subumbilical incision.
Under the impression that the tumour was splenic, an ovarian tumour of
the right side has been successfully removed through an incision in the
left linea semilunaris (R. W. Parker). An ovarian tumour, supposed to be
a renal cyst, has been successfully extracted through an incision in the
ilio-costal space (Le Bec). Strangest of all, a small ovarian dermoid
has been removed through the rectum under the impression that it was a
polypus of the bowel (Stock, Peters).

=Hysterectomy after bilateral ovariotomy.= After the removal of both
ovaries for cysts or tumours, the uterus is a useless organ: it is fast
becoming the practice under such conditions to remove it. There is much
to be said in favour of this procedure, especially if the uterus be
large and flabby, because it tends to fall backwards into the pelvis. In
such circumstances it is better surgery to remove it than to perform
hysteropexy. The risk of intestinal obstruction after bilateral
ovariotomy is greater than after hysterectomy. Cases are known in which
cancer has attacked the uterus years after bilateral ovariotomy and
oöphorectomy (see p. 55).

=Repeated ovariotomy.= Very many cases are known in which women have
been twice submitted to ovariotomy. Thus it is the duty of the surgeon
when removing an ovarian tumour to examine carefully the opposite ovary.
So many examples are known of women who have borne children after
unilateral ovariotomy (twins and even triplets) that this alone is
sufficient to prohibit the routine ablation of both glands.

A second ovariotomy is not attended with more risk than a first
ovariotomy. The abdominal incision must be made with extra caution,
because intestine may be adherent to it and runs a risk of being
wounded. In some instances the cicatrix is very thin, and the surgeon
cutting through it is liable to cut the intestine before being aware
that the knife has entered the abdomen.

Some surgeons recommend that in a second ovariotomy the opening may with
advantage be made a little to one side of the original incision.

Cases have been reported in which patients have been thrice submitted to
ovariotomy: in such instances it is probable that one of the tumours was
a sessile broad ligament cyst.

=Pregnancy after bilateral ovariotomy.= It is an interesting fact that
several cases have been carefully reported in which women who have had
bilateral ovariotomy have subsequently become pregnant. This event has
been explained by assuming that in some of the patients a portion of at
least one ovary has been left. This meets with more favour than the idea
of the existence of a supernumerary ovary. The cases have been collected
by Doran.

In order to afford some notion of the relative frequency of the various
cysts and tumours classed as ovarian, a list of one hundred consecutive
examples which I removed at the Chelsea Hospital for Women is
appended:--

    Fibromata              2
    Sarcomata              2
    Carcinomata            1
    Simple cysts          45
    Adenomata             25
    Dermoids              15
    Papillomata            2
    Parovarian             5
    Tubo-ovarian           3

The case classed as a carcinoma was secondary to cancer of the pylorus;
both ovaries were affected. The three classed as tubo-ovarian were
probably exceedingly large examples of hydrosalpinx; one was so big that
it came in contact with the liver.

I have compared this table with the experience of other surgeons, and
although there is much variation in them it represents a fair average of
the proportions of the different ovarian operations usually classified
under the head of ovariotomy.

=Ovariotomy at the extremes of life.= Cysts and tumours arise in the
ovary during intra-uterine, and at all periods during extra-uterine
life, even in extreme old age: they also attain such dimensions in
infants and old women as to demand the aid of the surgeon, and with
excellent results. Many years ago I collected the recorded cases and
tabulated one hundred instances in which ovariotomy had been performed
in infants and girls under fifteen years of age. These tumours fall into
three groups:

    Simple cysts and adenomata   41 with 3 deaths.
    Dermoids                     38  "   5   "
    Sarcomata                    21  "   7   "

In the case of simple cysts, adenomata, and dermoids, the results are
encouraging. It is possible that some of the cases described as
sarcomata belonged to the deadly group now known as malignant
teratomata.

Ovarian tumours sometimes attain large dimensions in children, and Keen
reported a case in which he removed an ovarian tumour from a girl which
weighed 44 kilogrammes: the girl weighed 27 kilogrammes after the
operation. An ovarian cyst with a twisted pedicle has been found in a
fœtus at birth (Otto von Franque).

The subjoined table shows cases in which ovarian tumours have been
removed from infants under three years of age. It is often stated that
Professor Chiene performed ovariotomy on an infant of three months. This
is an error; it was an ovary occupying the sac of an inguinal hernia.

    OVARIOTOMY IN INFANTS

  -+------------+-----------+--------+----------+----------------------
   | _Reporter_ |   _Age_   |_Result_|_Nature of| _Reference_
   |            |           |        |  Tumour_ |
  -+------------+-----------+--------+----------+----------------------
  1|D’Arcy Power|4 months   |   R.   |Dermoid   |_Trans. Path.
   |            |           |        |          |Soc._, xlix. 186.
  -+------------+-----------+--------+----------+----------------------
  2|MacGillivray|11 months  |   R.   |Cyst      |_Lancet_, 1907,
   |            |           |        |          |i. 1487.
  -+------------+-----------+--------+----------+----------------------
  3|Roemer      |1-3/4 years|   R.   |Dermoid   |_Deutsche Med. Woch._,
   |            |           |        |          |1883, ix. 762.
  -+------------+-----------+--------+----------+----------------------
  4|Péan        |2 years    |   R.   |Dermoid   |_Clin. Chir._,
   |            |           |        |          |1887-8, 8th series.
  -+------------+-----------+--------+----------+----------------------
  5|Hooks       |2-1/2 years|   D.   |Dermoid   |_Am. J. of Obst._,
   |            |           |        |          |1886, xix. 1022.
  -+------------+-----------+--------+----------+----------------------

=Ovariotomy in old age.= In 1891 I was able to find twenty-two records
of successful ovariotomy in women over seventy years of age. Since that
date Howard A. Kelly and Mary Sherwood made a collective investigation,
and succeeded in obtaining notes of one hundred cases of ovariotomy
performed on women over seventy years of age: the death-rate amounted to
12%.

The subjoined table concerns itself with ovariotomy performed on women
after the age of eighty years, and the results are remarkable,
notwithstanding the circumstance that these women of eighty years and
upwards must have been blessed with a stronger constitution than their
contemporaries.

    OVARIOTOMY IN WOMEN OF EIGHTY YEARS OF AGE

  --+-------------+-----+--------+------------------------------------
    | _Reporter_  |_Age_|_Result_|           _Reference_
  --+-------------+-----+--------+------------------------------------
   1|Owens        | 80  |   R.   |_Brit. Gyn. Soc. Journal_, iv. 88.
  --+-------------+-----+--------+------------------------------------
   2|Richardson   | 80  |   R.   |_Brit. Med. Journ._, 1894, i. 523.
  --+-------------+-----+--------+------------------------------------
   3|Heywood Smith| 81  |   R.   |_Lancet_, 1894, i. 1618.
  --+-------------+-----+--------+------------------------------------
   4|Spencer      | 82  |   R.   |_Brit. Med. Journ._, 1893, ii. 1271.
  --+-------------+-----+--------+------------------------------------
   5|Homans       | 82  |   R.   |_Bost. Med. and Surg. Journ._, 1888,
    |             |     |        |  454.
  --+-------------+-----+--------+------------------------------------
   6|Edis         | 81  |   R.   |_Brit. Med. Journ._, 1892, i. 860.
  --+-------------+-----+--------+------------------------------------
   7|Bush         | 84  |   R.   |_Ibid._, 1894, ii. 67.
  --+-------------+-----+--------+------------------------------------
   8|Remfrey      | 83  |   R.   |_Trans. Obstet. Soc._, xxxvii. 152.
  --+-------------+-----+--------+------------------------------------
   9|Kraft        | 84  |   R.   |_Hospitalstidende_, Copenhagen.
  --+-------------+-----+--------+------------------------------------
  10|Owens[1]     | 87  |   R.   |_Lancet_, 1895, i. 542.
  --+-------------+-----+--------+------------------------------------
  11|Thornton     | 94  |   R.   |_Trans. Obstet. Soc._, xxxvii, 158.
  --+-------------+-----+--------+------------------------------------
  12|Bland-Sutton | 85  |   R.   |Middlesex Hospital.
  --+-------------+-----+--------+------------------------------------
      [1] A second operation on patient No. 1 in the list.

=Mortality.= The death-rate after ovariotomy is hard to estimate,
especially as surgeons differ widely in the classification of the cases.
In the simple and uncomplicated forms of ovarian cysts and tumours the
operation should be almost free from risk. Many surgeons, excluding
malignant conditions, have had lists of a hundred operations with no
deaths.

If all kinds of tumours are included as represented in the table on p.
17, a 5% mortality in experienced hands would be regarded as a good
result. In general hospital work it is probably as high as 10%. With
less experienced surgeons who do not perform many operations the
death-rate will vary from 10 to 15%.

The risks and after-consequences of ovarian operations are set forth in
Chapter XI.


REFERENCES

DORAN, A. On complete Intraperitoneal Ligature of the Pedicle in
    Ovariotomy. _St. Bartholomew’s Hospital Reports_, 1877, xiii. 195.

---- Pregnancy after the Removal of Both Ovaries for Cystic Tumour.
    _Trans. Obstetrical Society_, 1902, xliv. 231.

BLAND-SUTTON, J. On Secondary (metastatic) Carcinoma of the Ovaries.
    _Brit. Med. Journal_, 1906, i. 1216.

---- On Cancer of the Ovary. Ibid., 1908, i. 5.

LE BEC. Ovariotomie double; un des kystes enlevé par la région lombaire,
    l’autre par le devant de l’abdomen; adhérences totales; guérison.
    _Gaz. des Hôpitaux_, 1887, 290.

STOCKS. Prolapse of an Ovarian Cyst. _Brit. Med. Journal_, 1857, ii.
    487.

PETERS, H. Ovariotomie per anum. _Wiener Klin. Wochensch._, 1900, xiii.
    110.




CHAPTER III

OÖPHORECTOMY


_Oöphorectomy signifies the removal through an abdominal incision of an
ovary and Fallopian tube for affections mainly inflammatory._

The evolution of this operation is of great interest to surgeons. The
removal of ovaries as a surgical operation was introduced independently
by Hégar in Germany and Battey in Georgia, for the relief of pelvic pain
and dysmenorrhœa, in 1872. In the same year Lawson Tait performed his
pioneer operation and removed an ovary and tube for the relief of pain
due to disease of the ovary. Subsequently he advocated bilateral
oöphorectomy for the purpose of inducing an artificial menopause in
women with uterine fibroids. From these beginnings the operation began
to be performed for the relief of a variety of conditions connected with
the generative organs, such as--

Pyosalpinx and tubo-ovarian abscess, hydrosalpinx, tuberculous ovaries
and tubes, sarcoma and carcinoma of the Fallopian tubes, gravid
Fallopian tubes, ovarian abscess, ovarian pregnancy, prolapse of the
ovary; finally bilateral removal of the ovaries has been practised for
the relief of inoperable cancer of the breast.

Bilateral oöphorectomy is occasionally performed for osteomalacia (a
rare disease in Great Britain), as it arrests pain and the excessive
output of phosphates in the urine, which is a marked feature of this
affection. This extension of the operation we owe to Fehling of Bâle
(1887).

Time and experience have considerably modified surgical opinion in
regard to oöphorectomy. Removal of the ovaries is no longer practised
for the relief of hæmorrhage due to fibroids: it is easier, safer, and
affords greater relief to the patient to remove the uterus (see p. 36).
When dysmenorrhœa is so severe as to need radical operation,
hysterectomy is the only certain method, with conservation of at least
one ovary. The removal of both ovaries in certain forms of insanity is
now abandoned, and this is true of bilateral oöphorectomy for the relief
of mammary cancer.

In other directions the operation has undergone extension, for in some
chronic diseases of the Fallopian tubes it is difficult to completely
extirpate the affected tissues without removing the uterus. These will
be considered in describing the actual operation.

Apart from the many modifications in the details of the operations some
operators prefer to remove the ovaries and tubes through an incision in
the vaginal fornix. This is known as Colpotomy, or Vaginal Cœliotomy.

Some writers attempt to subdivide the various modifications of
oöphorectomy and apply to them special terms: for example, the removal
of the ovary and tube would be termed salpingo-oöphorectomy. Removal of
the tube would be called salpingectomy, and the excision of the ovary,
oöphorectomy. This terminology may be precise, but it is certainly
clumsy. A few writers designate these operations as ‘removal of the
uterine appendages’; this phrase, though comprehensive, is neither
precise nor elegant.

=Operation.= The patient is prepared in the same manner, and the same
instruments are required, as for ovariotomy. In many of these operations
the Trendelenburg position is of the greatest advantage.

[Illustration: FIG. 3. AN INFECTED FALLOPIAN TUBE. The cœlomic ostium of
the tube is unoccluded and is in the process of slowly engulfing the
fimbriæ. Removed from a woman in the acute stage of salpingitis.
Three-quarter size.]

In a case of prolapse of the ovary, or a gravid tube or ovary in the
earliest stages, the operation presents no difficulty and can be carried
out with the ease and safety of the simplest ovariotomy; but there are
many cases where the tubes and ovaries contain pus and are distended
into cysts as big as a fist, or even as large as the patient’s head,
which are adherent to bowel, uterus, bladder, indeed everything with
which they come in contact; this renders their removal tedious and
exacting for the surgeon and dangerous to the patient. Although a
suppurating ovarian cyst adheres to surrounding organs, its removal is
simpler than in the case of a large pyosalpinx, because the Fallopian
tube is intimately enclosed within the folds of the broad ligament, and
these connexions serve to bind it firmly in the pelvis.

In undertaking the removal of such enlarged tubes the surgeon’s first
duty is to expose the parts by a free incision, and then carefully
isolate the intestines and upper parts of the abdomen with dabs in order
to prevent them from being contaminated with pus. He will quickly
recognize in the majority of cases that he has to deal with tubal
disease, because the distended uterine section of the tube will lie on
the more globular outer portion of the tube and assume the familiar
shape of a chemical retort. With the fingers the adherent omentum and
bowels are carefully detached, and the adhesions between the distended
tube or ovary and the rectum are carefully broken through with the
finger, and the parts withdrawn from the pelvis. With great care it is
usually possible to carry this out without bursting the tube. This is
important as it prevents the universal spread of pus in the pelvis. When
the tube bursts in the process of removal it is useful to swab it up
with some strips of gauze and thus keep the ‘Gamgee dabs’ clean for the
final stages.

[Illustration: FIG. 4. A TUBERCULOUS FALLOPIAN TUBE AND OVARY: ENTIRE
AND IN SECTION. Caseous matter has exuded through the cœlomic ostium of
the tube and become encapsuled. Natural size.]

As soon as the diseased parts are extracted, a dab is pressed into the
hollow to check the oozing: the pedicle is clamped with forceps and the
tube and ovary detached.

It is the common practice in dealing with inflamed and septic ovaries
and tubes to transfix and ligature the pedicles as in a simple clean
ovariotomy. The consequences of this practice are not satisfactory, for
the pedicles being infected often give rise to trouble, because the silk
acts as a seton, an abscess forms which may open up through the
abdominal wound, the rectum, or perforate into the bladder, and leads to
the establishment of a sinus which persists for many months until the
ligature is extruded. There are several methods of avoiding this: for
example, the arteries in these broad pedicles may be ligatured
separately with thin silk, and the edges of the peritoneum drawn
together by two or three mattress sutures (Fig. 11, p. 40).

In cases where the Fallopian tube is thickened quite up to the uterine
angle, it may be exsected from the uterus: in such cases the uterine
artery will be tied and the flaps at the uterine angle can be brought
into apposition by a mattress suture.

In acute cases of salpingitis the cœlomic ostium is open and the
infective material can be seen leaking from it (Fig. 3). In chronic
cases this ostium is firmly occluded (Fig. 4). Acute cases are dangerous
as they are apt to cause post-operative peritonitis. Chronic cases are
difficult on account of visceral adhesions.

The most serious complication likely to arise in the enucleation of a
pyosalpinx, especially on the left side, is a firm adhesion to the
rectum; this may be occasionally anticipated when the patient gives a
clear history of one or more sudden discharges of pus from the anus. An
accidental tear of the rectum through comparatively healthy tissues may
be repaired by interrupted sutures, but when the injury is in tissues
altered by chronic suppuration, the only course open to the surgeon is
to drain with a wide rubber tube, and it is surprising as well as
gratifying to know that a fistula of this kind low in the rectum will
often close in a week or ten days. It is important to bear in mind that
an undetected tear into the rectum, if the abdomen be closed without
drainage, will, in all probability, lead to fatal peritonitis.

It has happened that a surgeon in removing a pyosalpinx tore a hole in
the rectum; he was unaware of the accident, and a few hours after the
operation ordered 10 ounces of saline solution to be injected into the
bowel. This fluid passed through the rent in the gut direct into the
pelvis with fatal consequences.

After removing the diseased parts and securing the large vessels
directly concerned in the pedicles, attention is directed to the oozing
from the torn tissues in the floor of the pelvis. Any vessel which is
bleeding should be ligatured with thin silk, and then the recesses of
the pelvis may be firmly plugged with a dab wrung out of hot water: this
is a valuable measure of hæmostasis. This dab is removed in two or three
minutes, and any vessel which is bleeding is quickly seen and ligatured.

In cases where the enucleation of adherent and inflamed tubes leaves
large raw and slightly oozing surfaces in the pelvis, drainage is a wise
precaution. After a trial of a variety of measures for this purpose I
find the simplest to be a narrow rubber drainage tube reaching to the
bottom of the pelvis and emerging at the lower extremity of the
abdominal incision. It is rarely required for more than forty-eight
hours. Some surgeons are opposed to drainage, and one writer compares it
to ‘defending oneself against the sparks of Vulcan with an umbrella’;
his mortality is high.

In simple cases the incision is closed according to the method
described on p. 9; but after the removal of suppurating ovaries and
tubes it is better to unite the wound by a single layer of sutures
through all the tissues of the abdominal wall: buried sutures in such
conditions nearly always give trouble.

=Abdominal hysterectomy after bilateral oöphorectomy and ovariotomy.=
After the complete removal of the ovaries and tubes the uterus is a
useless organ, and when the ‘appendages’ have been removed for
inflammatory lesions, acute or chronic, it may become a troublesome
organ. In some instances a uterus devoid of its appendages has been
attacked by cancer. In a few instances in which patients have undergone
bilateral oöphorectomy, or bilateral ovariotomy, successful conception
has followed the operation (see p. 17).

The most annoying consequences which follow bilateral oöphorectomy for
salpingitis, acute or chronic, are hæmorrhage, pain, or a purulent
discharge. Every surgeon with an ordinary experience of this class of
surgery has probably had to remove the uterus on several occasions as a
sequel to bilateral oöphorectomy.

It is advised by many surgeons, when they find the appendages so
hopelessly diseased that they must be removed, to perform subtotal
hysterectomy at the same time. My own practice in this matter is to
perform subtotal hysterectomy when it is necessary to remove the uterus
as well as the appendages in chronic disease; and total hysterectomy
when it is deemed advisable to remove the uterus with the appendages in
acute infective conditions. The reasons for this modification are
obvious, because in chronic conditions there is little liability for the
stump to become infected, for experience teaches that though the
distended tubes contain pus in chronic cases, yet on bacteriological
examination this pus is sterile. In the acute cases the pus swarms with
micro-organisms--bacillus colli, staphylococcus, and occasionally
streptococcus; these infect the stump, set up suppuration, infect the
ligatures, and establish a chronic sinus. To cure this condition it is
necessary to remove the stump by the vaginal route.

In cases of tuberculous infection of the Fallopian tubes it is not
necessary to remove the uterus unless it is obviously implicated by the
disease. In several patients I have left an ovary without any subsequent
ill consequences.

=Mortality.= In order to estimate the risks of oöphorectomy it is
necessary to classify the heterogenous conditions for which this
operation is required. In the majority of cases the chief cause is
inflammatory (septic) affections of the Fallopian tubes: other causes
are tubal and ovarian pregnancy, and prolapse of the ovary. Tubal
pregnancy is considered in a separate chapter, and as prolapse of the
ovary is so often associated with retroflexion of the uterus it is
dealt with in the chapter on Hysteropexy.

In order to give some notion of the relative frequency of the infective
conditions of the tubes and ovaries usually classed in Hospital Reports
as ‘diseased uterine appendages’, I chose one hundred consecutive
operations from my case-reports at the Chelsea Hospital for Women. They
are classed thus:--

    Salpingitis         49
    Pyosalpinx          31
    Hydrosalpinx        10
    Tuberculous          8
    Ovarian abscess      2

In order to give some idea of the risks of unilateral and bilateral
oöphorectomy, I gathered the following facts from the Hospital Reports,
prepared by the Registrar. During the years 1903-7 (both years
inclusive) the staff performed the operation of oöphorectomy for
diseased uterine appendages on 287 women. Of these four died. During the
thirteen years I have filled the post of surgeon to this hospital I have
performed on an average twenty oöphorectomies yearly for the diseased
conditions set forth in the above table. I lost one patient during the
whole of this period, and that was in 1902. The chief risks of
oöphorectomy for inflammatory conditions are undetected injury to bowel,
especially the rectum, and septic peritonitis when the streptococcus is
present in the tubes in acute cases.

=Operation for primary cancer of the Fallopian tube.= This disease is
rarely diagnosed before operation. The treatment adopted in the cases
first reported was oöphorectomy, but in the majority of patients the
disease quickly returned and destroyed them in a few months.

It subsequently became the practice to remove the uterus as well as the
tubes and ovaries, but a quick recurrence in these circumstances is the
rule.

The really favouring factor in the case is the condition of the cœlomic
ostium of the tube. When this remains open, the cancerous cells escape
freely and implant themselves on the pelvic peritoneum and adjacent
organs. In very rare instances the cœlomic ostium is occluded: in this
happy circumstance a fairly long freedom from recurrence may be hoped
for.

The relation between the condition of the cœlomic ostium of the
Fallopian tube and the recurrence of cancer is illustrated by the
following cases:--

A woman, fifty-seven years of age, had a large submucous fibroid in the
uterus. At the operation the cœlomic ostium was not only patent, but the
carcinoma protruded through it and nodules of growth could be seen on
the wall of the rectum at the point where the tube rested on the bowel.
The patient recovered from the operation and enjoyed good health for
eleven months, then signs of recurrence became manifest and she died a
few weeks later.

[Illustration: FIG. 5. PRIMARY CANCER OF THE FALLOPIAN TUBE. An ovarian
cyst associated with primary cancer of the corresponding tube. The
cœlomic ostium is open and the cancerous material has leaked out on to
the cyst wall. Half size.]

[Illustration: FIG. 6. A SECTION OF PRIMARY CANCER OF THE FALLOPIAN
TUBE. This is the cyst wall and cancerous tube represented in the
preceding drawing: it shows the cancerous infiltration of the cyst wall.
Half size.]

A woman, forty-nine years of age, had a large fibroid in her uterus and
a Fallopian tube stuffed with cancer, but the cœlomic ostium was
completely occluded. The uterus, ovaries, and tubes were removed. The
patient subsequently remarried and was in good health three years later.

Primary cancer of the Fallopian tube is almost invariably unilateral and
its association with fibroids of the uterus is unusual. It is necessary
for the surgeon to remember that a cancerous Fallopian tube may lead to
complications with an ovarian cyst. Our knowledge of primary cancer of
the Fallopian tube has grown up within the last twenty years, and some
of the recorded cases puzzled the reporters because the disease was
associated with a cyst, sometimes of a large size.

In Fig. 5 I have represented an instructive specimen, which is an
ovarian cyst complicated with primary cancer of the corresponding
Fallopian tube. In this instance the cyst was as big as a cocoa-nut and
multilocular: the ampulla of the tube is stuffed with cancer, but the
ostium is patent and a ‘stream’ of cancerous material has flowed over
the wall of the cyst. In addition, the cancerous material has
infiltrated the wall of the ovarian cyst. The patient recovered from the
operation, but a year later she had an extensive recurrence.

The primary mortality of simple oöphorectomy, or oöphorectomy combined
with hysterectomy for primary cancer of the Fallopian tube, is about 5%,
and this is low in comparison with abdominal hysterectomy for cancer of
the cervix; it is due to the fact that tubal cancer does not so readily
become septic (Doran).


REFERENCES

DORAN, A. A table of over fifty complete cases of Primary Cancer of the
    Fallopian Tube. _Journal of Obst. and Gyn. of the British Empire_,
    1904, vi. 285.

BLAND-SUTTON, J. Tumours Innocent and Malignant, 4th Ed., 1906, 400.

---- On Cancer of the Ovary, _Brit. Med. Journal_, 1908, i. 5.




CHAPTER IV

OPERATIONS FOR EXTRA-UTERINE GESTATION


The systematic surgical treatment of extra-uterine gestation we owe to
the genius of Lawson Tait. His first operation for this condition was
performed in 1883. Tait wrote that he conceived and carried out this
operation in obedience to the canon of surgery relating to the arrest of
hæmorrhage, and which is valid in other regions of the body.

Many surgeons (even a butcher) had removed living, dead, and putrescent
extra-uterine fœtuses from the abdomen of living women, but Tait was the
first to attempt the operation in those early stages of tubal gestation
in which the tube bursts, or expels (tubal abortion) the products of
conception through the cœlomic ostium or a rent in the gestation-sac,
into the abdominal cavity, accompanied by an escape of blood so abundant
that it may destroy life in a few hours.

=Indications.= The operative treatment of extra-uterine gestation
depends mainly on the stage at which it is required.

When a gravid tube is detected before rupture, the operation is
practically that of oöphorectomy: and is simple and safe.

When the operation is required in consequence of the bursting, or
abortion, of an early gravid tube, great promptness is often required on
the part of the surgeon to prevent the patient dying from hæmorrhage,
and although the operation in these circumstances is really an
oöphorectomy, it often has to be performed in the patient’s room as an
emergency operation and without the elaborate surroundings of a modern
operating theatre.

There are few accidents which test the skill, nerve, and resource of a
surgeon more than cœliotomy for a suspected intraperitoneal hæmorrhage
from a gravid tube, and few operations are attended with such brilliant
results. Surgeons are often astonished to find a large amount of blood
in the pelvis due to a small perforation in a gestation-sac no bigger
than a cherry (Fig. 7).

=Operation.= In removing tubes of this kind it is necessary to apply the
ligature on the uterine side of the rent in cases of rupture of the
tube, but when the rent involves the wall of the uterus the opening will
require the application of a mattress suture for its complete closure.
In some rare instances of the interstitial variety of tubal pregnancy,
the uterus has been so involved that in order to effectually control the
bleeding it has been found necessary to remove the uterus.

After the pedicle has been safely ligatured and the blood removed, the
abdominal incision is sutured as described on p. 9. When the shock due
to the bleeding and operation has been great, it is sometimes judicious
to pour one or two pints of saline solution at the temperature of 102°
F. direct into the abdominal cavity.

[Illustration: FIG. 7. A GRAVID FALLOPIAN TUBE. There is a hole in the
gestation-sac, and tufts of villi project through it. The patient was in
the seventh week of her tenth pregnancy when she was seized with
abdominal pain and died in ten hours from hæmorrhage. (_Museum of St.
Bartholomew’s Hospital._) Natural size.]

The majority of cases of internal bleeding from gravid tubes in the
early stages are submitted to operation at periods varying from a few
hours, days, weeks, or even months, after the primary bleeding.

When the tube bursts, the hæmorrhage may not be so profuse as to induce
death; and the woman, recovering from the shock, does not manifest such
grave symptoms as to demand surgical aid. The consequence is that the
patient sometimes remains for several weeks under palliative treatment
(unless a renewal of bleeding kills her), and at last she seeks surgical
advice. Appreciation of the true nature of the case leads to operation.

In such cases, when the abdomen is opened, the free blood in the
abdominal cavity is easily removed by sterilized dabs of absorbent
material. The damaged tube and ovary are removed as in oöphorectomy.
When there is much free blood care must be taken that no clots are left
in the iliac fossæ. When the blood has remained in the belly for several
weeks after rupture, it is judicious to insert a small drain for a few
days. The importance of removing blood and blood-clot from the
peritoneal cavity is demonstrated on p. 98.

Where a tubal pregnancy progresses beyond the third or fourth month and
invades the broad ligament before giving trouble from internal
bleeding, an operation may be necessary at any moment. At this period
the operation consists in exposing the parts by a median subumbilical
incision, and then opening the gestation-sac, turning out the fœtus,
placenta, and clot, and controlling the bleeding by firmly packing the
cavity with dabs. The edges of the sac are then stitched to the lower
end of the wound; the upper part of the incision is closed, and the sac
is drained with a rubber tube of suitable size and allowed to gradually
heal.

In cases where the pregnancy continues beyond the fourth month to full
time an operation may be required at any moment. Up to the fourth month
it may be even possible, in some cases, to remove the embryo, placenta
and gestation-sac on the same plan as an ovarian cyst. This is
occasionally possible even when the gestation runs to term, but in the
majority of cases, when the gestation has passed the fourth month and
the fœtus is alive, the surgeon cannot expect to deal with the sac in
this summary manner, (unless it be a cornual pregnancy) he has to reckon
with the placenta.

[Illustration: FIG. 8. A GRAVID FALLOPIAN TUBE, CONTAINING TWINS.
(McCann’s case. _Museum R. College of Surgeons._) Full size.]

In operating for the removal of a gravid tube in the early weeks, the
surgeon may be exercised in his mind in regard to the opposite tube, for
a careful study of the literature of this subject clearly shows that the
patient is liable to conceive in the opposite tube, and in some
instances this has happened within a few weeks of the removal of its
fellow. The liability of a repeated tubal pregnancy may be fixed at 5
per cent. Moreover, in operating for tubal pregnancy, the opposite tube
should be carefully examined, because both tubes may be gravid, though,
as a rule, the pregnancies are of different dates. To spare a woman a
recurrence of tubal pregnancy it has been urged that the surgeon should
remove the opposite tube, but men of ripe experience and judgment are
averse to such a proceeding, for it is an established fact that uterine
pregnancy is not uncommon after unilateral tubal gestation. My own
experience is in harmony with this. In some cases of unilateral tubal
abortion the operator has cleared out the tubal mole and clot, and left
the tube. This is not good practice: I think a tube which has once been
pregnant should be removed. If the opposite tube is obviously diseased,
and this happens in a small proportion of patients, it should be
removed.

The method of dealing with the sac of an extra-uterine gestation after
the fifth month depends in a great measure upon whether the fœtus is
alive or dead. The gestation-sac after this date consists usually of the
expanded tube closely incorporated with the tissues of the broad
ligament, which may be thick in some parts and very thin in others. To
the walls of the sac, coils of the intestine, and particularly the
rectum, adhere. Experience decides that the safest plan, after exposing
the gestation-sac through an abdominal incision, is to cut into it and
remove the fœtus and placenta. When the fœtus is dead there will be
little trouble from the placenta. The edges of the incision are stitched
to the margin of the abdominal wound and drained.

In those rare cases where the amnion erodes the tube and invades the
belly (ventral pregnancy), the gestation-sac, with its contents, has
been successfully removed by merely transfixing its base with silk
ligatures.

The great danger of operations for extra-uterine gestation after the
fifth month, when the fœtus is alive, or only recently dead, is the
furious bleeding which accompanies the detachment of the placenta. It
may be stated that an operation for tubal pregnancy after the fifth
month of gestation, with a quick placenta, is the most dangerous in the
whole range of surgery. About two-thirds of the patients die. The
greatest danger is hæmorrhage, and the other is sepsis when the placenta
has been left to slough. It cannot be urged with too much force that
when it is fairly evident that a woman has an extra-uterine gestation,
it should be dealt with by operation without delay: and my experience of
the operation leads me to believe that it is a wise plan to remove the
placenta at the primary operation. Fortunately very few extra-uterine
fœtuses survive to term.

In cornual pregnancy, or, as it is often termed, ‘pregnancy in the
rudimentary horn of a so-called unicorn uterus,’ the removal of the
uterus is often necessary; there is, however, a variety of this form of
pregnancy in which the fully developed cornu may be spared, namely, that
in which the rudimentary but gravid cornu is connected with it by a
distinct and usually solid pedicle. Many such have been observed and
very carefully described.

In nearly all varieties of tubal pregnancy the uterine tissues are
sometimes so torn that it is difficult to arrest the hæmorrhage: in
this case it is now and then a wise practice to remove the uterus.

=Concurrent intra- and extra-uterine pregnancy.= The operative treatment
of this condition requires consideration under three headings:--

1. =Tubal and uterine pregnancy coexist, but the complication is
recognized in the early stages.= In this condition the signs are those
of an early tubal rupture or abortion (Fig. 7); in the majority of the
reported cases operation has been undertaken with the impression that
the trouble was simply due to tubal pregnancy, the intra-uterine
gestation being detected, or in some cases merely inferred from the size
of the uterus, in the course of the operation.

In these circumstances the operation is carried out as for a simple
tubal pregnancy, care being taken to disturb the uterus as little as
possible. In many instances such an operation has been followed by
brilliant consequences, for the intra-uterine pregnancy has remained
undisturbed and the patients have become the happy mothers of living
children.

Occasionally the operation has been followed by miscarriage and other
untoward results, but, speaking generally, a gravid uterus is very
tolerant of interference.

2. =Uterine and extra-uterine pregnancy running concurrently to term.=
(Compound pregnancy.) This may be described as the most dangerous
combination to which child-bearing women are liable. In order to show
what a disastrous conjunction it is to women with two ‘quick’
children--one intra- and the other extra-uterine--I have arranged some
recorded cases in the table on p. 35. Fortunately this form of compound
pregnancy is rare, but a rarer combination has been recorded by Menge,
in which the extra-uterine fœtus occupied the ovary and ran nearly to
term. When the woman came into labour, the ovarian pregnancy was
regarded as an obstructing tumour, and preparations were made for
performing cœliotomy. The intra-uterine child was born in the meantime.
When the supposed tumour was extracted, to the surprise of all it
contained a living fœtus. The mother and both children survived.

3. =Uterine pregnancy complicated with a sequestered extra-uterine
fœtus.= This is a very rare condition, but some cases have been very
carefully recorded (Leopold, Stonham, Worrall).

The physical signs are those of a pelvic tumour incarcerated by a gravid
uterus. The nature of the swelling may be sometimes accurately inferred
before operation, as in Worrall’s remarkable case. The sequestered fœtus
should be removed by cœliotomy.

After the death of the fœtus the operative treatment of extra-uterine
gestation is, as a rule, a simple proceeding, the fœtus and placenta can
be easily and safely removed. We have no certain means of deciding when
an extra-uterine fœtus is dead, nor do we know exactly how long after
the death of the fœtus the placental circulation ceases, but we do know
that in course of time, if the fœtus is retained, the placenta
disappears, because in cases where the fœtus is in the condition known
as lithopædion there is usually no placenta. When a retained
extra-uterine fœtus is wholly or partially converted into adipocere, the
tissues have a strong tendency to adhere to the walls of the sac. This
is especially marked in connexion with the hairy scalp.

Although a sequestered extra-uterine fœtus is uncommon, yet a surgeon
may stumble on one when he least expects it: these bodies may remain
undisturbed in the pelvis many years, even fifty, and be only discovered
in the post-mortem room, but they are always liable to be infected from
the adjacent bowel or bladder; then suppuration is inevitable. In some
instances the pus makes its escape at the umbilicus, and as the sinus
persists the surgeon explores it, and, on laying it open, is surprised
when he extracts the fœtus, sometimes entire.

This is sometimes referred to as ‘navel delivery’, and of this several
examples have been recorded. In one such case a fœtus was extracted by a
butcher: the woman recovered, and the account of this remarkable case
ends thus: ‘She had a navel rupture, owing to the ignorance of the man
in not applying a proper bandage’ (_Phil. Trans._, Abridged Edition,
1805, vol. viii, p. 517). This is a good instance of professional bias
in the apportioning of blame.

Usually, when pathogenic micro-organisms gain access to the
gestation-sac the fœtus decomposes, and fistulæ form, by which pus,
accompanied by fragments of fœtal tissue and bones, finds an exit and
affords evidence of the nature of the case. These fistulæ may open into
the rectum, bladder, vagina, uterus, or some spot on the anterior
abdominal wall below or near the umbilicus. The treatment is simple, and
consists in dilating the sinus and extracting all the fragments. If this
be thoroughly carried out the sinus quickly closes. Partial operations
are useless: if but a bit of a bone remain, a troublesome sinus will
persist. It is bad practice to attempt to extirpate the sac in such
condition; such an operation usually terminates fatally.

In a case of old-standing lithopædion it is unusual to find any trace of
the placenta. J. W. Smith operated on a woman in whom a lithopædion had
caused intestinal obstruction. The fœtus had probably been retained
15-1/2 years, and the placenta was represented by a calcified encapsuled
ball, with an average diameter of 6 cm.

=Results of operative treatment.= In order to afford some notion of the
risks attending the surgical treatment of extra-uterine gestation, as
well as to give an idea of its relative frequency in hospital practice,
the following figures will serve. From 1896 to 1907, both years
inclusive, 116 operations were performed for extra-uterine gestation in
the Chelsea Hospital for Women. During this period all the varieties of
tubal pregnancy were encountered (ampullary, isthmial, tubo-uterine),
including the rare condition of a full-time living fœtus free among the
intestines, and the more uncommon condition of a full-time cornual
pregnancy. There were four deaths in the series, one in 1897, 1902, and
two in 1905. Death in the fatal cases was attributed to pulmonary
embolism, peritonitis, and in two to heart failure.

    A TABLE SHOWING CASES OF CONCURRENT INTRA- AND EXTRA-UTERINE
    PREGNANCY (COMPOUND PREGNANCY) RUNNING TO TERM, WITH THE FATE OF THE
    MOTHER AND CHILDREN.

    +-----------+-------+---------+--------------+--------------+
    |_Recorder._|_Year._|_Fate of |_Intra-uterine|_Extra-uterine|
    |           |       | Mother._|    Child._   |    Child._   |
    +-----------+-------+---------+--------------+--------------+
    |Cooke      | 1863  |  Died   |    Died      |   Died       |
    |Sale       | 1871  |  Died   |    Lived     |   Lived      |
    |Wilson     | 1880  |  Died   |    Died      |   Lived      |
    |Galabin    | 1881  |  Died   |    Died      |   Died       |
    |Franklin   | 1893  |  Died   |    Lived     |   Died       |
    |Matthewson | 1894  |  Lived  |    Lived     |   Killed[1]  |
    |Ludwig     | 1896  |  Lived  |    Lived     |   Lived      |
    |Allardice  | 1905  |  Lived  |      ?       |   Dead[2]    |
    |Menge      | 1907  |  Lived  |    Lived     |   Lived      |
    +-----------+-------+---------+--------------+--------------+

[1] This fœtus was killed by means of a stilette passed through the
abdominal wall of the mother into its thorax. The patient had two
subsequent confinements without difficulty. In 1898 the ‘lump’ had
shrunk, but was movable and caused no difficulty. _Pacific Medical
Journal_, September, 1898.

[2] Intra-uterine child born naturally at the seventh month.
Extra-uterine fœtus died, set up septic changes, and was removed by
cœliotomy some weeks later.


REFERENCES

LEOPOLD. Ovarialschwangerschaft mit Lithopädionbildung von 35-jähriger
    Dauer. _Arch. f. Gyn., 1882_, Bd. xix. 210.

MENGE. Eine reine Ovarialschwangerschaft mit bebendem Kinde. _Vide_
    Fränkische Gesellschaft für Geburtshülfe and Frauenheilkunde.
    _Münch. med. Wochensch., 1907_, liv. 2452.

SMITH, J. W. _Jour. of Obstet. and Gyn. of the British Empire, 1908_,
    xiii. 180.

STONHAM, C. Lithopædion, _Trans. Path. Soc., 1887_, xxxviii. 445.

WORRALL. Ectopic Gestation complicating Normal Pregnancy. Abdominal
    section. Recovery. _Med. Press and Circular, 1891_, i. 296.




CHAPTER V

HYSTERECTOMY AND MYOMECTOMY


_Hysterectomy is the name applied to the surgical operation for the
removal of the uterus._

=Indications.= Hysterectomy is mainly required in the radical treatment
of fibroids and malignant disease (carcinoma, sarcoma, and
chorion-epithelioma). It is occasionally required for injury, and
certain morbid states due to acute and chronic sepsis; and for a
condition but little understood, termed generically fibrosis.
Hysterectomy is also carried out for such conditions as diffuse
adenomyoma of the uterus, hæmato-metra, tuberculous endometritis, and on
rare occasions for chronic inversion of the uterus and inveterate
dysmenorrhœa.

The presence of fibroids in the uterus is a common cause for which
hysterectomy is required, and the history of this operation is full of
interest.

The uterus may be removed by two methods. In one, access is obtained to
the uterus through an incision in the belly-wall; this is termed
abdominal hysterectomy. In the other, the whole uterus is extirpated
through the vagina, and on this account it is termed vaginal
hysterectomy or colpo-hysterectomy.

The abdominal method of removing the uterus may be performed in two
ways:--

In one the body of the uterus and a portion of its neck is removed; this
is called subtotal hysterectomy (or supravaginal hysterectomy). In the
other the body of the uterus and the whole of its neck are excised: this
is total hysterectomy (or panhysterectomy). The ovaries and Fallopian
tubes may, or may not, be removed, according to the disease for which
the operation is undertaken. This is a matter which will receive ample
consideration later on (see p. 56).

For the satisfactory performance of abdominal hysterectomy the
Trendelenburg position is necessary.


SUBTOTAL HYSTERECTOMY

The abdomen is opened by the median subumbilical incision; but when the
operation is performed for the removal of large tumours it will
frequently require extension above the umbilicus. The operator should
never allow himself to be embarrassed by a small incision. As soon as
the peritoneal cavity is reached, the surgeon introduces his hand and
carefully makes out the nature of the case, the presence or otherwise of
adhesions, other tumours, and the relation of the fibroid to the uterus,
and determines whether it is impacted in the pelvis. The uterus is then
carefully lifted out through the incision, or drawn out with the
assistance of a volsella; the intestines and omentum are isolated from
the pelvis with a large warm dab.

[Illustration: FIG. 9. A DIAGRAM TO SHOW THE ARTERIAL SUPPLY OF THE
UTERUS.]

In a simple case the broad ligaments are seized with hæmostatic forceps;
if the ovaries and tubes are healthy and the surgeon wishes to preserve
them, the forceps are applied between the ovary and the uterus; but if
they are obviously diseased and must be sacrificed, the forceps are
applied to the broad ligaments near the brim of the pelvis beyond the
outer pole of the ovary. In some instances the round ligament of the
uterus can be seized with the same forceps, but in many cases it is
necessary to clip it separately. It is an advantage to secure the round
ligament at this stage, for the forceps controls its artery and prevents
the stump of the ligament unduly retracting the peritoneum. The broad
and round ligament on each side are divided, and the uterine artery is
exposed on each side of the uterus and caught with forceps: a peritoneal
flap is then fashioned on the anterior wall of the uterus at its
junction with the neck, taking care not to injure the bladder; and a
similar flap is cut on the posterior wall. The uterus is then detached
at a point well below the junction of the cervix with the body of the
uterus: if the forceps are correctly applied to the vessels the
detachment of the uterus is an almost bloodless proceeding: a small
vessel here and there will perhaps require the application of a pair of
forceps.

The principle involved in this part of the operation may be explained by
reference to the diagram (Fig. 9). The blood-supply of the uterus
follows four routes; two of these are the ovarian arteries which
traverse the broad ligaments to reach the cornua of the uterus, where
they anastomose with the terminations of the uterine arteries; the
latter come into relation with the uterus near the junction of the body
and cervix, and then ascend the sides of the uterus to the cornua. No
large vessels are found on the anterior or posterior surface of the
uterus. An arterial twig runs along the round ligament, bringing the
ovarian artery into relation with the deep epigastric artery. If the
surgeon thoroughly appreciates the distribution of the ovarian and
uterine vessels he will at once perceive that if the four forceps are
properly applied to the vessels the blood-supply is under absolute
control: indeed, in many cases a subtotal hysterectomy can be performed
without the loss of more than an ounce of blood. When the broad ligament
is clamped and detached there is a spurt of blood from the uterine cornu
which lasts until the corresponding uterine artery is caught with the
forceps, and the cessation of the bleeding at the uterine cornu is a
sign that the artery is securely clipped. It must be remembered that
with a small tumour in the uterus the vessels follow their normal
courses and can be easily found, but when the uterus is deformed by huge
tumours, the vessels are not so easily seen, and they are of large size
and give rise to furious bleeding when divided. In dealing with large
and vascular uterine fibroids another factor has to be reckoned with,
namely, the enormous veins in the pampiniform plexus, interspersed with
lymphatics which in some cases are as thick as the index-finger; it is
not an uncommon thing to meet with lymphatics in this situation a
centimetre in diameter and filled with straw-coloured lymph.

[Illustration: FIG. 10. A FIBROID GROWING NEAR THE RIGHT UTERINE CORNU.
It separates the ovarian ligament, Fallopian tube, and round ligament of
the uterus from each other. Full size.]

The surgeon now secures the vessels. The ovarian pedicles are transfixed
and ligatured with silk as in ovariotomy: the round ligament is usually
included in the ovarian pedicle. It occasionally happens that a fibroid
situated near the uterine cornu will grow in such a manner that it
widely separates the ovarian ligament, the Fallopian tube, and the round
ligament from each other as shown in Fig. 10. In such a condition it is
impossible to save the ovary without risk, and also inadvisable to
attempt the inclusion of the round ligament in the pedicle containing
the ovarian vessels. In these circumstances the round ligament is easily
secured by a mattress suture, which should include both layers of the
corresponding broad ligament.

[Illustration: FIG. 11. THE MATTRESS SUTURE. A diagram to show the
method of applying it.]

When the surgeon decides to leave an ovary and the corresponding
Fallopian tube, these structures are carefully examined to determine if
they are healthy and free from any suspicious fluid. _When the
endometrium is septic or cancerous both ovaries and tubes should be
removed._ When the surgeon decides to leave an ovary and its
corresponding Fallopian tube, he should take care in securing the
ligatures to include the ligament of the ovary: it is very liable to
slip out of the encircling loop of silk. It is often convenient to
include the round ligament of the uterus in the pedicle, but it is not a
disadvantage when it is tied separately.

[Illustration: FIG. 12. THE STUMP AFTER SUBTOTAL HYSTERECTOMY. To show
the method of applying the continuous suture.]

The uterine arteries are ligatured with thin silk; these vessels as they
run up the sides of the uterus are accompanied by veins, so that there
is a vascular tract at the point where the cervix is divided. If after
the uterine vessels are secured there is oozing from these veins, it is
easily controlled by a mattress suture. This kind of suture is so useful
that the mode of inserting it may be given in more detail. In the
diagram (Fig. 11) the silk is represented in position before it is tied,
and in that particular instance it is represented as being passed
through the peritoneal flaps from before backwards, and this is usually
the most convenient route; occasionally the reverse direction is
easier. It will be noticed in the diagram that this suture not only
controls oozing from the tissue in the immediate neighbourhood of the
uterine vessels, but it also embraces the main vessels, and thus serves
as an additional security against hæmorrhage; it also brings the
peritoneal flaps into apposition.

As soon as the oozing of blood has been controlled, the cervical canal
is examined to ascertain if it be free from polypi or cancer. Should the
condition of the cervix be in the least degree suspicious of cancer it
must be extirpated. When it is healthy, then the flaps are brought
together by one or two interrupted sutures, and the edges more carefully
approximated by a continuous suture of thin silk. In suturing the flaps
it is necessary to avoid puncturing the bladder, which is quite close
to, and often forms part of, the anterior flap. Care must also be taken
in passing the needle (especially when it has sharp edges) in the
neighbourhood of the stumps of the uterine arteries, or they will be
pricked, and then free bleeding will cause delay in the operation.

When this operation is properly performed, there should be no projecting
stump on the floor of the pelvis; the sutured edges of the peritoneum
merely appear as a thin line below the base of the bladder.

The pelvis is now cleared of blood and clot; the dabs and instruments
are counted, and it is also useful to examine the condition of the
vermiform appendix, and if grossly diseased it should be removed.

The abdominal incision is then sutured in the way described on p. 9.


TOTAL HYSTERECTOMY

This operation differs from the preceding in the fact that the neck of
the uterus is removed as well as its body. The abdomen is opened in the
usual way and the uterus is withdrawn from the abdomen and the arteries
controlled by forceps, and the broad ligaments divided exactly as in the
case of the subtotal operation. Unless the uterus be very big it is
drawn well out of the abdomen and the bladder peeled off its anterior
aspect. The surgeon then feels for the extremity of the cervix and opens
the vagina with the scalpel and carefully detaches it from the neck of
the uterus, taking great care to keep close to the cervix in order to
avoid wounding the bladder or the ureters. As soon as the uterus is
detached, the cut edge of the vagina is seized with the volsella to
prevent it retracting. In some instances the body of the uterus may be
removed as in the subtotal operation, and the cervix detached
separately; occasionally the surgeon begins his operation with the
intention of performing the subtotal operation, but finds the cervix
unhealthy or cancerous, and removes it.

As soon as the uterus is removed and all bleeding under control, then
the blood-vessels are secured with ligatures; the ovarian artery and
vein are secured on each side in the usual manner. The chief point in
this operation is the method of dealing with the vaginal opening. In the
subtotal operation the vessels concerned in the stump are the uterine
arteries, but in the total operation the territory of the vaginal
arteries is invaded, and these vessels are apt to bleed when the patient
is returned to bed, unless care is taken to secure them in the course of
the operation. The parts which require most attention are the lateral
angles in the immediate neighbourhood of the uterine arteries; these
angles may be secured by a mattress suture involving the anterior and
posterior wall of the vagina; any oozing on the anterior or posterior
wall is commanded by a mattress suture involving these walls separately,
so as not to completely close the vaginal opening. Bleeding from the cut
edges of the vagina may also be readily controlled by means of a
continuous suture of thin silk. The peritoneum is sutured over the cut
ends of the vagina, so that when the operation is completed a thin seam
is seen lying under the base of the bladder.

In cases where the uterus is removed for septic conditions, such, for
example, as an infected or gangrenous fibroid, or when cancer of the
corporeal endometrium and a submucous fibroid coexist, I modify the last
stages of the operation. After the ovarian and uterine arteries are
ligatured, the cut edges of the vagina are secured in the following way:
the cut edge of the peritoneum covering the bladder is stitched to the
cut edge of the anterior wall of the vagina, and in the same way the
peritoneum in relation with the posterior vaginal wall is stitched to
the corresponding cut edge of the vagina. The flaps at the lateral
angles of the vaginal opening are drawn together with a suture and the
intervening segment is left with merely the cut edges in apposition:
this affords a route for the escape of pus if required.

Whether the peritoneum is sutured over the vaginal opening, or whether
the edges are merely left in apposition, the recesses of the pelvis are
thoroughly cleared of fluid and clot. The dabs and instruments are
counted, and the wound sutured as recommended on p. 9. In septic
conditions the abdominal incision should be closed with a single row of
through and through sutures. Before the patient leaves the operating
table it is useful to examine the vagina and mop out any blood which has
found its way there in the course of the operation. It is also useful to
pass a glass catheter and withdraw any urine that has accumulated during
the operation.

If there is evidence of free oozing it is most likely to come from the
cut edges of the vaginal wall in a case of total hysterectomy: under
such conditions it is easy to apply a pair of fenestrated forceps to
the oozing area and leave them on for thirty-six hours. They will cause
the patient trifling inconvenience. Care must be taken not to fix the
blade too far on the anterior flap, or it will lead to subsequent
sloughing of the bladder.

When there is free oozing of blood from the cervical canal after
subtotal hysterectomy, it is easily and safely controlled by applying a
pair of fenestrated forceps on each side of the cervix, but not too
deeply, or the ureters may be nipped. These should be left on for
thirty-six hours.

[Illustration: FIG. 13. A BICORNATE UTERUS. This uterus is shown in
coronal section; each cornu contains a fibroid. Removed from a spinster
aged 32 on account of acute pain probably caused by the axial rotation
of one cornu. Two-fifths size.]

The details of the operation set forth in this account refer to a simple
or uncomplicated hysterectomy, and under these conditions it cannot be
described as a difficult operation to any surgeon accustomed to
abdominal operations, but the complications not infrequently met with in
connexion with uterine fibroids are occasionally very formidable, and
tax the skill and resource of the boldest; _e.g._ fibroids which are
inflamed and adherent to the colon, rectum, or small intestines;
fibroids associated with unilateral or bilateral pyosalpinx, or a
suppurating ovarian cyst incarcerated in the pelvis by the enlarged
uterus; fibroids complicated by cancer in the neck of the uterus; or a
cervix fibroid firmly incarcerated in the pelvis by a big fibroid in the
fundus of the uterus, and pushing the bladder upwards in front of the
tumour.

=Cervix fibroids.= The operative treatment of this variety needs
separate consideration because these tumours do not lend themselves to
any routine method.

When the uterus with the tumour in its cervix can be raised out of the
pelvis far enough to allow the necessary manipulations, then total
hysterectomy can be performed easily and quickly. Occasionally the
tumour is wide and so fixed in the pelvis that it will be necessary to
split the uterus longitudinally and to enucleate the fibroid from its
bed; then an ordinary subtotal or total hysterectomy can be carried out.
The enucleation of a large impacted cervix fibroid requires to be
conducted carefully, without undue display of force, or so much shock is
produced that the patient’s life will be placed in the gravest peril.

[Illustration: FIG. 14. A BICORNATE UTERUS SHORTLY AFTER DELIVERY. The
pregnancy occurred in the left half. The vesico-rectal ligament is well
shown.]

=On hysterectomy when the uterus is double.= Fibroids and cancer arise
in malformed uteri, as well as in those of normal shape (Fig. 13). When
the body of the uterus is double (bicornate) and the surgeon stumbles
upon it in the course of a pelvic operation he may be puzzled if he is
not familiar with the anatomical conditions associated with this
malformation.

When the body of the uterus is bicornate the rectum lies in the middle
line of the pelvis, and a median vertical fold of peritoneum, the
_ligamentum vesico-rectale_ passes, from its anterior aspect through the
gap between the uterine cornua to become continuous with the peritoneum
covering the posterior surface of the bladder (Fig. 14). That portion of
the vesico-rectal ligament which lies between the rectum and the neck of
the uterus divides the recto-vaginal fossa into a right and a left
half. This peritoneal ligament requires careful treatment, or the
surgeon may accidentally open the rectum or the bladder. In closing the
peritoneum over the cervical stump it is sometimes necessary to bring
the edges of the abnormal fold into apposition vertically by a
continuous suture.

In a case of this kind in which I performed total hysterectomy for
cancer of the neck of the uterus the extensive peritoneal connexions
were somewhat troublesome, and when the uterus was removed it seemed as
if the floor of the pelvis had been stripped of its serous covering. The
bifid nature of the uterus had been anticipated before the operation, as
an imperfect vertical septum was known to exist on the posterior vaginal
wall. The patient made an excellent recovery.

Experience teaches that bicornate uteri cause more difficulties in
diagnosis than in technique, but the presence of the vesico-rectal
ligament would probably bar the removal of the uterus by the vaginal
route. The existence also of a median longitudinal septum, partial or
complete, in the vagina would be another difficulty.

=Mortality.= In order to give some idea of the great improvement which
has taken place in the operation of abdominal hysterectomy for fibroids
in London the following figures will be found of great interest.

In the year 1896 the results of abdominal hysterectomy for fibroids in
the hospitals of London may be inferred from the following table:--

    St. Bartholomew’s               7 with 3 deaths
    St. Thomas’s                    5  "   2   "
    St. George’s                    1  "   0   "
    Middlesex                       6  "   1   "
    University College              3  "   0   "
    Samaritan                      17  "   4   "
    Soho (for women)                1  "   0   "
    Chelsea Hospital for Women      9  "   1   "
                                   __     __
                                   49  "  11   "

In these hospitals and the New Hospital for Women the returns in 1906
are as follow:--

    St. Bartholomew’s              26 with 4 deaths
    St. Thomas’s                   40  "   2   "
    St. George’s                    8  "   0   "
    Middlesex                      50  "   0   "
    University College             21  "   1   "
    Samaritan                      37  "   2   "
    Soho (for women)               60  "   1   "
    Chelsea (for women)            80  "   1   "
    New (for women)                26  "   0   "
                                  ___     __
                                  348  "  11   "

The returns during 1906 and 1907 from my service at the Chelsea
Hospital for Women and the Middlesex Hospital, as verified by the
Registrars, were 101 abdominal hysterectomies for fibroids; all the
patients recovered. Of these 101 operations, 7 were total and the
remainder subtotal hysterectomy.

[Illustration: FIG. 15. VILLOUS DISEASE OF THE UTERUS. The uterus is
shown in sagittal section. The cavity is dilated and occupied by a
villous tumour growing from its posterior wall. Successfully removed
from a multipara aged 83. Full size.]

=The risks of abdominal hysterectomy.= The dangers of hysterectomy are
those common to cœliotomy, such as sepsis, peritonitis, shock, and the
risks of the anæsthetic. There are certain special dangers, such as
hæmorrhage; injury to the vesical segments of the ureters, and
especially the bladder; injury to the intestines, especially the rectum;
acute intestinal obstruction; thrombosis and pulmonary embolism. These
risks and dangers are considered fully in their relation to all forms of
abdominal gynæcological operations in a special chapter (see Chap. XI).

Among the rarer forms of death after hysterectomy may be mentioned acute
perforation of the stomach or the small intestine, cerebral hæmorrhage,
lobar pneumonia, thrombosis of the right auricle, embolism of the
femoral artery ending in gangrene of the leg, suppression of urine, and
acute mania. These are fatal conditions which follow any major operation
in surgery, and have no special connexion with hysterectomy.

The removal of the uterus has been rendered so safe that even in
advanced age it has been employed with success, as the subjoined table
shows:--

    TABLE OF CASES IN WHICH HYSTERECTOMY WAS PERFORMED ON WOMEN OF
    SEVENTY YEARS AND UPWARDS.

  -----------+------+----------------+---------+-----------------------
  _Reporter._|_Age._|  _Nature of    |_Result._|     _Reference._
             |      |    Operation._ |         |
  -----------+------+----------------+---------+-----------------------
  Bland-     |  73  |Subtotal for    |    R.   |_Trans. Obstet. Soc._,
    Sutton   |      |  Fibroid 28 lb.|         |  1900, xli. 300.
  Stewart    |  70  |Subtotal for    |    R.   |_Australian Med. Gaz._,
    McKay    |      |  Fibroid 19 lb.|         |  1907, 14.
  Bland-     |  83  |Vaginal Hyst.   |    R.   |_Trans. Obstet. Soc._,
    Sutton   |      |  for Villous   |         |  1906, xlix. 46.
             |      |  disease.      |         |
             |      |  Fig. 15.      |         |
  Malcolm    |  74  |Total for       |    R.   |_Brit. Med. Journal_,
             |      |  Fibroids.     |         |  1907, ii. 1571.
  -----------+------+----------------+---------+-----------------------


ABDOMINAL MYOMECTOMY

_Under this general term it is usual to include operations for the
removal, through an abdominal incision, not only of pedunculated
subserous fibroids, but also sessile and interstitial (intramural)
fibroids of the uterus._

The earliest operations of this kind were performed by Spencer Wells
(1863); but little attention was given to this matter until the
advantages of abdominal myomectomy were strongly advocated by A. Martin
(1880) and Schroeder (1893). The operation has been practised by many
surgeons and gynæcologists imbued with conservative ideals in regard to
the uterus. In its early days the operation was attended with a very
high mortality, but the great improvements in hysterectomy have limited
very materially the scope of abdominal myomectomy.


ABDOMINAL MYOMECTOMY AND ENUCLEATION FOR FIBROIDS

_Abdominal myomectomy._ This signifies the removal of one or more
pedunculated subserous fibroids through an incision in the abdominal
wall, preserving the uterus, Fallopian tubes, and the ovaries.

_Abdominal enucleation._ In this operation a sessile fibroid is shelled
out of its capsule: the uterus, ovaries, and tubes are preserved.

_Hysterotomy._ In this operation a submucous fibroid is removed, through
an incision in the wall of the uterus, which opens the uterine cavity.

The preliminary steps for each of these procedures is the same as for
ovariotomy, and the Trendelenburg position is of great advantage.

After opening the abdomen the intestines are carefully protected by a
warm dab, and the tumour carefully examined.

When the stalk is narrow it may be transfixed and secured with silk
thread, like the pedicle of an ovarian cyst. When the pedicle is short
and broad the tumour should be shelled out of its capsule, and any
obvious blood-vessel is easily secured with forceps and ligatured with
silk. The opposite flaps of the capsule are brought into apposition by
mattress sutures, and the redundant portions of the capsule cut away and
the free edges carefully brought together by a continuous suture of thin
silk.

When a fibroid is embedded in the wall of the uterus, the tumour is
exposed by cutting through its capsule and seizing it with a volsella;
as a rule, it shells out quite easily. This is followed by free
bleeding. The vessels are then seized with forceps and ligatured with
thin silk. In order to completely control the oozing, mattress sutures
are passed through the wall of the capsule on each side, their number
varying with the size of the tumour.

In some instances a uterus contains ten or more fibroids, and each must
be enucleated and the capsule secured with ligatures, as described
above.

Sometimes the oozing is difficult to control, and the surgeon sutures
the edges of the capsule to the lower angle of the incision, and stuffs
the cavity or bed of the tumour with gauze.

In removing a large submucous tumour through an incision in the wall of
the uterus, the surgeon necessarily opens the uterine cavity
(hysterotomy). After controlling the bleeding the walls of the uterine
incision are closed, as in Cæsarean section.

In many instances in which the surgeon attempts to carry out myomectomy
or enucleation, he has such difficulty in controlling the oozing that he
is driven to remove the uterus.

It is admitted by most writers that the ideal method of dealing with
fibroids requiring removal by cœliotomy is to remove them either by
ligature or by enucleation. In actual practice this ideal operation of
removing the tumours and leaving the uterus and ovaries intact can only
be carried out in a small proportion of cases, probably in less than 10
per cent., and it is fair to state that enucleation and hysterotomy are
often more troublesome and serious operations than hysterectomy; also
the preservation of the uterus is not always an advantage to the
patient.

When a woman is submitted to hysterectomy for fibroids we can assure her
that the tumours will not recur, but after a myomectomy or enucleation
in a woman in the reproductive period of life we cannot give her this
assurance, for she may have in her uterus many ‘seedlings’ or ‘latent
fibroids’ and one or several of these may grow into formidable tumours.

There are three conditions in which myomectomy and enucleation are
legitimate procedures:--

1. A young woman contemplating marriage, or a married woman anxious for
offspring, if her tumour be single and admits of myomectomy or
enucleation, may have her uterus spared. Although I have carried out
these measures on many occasions, I only know of five patients who have
subsequently borne children.

2. Occasionally in pregnancy (see p. 82).

3. Myomectomy is a very safe undertaking in patients at, or after, the
menopause, where a stalked fibroid gives trouble by twisting its
pedicle, or by shrinking to such a size that it falls into the true
pelvis and becomes impacted; or, more rarely, the pedicle of such a
tumour entangles a loop of small intestine and obstructs it.

In order to give the matter a statistical basis I have drawn up an
analysis of ninety-five consecutive cases of myomectomy and enucleation
out of my practice, with the subsequent history of some of the patients.
This experience covers a period of twelve years.

Of these ninety-five patients three died as the result of the
operation--two from pneumonia in the fourth week after operation, and
one a few days after operation: in this case there is reason to believe
that the tumour was complicated with cancer of the body of the uterus.

Six of the women were submitted to myomectomy during pregnancy, and in
four cases the operation was undertaken under the impression that the
tumour was an ovarian cyst which had undergone axial rotation. These
cases occurred in the days before I recognized that ‘red degeneration’
of fibroids complicating pregnancy caused them to be painful and tender
(see p. 78). In one patient this complication was clearly recognized. In
the sixth patient the tumour was regarded by some capable gynæcologists,
who examined her, as a tubal pregnancy complicating a gravid uterus.
Five of these patients went to term and were delivered of living
children. The sixth miscarried two months after the myomectomy.

Of the ninety-two successful myomectomies, five subsequently became
pregnant and had living children, but in each instance the fibroids were
subserous. I have not known a patient to become pregnant after abdominal
myomectomy for a submucous fibroid, large or small. In calculating the
probability of pregnancy from these statistics it must be mentioned that
the patients fall into three categories:--

1. Forty women were in the child-bearing period of life and married;
many of them were multiparæ.

2. Twenty were single women and probably capable of bearing children in
a favouring environment.

3. The remainder were spinsters or barren wives.

A significant feature in the after-history of ten of these women is the
fact that some years later other fibroids grew in the uterus, and
hysterectomy became a necessity on account of menorrhagia in seven of
them; of these, two died from the operation, which was difficult and
tedious. One patient was operated upon two years after the myomectomy,
and had borne a child in the interval, and the other seven years.

The last fact to mention is that one patient, from whom a submucous
fibroid had been enucleated from the cavity of the uterus (hysterotomy),
died four years later from cancer arising in the body of the uterus (see
p. 51).

Olshausen has recently considered this question, and indicates that the
chief objection to the abdominal enucleation of uterine fibroids is its
high mortality.

He furnishes a table of 563 cases, collected from twelve operators,
including himself; of these 59 patients died, representing a mortality
of 10.5 per cent. Olshausen, in the years 1900-5, performed enucleation
on 124 patients with 14 deaths. Eight of the patients subsequently came
under notice with recrudescence of fibroids. Christopher Martin has
performed abdominal myomectomy 73 times with 1 death.

The question of myomectomy, when fibroids complicate pregnancy and
labour, or give trouble after labour, is considered in detail on p. 78.


REFERENCES TO REPORTS OF HYSTERECTOMY PERFORMED FOR FIBROIDS IN
MALFORMED UTERI

BLAND-SUTTON, J. Fibroids in a Unicorn Uterus. _Clin. Journ._, Lond.,
    1901-2, xix. 1.

BLAND-SUTTON, J. Case of Fibroids in both halves of a Bicornate Uterus.
    _Proc. R. Soc. of Medicine_, 1908. Obstet. and Gyn. Sect., ii. 95.

CZERWENKA. Uterus bicornis unicollis, &c. _Centralbl. f. Gyn._, Leipz.,
    1900, xxiv. 207.

DORAN, A. The Removal of a Fibroid from a Uterus Unicornis in a Parous
    Subject. _Brit. Med. Journ._, 1899, i. 1389.

GOW, W. J. Cystic Intraligamentous Myoma with Double Uterus. _Trans.
    Obstet. Soc._, Lond. (1898), 1899, xl. 134.

HEINRICIUS. Ein Fall von Myoma im rudimentaren Uterus bicornis
    unicollis. _Monatschr. f. Geburts. u. Gyn._, Berl., 1900, xii. 419.

KAMANN. Uterus bicornis unicollis with a Myoma in the Left Horn;
    Subtotal Extirpation of the Left Horn. _Centralbl. f. Gyn._, 1905,
    xxix. 795.

MARTIN C. The Ingleby Lectures. On the Dangers and Treatment of Myoma of
    the Uterus. _Lancet_, 1908, ii. 1682.

OLSHAUSEN, R. In Veits’ _Handbuch der Gynäkologie_, Wiesbaden, 1907, Bd.
    ii, p. 607.

ROUTH, A. Fibroid of One-horned Uterus. _Trans. Obstet. Soc._, 1888,
    xxix. 2 and 57, with a good drawing.




CHAPTER VI

ON THE RELATIVE VALUE OF TOTAL AND SUBTOTAL HYSTERECTOMY


The great success which followed the use of the short ligature in
ovariotomy induced several surgeons to apply the same principle to the
cervical pedicle when removing the uterus for fibroids. The result was
dismal failure. Matters improved somewhat after Koeberlé introduced the
serre-nœud, and this continued the safest method until 1892. In the
meantime antisepsis had begun to take effect in pelvic surgery, and
attempts were made by Bardenheuer (1881), Polk, and other surgeons to
avoid the dangerous difficulties connected with the treatment of the
stump by removing the cervix as well as the uterus (total hysterectomy),
and they attained an encouraging measure of success. Nevertheless, other
surgeons (Goffe, Milton, Heywood Smith, and Stimson) felt that the
enucleation of the cervix was not always necessary, and sought to find a
way of avoiding it. The credit of solving this difficulty fell to Baer
of Philadelphia (1892), for he showed that it is dangerous to constrict
the neck of the uterus with ligatures, it is only necessary to secure
the arteries.

Baer’s method of supravaginal hysterectomy, or, as it is now commonly
termed, the subtotal operation, soon supplanted the total method of
Bardenheuer. The publication of Baer’s paper had great consequences; it
came at a time when the attention of gynæcologists was centred on
improvements in hysterectomy. The method was promptly tested and adopted
in London. The effects of this improvement in technique in a few years
revolutionized the surgical treatment of uterine fibroids, as the
statistical results set forth on p. 44 amply prove.

The great advantage of Baer’s method is its simplicity and safety; but
there is a disposition on the part of a few surgeons to prefer the total
operation, mainly on the ground that the cervical stump left after
subtotal hysterectomy is liable to become attacked by cancer.

As far as I can ascertain, Dr. M. Mann, of Buffalo, was the first to
draw attention to the occurrence of cancer in the neck of the uterus
after the body of the organ had been removed. He stated in 1893 that he
‘removed an ovarian tumour and the body of the uterus, by accident,
along with it; the cervix was left’. The patient recovered. ‘Six months
afterwards cancer developed in the cervix, from which she died.’

When cases of cancer supposed to arise in the stump left after subtotal
hysterectomy come to be critically analysed, they fall into four
groups:--

    1. The disease existed in the neck of the uterus at the time
       of the primary operation, but was overlooked.
    2. Cancer attacked the cervical stump subsequent to subtotal
       hysterectomy.
    3. The fibroid which necessitated the hysterectomy was really
       a sarcomatous tumour of the uterus.
    4. The suspected growth on the cervix is not malignant, but a
       granuloma.

Each of these postulates requires separate consideration.

Many observations have been published which show beyond dispute that
surgeons have performed subtotal hysterectomy in ignorance that the
cervix was already cancerous, and the hæmorrhages of which the patients
complained before the operation were due as much to the cancer in the
neck of the uterus as to the fibroids. This should serve as a warning
that, in cases where the surgeon contemplates performing a subtotal
hysterectomy, he should carefully examine the cervix beforehand; at the
time of the operation he should also critically examine the cut surface
of the cervix, and if it be in the least suspicious he should remove the
neck of the uterus. It is necessary to remember that cancer attacks any
part of the cervical endometrium, therefore an early cancerous ulcer in
the middle of the cervix will run a great chance of being missed by a
surgeon who is content with a subtotal hysterectomy.

It is certain that cancer does occasionally attack a cervical stump left
after subtotal hysterectomy at such an interval after the operation as
to make it certain that the cancer did not exist at the time of the
operation. Such a case occurred in my practice. I performed subtotal
hysterectomy in 1901 on a woman forty-two years of age, mother of one
child; eighteen months later there was a cancerous ulcer on the cervix;
the whole of the cervical stump was promptly removed and the nature of
the disease established microscopically. In 1908 the patient was in
excellent health.

In another case under my care I performed total hysterectomy for
fibroids in ignorance that the patient had cancer of the cervix. Some
months after the operation cancer recurred in the vaginal vault and scar
of the hysterectomy; the neck of the uterus had been preserved by the
doctor, and on examination the cancer was found. In this instance,
although total hysterectomy was performed, it had no effect in staying
the course of the disease.

It is necessary to utter a caution in regard to the occurrence of cancer
of the cervix after subtotal hysterectomy. I removed a uterus
containing a large globular submucous fibroid from a barren married
woman forty-five years of age. Six years later she came under my
observation with a large granulating and bleeding growth on the cervix
uteri. I had no doubt from the naked-eye characters that this was a
primary carcinoma, although it surprised me to find it there, especially
as the woman had never been pregnant. On my urgent representations she
allowed me to remove the cervix. On microscopic examination the
suspected cancer turned out to be a granuloma. Two years later the
patient was in good health. Polk has recorded a similar experience.
These facts show that caution is necessary in accepting reports of
cancer of the uterine stump after subtotal hysterectomy.

=Cancer of the body of the uterus and fibroids.= In deciding between
total and subtotal hysterectomy for fibroids the probable presence of
cancer requires consideration in another aspect. Although uterine
fibroids do not predispose to cancer of the neck of the uterus, many
writers in recent years have expressed their suspicions that the
presence of a submucous fibroid favours the development of cancer in the
corporeal endometrium. Piquand, in 1905, drew attention to this matter
and emphasized what other observers had pointed out, namely, that a
submucous fibroid is often associated with changes in the mucous
membrane of the uterus, which not only causes excessive bleeding, but
sets up inflammatory conditions giving rise to leucorrhœa, salpingitis,
pyosalpinx, and morbid changes in the endometrium, rendering it
susceptible to cancer. His statistics support his conclusions, for they
represent that in one thousand women with fibroids fifteen will probably
have cancer of the body of the uterus. My own observations support this
opinion. This complication is found most frequently between the fiftieth
and the sixtieth year of life. If we narrow the ages of the patient and
exhibit the liability in its most emphatic form it would run thus: that
in patients submitted to hysterectomy for fibroids over the age of fifty
years, about ten per cent of them will have cancer of the corporeal
endometrium.

In 1906 I looked through the case-notes of five hundred patients who had
been submitted to operation for uterine fibroids under my care. Of these
sixty-three patients had attained the age of fifty years and upwards.
Among these sixty-three women there were eight cases of cancer of the
corporeal endometrium; the nature of the disease in each case was
verified by careful microscopic examination.

Consequently, in performing subtotal hysterectomy for fibroids in women
of fifty years and upwards, the surgeon should have the uterus opened
immediately after its removal and assure himself that the endometrium is
free from cancer. If there be any suspicion in this direction he should
remove the cervix.

=Sarcoma.= The most insidious danger which besets the surgeon in dealing
with fibroids of the uterus is the occurrence of an encapsuled sarcoma
in the guise of an innocent fibroid. I have for some years dropped the
name of myoma for these common uterine tumours, preferring to apply the
term fibroid in a generic sense to all encapsuled tumours of the uterus.
Every histological condition is found in them, from the hard calcified
body looking like a block of coral to a soft diffluent collection of
œdematous connective tissue, and tumours composed of tissue
indistinguishable from spindle-celled sarcomata.

I have elsewhere recorded briefly a case in which I removed the uterus
from a woman forty years of age, which contained a fibroid as big as an
ostrich’s egg. On section it appeared to be a moderately firm fibroid,
with its tissue whorled as is usual in hard fibroids and enclosed in a
complete capsule. Some months later the patient complained of pain, and
on examination a hard mass occupied the floor of the pelvis; a portion
of this was excised and submitted to three competent histologists, who
reported the growth to be an innocent fibroid. The patient died fourteen
months after the primary operation with her pelvis filled with recurrent
growth. The tumour was a spindle-celled sarcoma.

Much has been written regarding the sarcomatous degeneration of
fibroids. In this matter I have maintained an attitude of active
scepticism. My experience amounts to this: the case which I have briefly
described is the only example in a thousand cases of hysterectomy in
which an encapsuled sarcoma in the guise of an innocent fibroid has come
under my observation, therefore I come to the conclusion that it is an
uncommon event, and on turning to the literature of the subject it will
be found that unequivocal examples are few.

From a careful study of the question, I have formed the opinion that if
a woman with fibroids and concomitant cancer of the neck of the uterus
seeks advice on account of hæmorrhage, and the cancer has attacked the
vaginal portion of the cervix, the nature of the case will be
appreciated. The cases likely to be overlooked are those where the
cancer is situated somewhat higher in the cervical canal than usual, so
that it is not easily detected by the examining finger, and so low in
the cervix that the disease is not exposed when the body of the uterus
is amputated in the course of a subtotal hysterectomy. A knowledge of
this, as well as the fact that cancer of the cervix is almost
exclusively a disease of women who had been pregnant, should make the
surgeon particularly careful in performing subtotal hysterectomy for
fibroids in women who have had children, in order to assure himself that
it is not cancerous.

In addition to the liability of the stump left after subtotal
hysterectomy to become cancerous, it is stated by some surgeons that the
patient is more liable to intestinal obstruction than after the total
operation. This objection is easily met, because a perusal of their
writings shows clearly that they do not perform the operation properly.
In subtotal hysterectomy, performed according to Baer’s instructions,
there should be no stump projecting from the pelvic floor, but merely a
thin seam underlying the base of the bladder.

[Illustration: FIG. 16. AN ADENOMYOMATOUS UTERUS. The organ is shown in
sagittal section in order to display the great thickening of the
endometrium. From a spinster aged 43 years. Two-thirds size.]

I have dealt in detail with these two methods of hysterectomy, because
when it can be performed subtotal hysterectomy is, as a rule, a simpler
operation than total hysterectomy. There are conditions in which it is
imperative to remove the whole of the cervix, especially when the canal
is very patulous and perhaps septic; when it is large and hard, or large
and spongy; and especially if there is the least suspicion of malignancy
in the cervix, or in the body of the uterus.

It must, however, be borne in mind that cancer has attacked the scar
left in the vagina after a total hysterectomy (Quénu). At the present
time the subtotal method enjoys the greatest favour in London, but it
must be remembered that where the total operation is most indicated, it
is often difficult of execution. Although I have a decided preference
for the subtotal operation, especially in spinsters and barren wives, I
have performed total hysterectomy in more than 200 patients, so that I
am in no way blind to its merits.

=Cancer of the uterus after bilateral ovariotomy.= The uterus, after
complete removal of both ovaries, is not only a useless organ, but it
may become attacked by cancer. Blacker reported a case in which a woman,
thirty-nine years of age, underwent bilateral oöphorectomy for a uterine
fibroid: eight years later cancer attacked the neck of the uterus and
destroyed the patient.

[Illustration: FIG. 17. AN ADENOMYOMATOUS AND TUBERCULOUS UTERUS. The
uterus is opened by a vertical incision in its posterior wall. The
anterior wall is occupied by a mass of tuberculous adenomatous tissue.
The patient, a spinster aged 46, was in excellent health four years
after the operation. Two-thirds size.]

In 1902 I performed abdominal myomectomy on a woman forty-seven years of
age, and removed both ovaries and Fallopian tubes; the latter contained
pus. Four years later this patient came under observation with extensive
cancer of the cervix.

In 1901 a patient had bilateral ovariotomy performed; five years later
she complained of severe uterine hæmorrhage. I removed the uterus by the
abdominal route (total hysterectomy). The corporeal endometrium was
cancerous throughout. The patient survived the operation six months.
Similar cases have been recorded by Martin, Butler-Smythe, and
Playfair.

=Adenomyoma of the Uterus.= This disease has not received adequate
recognition at the hands of British surgeons, yet it is a condition
which occasionally causes much doubt in the surgeon’s mind in the course
of hysterectomy. This adenomyomatous change affects the endometrium and
is, in some cases, associated with interstitial and subserous fibroids:
it causes often great enlargement of the uterus, and under these
conditions the fundus can be felt high in the hypogastrium. The patients
are often profoundly anæmic as the result of long-continued menorrhagia.
The physical and clinical signs of the disease are those present in
patients with a large degenerating submucous fibroid. Indeed the surgeon
often removes the uterus under this impression, and, after the operation
is completed, when he divides the uterus expecting to see the usual
encapsuled tumour, to his surprise finds a uterus with greatly thickened
walls (Fig. 16).

Microscopically the adventitious material is made of irregular tracts of
endometrium containing glands and strands of unstriped muscle tissue.

It is important for the surgeon to recognize these cases because,
contrary to the rule with simple uterine fibroids, these adenomyomatous
uteri are often adherent to the adjacent bowel and to the bladder: in
connexion with this fact several observers have pointed out that uteri
affected with this disease are often associated with inflammatory
affections of the Fallopian tubes, and there are good reasons for the
belief that the adenomyomatous change has a microbic origin. In this
connexion it is worth mention that adenomyomatous uteri are sometimes
tuberculous (Fig. 17). Some examples of this disease have been mistaken
for cancer of ‘the body of the uterus’.

In this disease subtotal hysterectomy gives admirable results, immediate
and remote.


THE FATE AND VALUE OF BELATED OVARIES

The only improvement of any importance made in Baer’s operation of
subtotal hysterectomy concerns the ovaries. These Baer removed with the
Fallopian tubes, but in 1897 I advocated, at the Obstetrical Society,
London, that they were of great value to the patient, and pointed out
that their conservation, when healthy, spared the patient the annoyance
of that curious vaso-motor phenomenon, known to women as ‘flushings’,
which is the only obtrusive sign of the menopause.

It is now admitted by those surgeons in London who have had much
experience of hysterectomy for fibroids, that the immediate results of
preserving at least one healthy ovary in this operation are admirable,
especially in women under forty years of age, for the retention of an
ovary is of striking value ‘in warding off the severity of an artificial
menopause’ (Crewdson Thomas).

Although I have left one or both ovaries in the performance of abdominal
hysterectomy for fibroids in more than 300 patients, in only two
instances have I found anything detrimental in the practice. In these
two patients it was necessary to remove one of the ovaries. Since 1906 I
have modified the method by leaving only one ovary, even when both were
healthy, and find that the immediate good consequences of the operation
are in no way impaired. There is reason to believe that whatever good
effects follow the practice of leaving a belated ovary (that is, an
ovary divorced from the uterus and left in the pelvis), they are
temporary, for in the course of a few years the ovarian tissue
disappears and the patients experience the usual symptoms of the
menopause. It is possible that the rate of atrophy of the secreting
tissue of a belated ovary depends on the age at which a patient is
submitted to hysterectomy.

In 1898 I performed subtotal hysterectomy on a woman, thirty-one years
of age, for fibroids, conserving the right ovary. Nine years later
(1907) I operated again for intestinal obstruction, and found this ovary
healthy and functional, for a ripe corpus luteum was visible on its
surface. Even a portion of an ovary, if it contain follicles, will
maintain menstruation.

In performing abdominal hysterectomy for fibroids, there are three
points which require consideration in relation to the subsequent comfort
of the patient, and they depend mainly on the conservation of a healthy
ovary. These three points relate to: (_a_) the patient’s comfort in
securing freedom from flushings; (_b_) if she be married, her marital
relations; and (_c_) if single, her nubility.

In regard to marital relations in women with a belated ovary, nothing
trustworthy is forthcoming, but I believe the retention of an ovary is
an additional factor in promoting domestic bliss. The question of
nubility is interesting; I am able to state that women who have had
subtotal hysterectomy performed, with conservation of one ovary, have
married and lived happily with their husbands; and I am of opinion that
the preservation of the vaginal segment of the neck of the uterus is an
important factor, as it leaves the vagina intact, and though such women
are sterile, they are certainly nubile.

Without overstating the case it may be said that a belated ovary is a
very precious possession to a woman under forty years of age, whether
she be married or single.

In regard to the fate of such ovaries, in the present condition of our
knowledge it may be stated that:--

In a woman under the fortieth year of life, a belated ovary remains
active and discharges ova.

[Illustration: FIG. 18. UTERUS WITH THE DECIDUA IN SITU. The parts of
the uterus occupied by the decidua represent the menstrual area of the
uterus.]

An ovary belated after the fortieth year of life atrophies, and
menopause symptoms will often ensue in the course of a few months after
the operation. The retention of an ovary minimizes the menopause
disturbances, and they are never so acute and prominent under these
conditions as they are when an acute menopause is induced by the sudden
and complete removal of all ovarian tissue. Some experienced observers
maintain that an ovary is a valuable possession to any woman who
menstruates, even at the age of fifty years, the persistence of
menstruation being obtrusive evidence that this gland is functional.
Experimental evidence, obtained from rabbits, proves that the removal of
the whole uterus has no deterrent effect on ovulation, and it does not
prevent the occurrence of œstrus and ovulation at periodically recurring
intervals. There is no necessity to appeal to experiments on animals in
this matter, as clinical observations on women are most eloquent in
proclaiming the great value of a conserved ovary when the uterus is
removed on account of troublesome and dangerous fibroids.

In reference to the value of ovarian tissue after hysterectomy for
fibroids, attention should be drawn to a modification of this operation
known as the Abel-Zweifel method, by which a small segment of the
menstrual area of the uterus is left as well as one or both ovaries:
this permits menstruation to continue in a subdued form.

Doran has particularly studied this method and practised it, but I
cannot express any opinion as to its value, never having had the courage
to perform it.

My aim in performing hysterectomy for fibroids is to abolish as
completely as possible the menstrual area of the uterus (Fig. 18), and
up to the present my efforts have been successful, and I have no
complaint from any patient that this disagreeable phenomenon has
manifested itself, although I have been at great pains by my own
exertions, as well as by the kind efforts of those who have been
associated with me in my hospital work, to keep in touch with women who
have been so unlucky as to require such a serious operation as the
removal of the uterus.


REFERENCES TO THE HISTORY OF HYSTERECTOMY FOR FIBROIDS

BAER, B. F. Supra-vaginal Hysterectomy without Ligature of the Cervix in
    Operation for Uterine Fibroids. A new method. _Transactions of the
    American Gynæcological Society_, 1892, xvii. 235.

BARDENHEUER. _Die Drainierung der Peritonealhöhle._ _Im Anhang: Thelen:
    Die Totalextirpation wegen Fibroid._ Stuttgart, 1881, 271.

GOFFE, I. RIDDLE. This surgeon furnishes an interesting account of the
    development of Total and Subtotal Hysterectomy for Fibroids, in _The
    Transactions of the American Gynæcological Society_, 1893, xviii.
    372.

KOEBERLÉ, E. Documents pour servir à l’histoire de l’extirpation des
    tumeurs fibreuses de la matrice par la méthode suspubienne. _Gaz.
    med. de Strasbourg_, 1864, xxiv. 17; 66; 158. 1865, xxv. 78; 118.

POZZI, S. _Traité de Gynécologie_, 1905, i. 424. This contains an
    interesting review of the serre-nœud and clamp period of
    hysterectomy. He states that Tillaux, in a communication to the
    Academy in 1879, proposed the use of the word Hysterectomy.


LITERATURE RELATING TO CANCER OF THE CERVICAL STUMP AFTER SUBTOTAL
HYSTERECTOMY

DORAN in his Harveian Lectures, London, 1902, gives an admirable
    critical summary of this important question up to that date.

BLAND-SUTTON, J. _Essays on Hysterectomy_, 1905, 2nd Ed., 60.

---- _Journal of Obs. and Gyn. of Gt. Britain_, 1904, v. 434.

MANN, M. _Trans. Am. Gyn. Soc._, 1893, p. 123.

POLK. _Am. Journ. of Obstetrics_, 1906, liv. 78.

QUÉNU. _Rev. de Gyn. et de Chir. Abdom._, 1905, Sept.-Oct., ix. 720.

RICHELOT. _La Gynécologie_, 1903, viii. 399.

TURNER, G. _Brit. Med. Journ._, 1905, ii. 953.


REFERENCES IN RELATION TO THE OCCURRENCE OF CANCER IN THE UTERUS AFTER
BILATERAL OVARIOTOMY

BLACKER, G. F. Uterus with Fibroids and Carcinoma of the Cervix. _Trans.
    Obstet. Soc._, 1896, xxxvii. 213.

BLAND-SUTTON, J. A Clinical Lecture on Adenomyoma of the Uterus. _Brit.
    Med. Journal_, 1909, 1.

BUTLER-SMYTHE. Carcinomatous Uterus removed eighteen and a half years
    subsequent to Double Ovariotomy. _Trans. Obst. Soc._, 1901, xliii.
    214.

PLAYFAIR. Carcinoma of Uterus. Ibid., 1897, xxxix. 288.

MARTIN, A. _Die Krankheiten der Eierstöcke und Nebeneierstöcke_, 1899,
    s. 907.


REFERENCES CONCERNING THE VALUE OF BELATED OVARIES

BLAND-SUTTON, J. Abdominal Hysterectomy for Myoma of the Uterus, with
    brief notes of twenty-eight cases. _Transactions of the Obstetrical
    Society_, 1897, xxxix. 292.

---- The Value and Fate of Belated Ovaries. _The Medical Press and
    Circular_, 1907, ii. 108.

BOND. An Inquiry into some Points in Uterine and Ovarian Physiology and
    Pathology in Rabbits. _British Medical Journal_, 1906, ii. 121.

DORAN, A. Subtotal Hysterectomy: after history of sixty cases.
    _Transactions of the Obstetrical Society_, 1905, xlvii. 363.

THOMAS, G. C. The after histories of one hundred cases of Supravaginal
    Hysterectomy for Fibroids. _Lancet_, 1902, i. 294.




CHAPTER VII

HYSTERECTOMY FOR PRIMARY CARCINOMA OF THE UTERUS


The modern operation of hysterectomy as a radical measure for the relief
of cancer of the uterus has a somewhat curious history. In 1878 Freund
extirpated the uterus for carcinoma of the cervix through an abdominal
incision; his method was quickly practised by other surgeons, but the
great mortality of the operation soon caused it to be abandoned for the
vaginal route advocated by Czerny and supported by Schroeder, Olshausen,
Martin, and Péan amongst other gynæcologists. This method, however, has
been abandoned, for, although the operative mortality of vaginal
hysterectomy for cancer of the uterus has fallen to 5 per cent., the
operation has disappointed expectation, as it can only be employed on
early cases of the disease with anything like a hopeful prospect of
curing the patient, and, even when performed on carefully selected
cases, the risks of recurrence are so great and often follow so rapidly
on the operation that surgeons have lost confidence in the method. This
has induced gynæcologists to turn their attention again to the abdominal
route. The cancerous uterus is now subjected to what is known as
‘radical abdominal hysterectomy’, a method with which the names of Ries,
Mackenrodt, Dührssen, and Wertheim are closely associated.

=Hysterectomy for cancer of the cervix.= The greatest obstacle to the
success of vaginal hysterectomy in the radical treatment of cancer of
the neck of the uterus is the limitations which the anatomical
environment imposes on the surgeon, for as soon as the disease overruns
the cervix it implicates the vagina, the bladder, the vesical portions
of the ureters, and the rectum. The ‘radical abdominal operation’
enables the operator not only to remove the uterus and its neck, but the
broad ligament, the ovaries, Fallopian tubes, infected lymph glands, and
the infected para-uterine connective tissue, and by affording the
operator free access to the floor of the pelvis the proceedings may be
carried out with a free exposure of the operating field, thus allowing
important structures like the ureters to be dissected out of implicated
tissue. Indeed it has even been recommended, in cases where the bladder
has been extensively involved, to resect this viscus and engraft the
ureters into the rectum.

The primary object of these extensive operations is not only to
facilitate the wide removal of connective tissue around the cervix in
early cases of carcinoma, but also to allow the advantages of operative
treatment to be extended to patients to whom it would be otherwise
absolutely barred.

One great danger which attends operations for the removal of cancerous
organs is what may be called ‘post-operative cancer-infection’, that is,
in the course of the operation tracts of connective tissue are opened up
and become soiled with cells, which engraft themselves on this tissue
and on the peritoneum, and give rise to extensive masses of cancer which
are often described as recurrent cancer. This accident often causes the
patient to die quicker than if the primary cancer had been left
untouched. In the radical operation it is one of the essentials to avoid
soiling the wound with cancer cells. This rule, of course, applies to
operations for cancer in any part of the body.

=Operation.= The steps of the radical abdominal operation advocated by
Wertheim are as follows:--

As a preliminary, the cancerous cervix is treated by scraping,
cauterizing, and disinfectants. It is an advantage to carry out these
measures a few days before the main operation. The Trendelenburg
position is indispensable and the abdomen is opened by a free median
subumbilical incision. After isolating the intestines with dabs, the
_ureters_ are exposed by incising the posterior layer of the broad
ligament; they are then traced to the parametrium. It is necessary to
avoid too free a disturbance of their vascular network or they will
slough.

The _bladder_ is then separated from the uterus. The
_infundibulo-pelvic_, the _broad_, and the _round ligaments_ are
ligatured and divided. The particular order in which they are dealt with
is not a matter of consequence. The uterine vessels are secured in the
following manner:--The index finger is pushed along the ureter through
the parametrium towards the bladder, until the tip of the finger appears
there; the vessels are then raised on the finger, which covers the
ureter so as to protect it whilst the vessels are ligatured and divided.
As soon as the uterine vessels are divided the vesical segments of the
ureters are exposed, cleaned if necessary, and separated from the
cancerous cervix.

The posterior layer of the peritoneum is divided and the rectum
separated from the vagina: at this stage the uterus is sufficiently
isolated from the surrounding structures to allow of removal. This is
effected in the following way:--

The two layers of the parametrium are taken off as close as possible to
the pelvic wall, and the vagina closed with bent clamps and divided
below them: the clamps are used to prevent soiling the operation-area
with cancerous cells.

In order to extirpate the _lymph glands_, the peritoneum is divided
upwards and the iliac vessels laid bare, and every enlarged gland from
the division of the aorta to the obturator foramen is removed and the
oozing vessels carefully secured.

The wound is treated in the following way:--

The cavity created by the removal of the uterus is filled in loosely
with iodoform gauze, which extends to the vulva. An exact closing of the
peritoneal cavity over this gauze is effected by the sewing up of the
anterior and posterior flaps of peritoneum. The final step is the
closure of the abdominal incision.

=After-treatment.= This is relatively simple. The strips of iodoform
gauze are removed through the vagina in from five to ten days
successively. The patient gets up on the fifteenth day. The bladder
requires very careful attention, as it is usually paralysed for some
days.

=Mortality.= The immediate mortality of these extensive abdominal
operations for cancer of the neck of the uterus is very high, more than
20%, but recent statistics (1909) show that this death-rate is being
considerably improved with increased experience on the part of the
operators.[1]

[1] Comyns Berkeley and Bonney have published the best immediate results
of this operation which have been obtained in England. _British Medical
Journal_, 1908, ii. 961, and _Lancet_, 1909, i. 320.

=Dangers.= The chief risks of the operation are sepsis,
cancer-infection, and injury to the ureters.

The ureters have proved a fertile source of trouble because they are
deliberately exposed in the course of the operation, and they are
sometimes accidentally divided. It is not uncommon to find a ureter
completely blocked by cancer, and occasionally the ureter, after being
bared by the operator, undergoes necrosis a few days later.

Wertheim points out that in some instances ureteral fistulæ due to
necrosis may be induced to close by the application of iodine or
sulphate of copper. It is, however, unfortunately true that many
patients with ureteral fistulæ after the radical operation have been
obliged to undergo nephrectomy (see p. 112).

The ‘radical operation’ for cancer of the neck of the uterus is on its
trial in Great Britain. The operative mortality is very high, and no
reliable returns concerning the remote results are at present available.

=Hysterectomy for cancer of the body of the uterus.= The most
satisfactory method of dealing with cancer arising in the corporeal
endometrium consists in performing total abdominal hysterectomy (see p.
40), removing not only the uterus and its neck, but both ovaries,
Fallopian tubes, mesometria, and any enlarged lymph glands that are
detected. In the course of the operation the surgeon should avoid any
undue handling of the uterus, and, in withdrawing it from the pelvis,
care should be taken not to infect the operation area with any fluid or
semi-fluid stuff which is liable to escape from the cervical canal.

[Illustration: FIG. 19. CANCER OF THE UTERUS. Coronal section through a
uterus affected with primary cancer of the corporeal endometrium. The
mass measured 10 centimetres transversely and 12 centimetres vertically.
Removed by abdominal hysterectomy. Two-thirds size.]

There is a rare variety of cancer of the corporeal endometrium, namely,
that which attacks small atrophic uteri. These small uteri may sometimes
be extirpated by the vagina, but often the narrowness of the vagina in
aged spinsters compels the surgeon to resort to the abdominal route.

Cancer of the body of the uterus occasionally causes such enlargement of
this organ as to render its removal by the vaginal route difficult as
well as undesirable. When this form of cancer is complicated with
fibroids, as a rule, vaginal hysterectomy is impracticable.

Cancer of the body of the uterus is more frequent in spinsters and
barren wives than in multiparæ; for this reason the cancer often assumes
the massive form, because the cervical canal being narrow, pathogenic
micro-organisms do not obtain such free ingress as in the case of women
with a patulous canal. In some instances the cancerous mass will expand
the uterine cavity and lead to thinning of the walls as in Fig. 19.

Clinically, cancer of the corporeal endometrium is a more insidious
disease than cancer of the neck of the uterus, but since its frequent
association with fibroids has been recognized (see p. 52) mainly as a
consequence of the vulgarization of hysterectomy, many cases are
detected fairly early and with improved results for the patients.

=Mortality.= The risk to life in abdominal hysterectomy for cancer of
the body of the uterus is somewhat greater than after removal of the
uterus for fibroids. This is due to the fact that when the cancer
ulcerates and sloughs, the risk of sepsis is therefore increased; this
also makes convalescence slower.

The remote results vary greatly; these depend in a large measure on the
extent of the disease at the time of the operation. When the cancerous
mass is compact, as in Fig. 19, good results may be expected. When the
growth has perforated the uterine wall and small bud-like processes
project on the serous surface, the disease may be expected to recur
rapidly in the abdomen. Cancer of the uterus remains an opprobrium to
operative gynæcology.




CHAPTER VIII

OPERATIONS FOR DISPLACEMENT OF THE UTERUS

HYSTEROPEXY (VENTRO-SUSPENSION AND VENTRO-FIXATION OF THE UTERUS)


_Hysteropexy is a term applied to an operation for fixing the uterus, by
means of sutures, to the anterior abdominal wall._

This procedure was advocated as a definite surgical operation for
displacements of the uterus independently by Olshausen and Kelly (1886).

The operation when employed for severe retroflexion of the uterus is now
known as ventro-suspension of the uterus; when carried out for prolapse
it is termed ventro-fixation of the uterus. When care is taken in the
selection of patients, hysteropexy is an operation which is followed by
satisfactory consequences.


VENTRO-SUSPENSION FOR RETROFLEXION OF THE UTERUS

The preliminary preparation and the instruments required as those used
for a simple cœliotomy (see p. 5).

=Operation.= The patient is placed in the Trendelenburg position, and
the abdomen is opened as for ovariotomy, except that the incision is
shorter; the operator then determines with his fingers the position and
condition of the body of the uterus. If it be free, it is then
straightened, and the condition of the ovaries and the tubes
ascertained.

In many patients, where retroflexion of the uterus is accompanied by
pain, the distress is often due to a prolapsed ovary, incarcerated in
the pelvis by the retroflexed fundus of the uterus; in another set of
cases the retroflexion is produced by a tumour in the ovary, such as a
small dermoid, but more often the body of the uterus is drawn backwards
by a small fibroid in the fundus of the organ. In these conditions an
operation embarked upon as a simple hysteropexy may become an
oöphorectomy, an ovariotomy, or a myomectomy, according to the necessity
of the case. When the enlargement of the ovaries is due to œdema from
incarceration, they should be left, as the swelling will quickly subside
when the misplacement of the uterus is corrected.

The uterus is fixed to the abdominal wall in the following way:--

A curved needle armed with a silk thread (No. 4) which has been
carefully boiled is passed through the aponeurosis and adjacent
peritoneum on one edge of the wound, then through the anterior surface
of the uterus near the fundus, and finally through the peritoneum and
aponeurosis on the opposite edge of the incision; when this suture is
tightened, it will be found to draw the uterus to the anterior
abdominal wall, and at the same time approximate the edges of the wound.
Two sutures should be introduced. In patients who have had children care
should be taken not to pass the needle so deeply into the uterus that
the suture traverses the superficial parts of the endometrium and
becomes infected: this will lead to a suture sinus. The rest of the
wound is then closed according to the method described on p. 9.


VENTRO-FIXATION FOR PROLAPSE OF THE UTERUS

=Operation.= When hysteropexy is needed for a large, bulky, and
prolapsed uterus, the steps of the operation are the same as for
retroflexion, but it is necessary to introduce a greater number of
retaining sutures. Further, as the uterus tends to slip downward into
the vagina, it is an advantage, as soon as the fundus of the uterus is
drawn into the wound, to transfix it with a stout suture, in order that
the assistant may use it as a tether to keep the uterus in position
whilst the surgeon introduces the main sutures. In some cases, where the
uterus is very large, it may be requisite to employ four, five, or even
six sutures to secure it to the abdominal wall.

In all cases of hysteropexy the uterus is of necessity sutured to the
lower angle of the wound, and is therefore in close relation to the
bladder. It facilitates the operation to introduce the lowest sutures
first and then gradually work up to the fundus. The wound is then closed
and dressed as described for cœliotomy.

=After-treatment.= This is conducted on the same lines as after
ovariotomy.

=Risks.= Hysteropexy, when performed by surgeons experienced in pelvic
surgery, is such a simple operation that it should have no mortality. At
the Chelsea Hospital for Women, from 1904 to 1906, both years inclusive,
this operation was performed on 190 patients, all of whom recovered from
the operation.

Many of these operations were complicated with oöphorectomy, ovariotomy,
or myomectomy. A wide study of operation returns show that hysteropexy
is not absolutely free from risk, as deaths from sepsis, lung
complication, and intestinal obstruction have been reported.

The remote consequences of hysteropexy are of interest. When the uterus
has been enlarged by previous pregnancy its fundus can be brought
without undue strain into contact with the anterior abdominal wall, so
that when it is secured by sutures there is little or no strain on them.
When hysteropexy is performed on spinsters or barren married women in
whom the uterus is small, there is, in many instances, a strain on the
sutures. The effect of this strain is twofold. When the uterus is
attached to the abdominal wall by an aseptic suture, lymph is exuded
from the surfaces of the peritoneum in contact with the retaining
sutures. This effused lymph organizes into a tenacious tissue, and the
strain of the uterus, when the operation is performed on virgins, or the
weight of the organ when it is done for prolapse, will cause the sutures
to erode their way out of the uterine wall, but the plastic material
effused around the silk threads slowly stretches as the uterus descends
into the pelvis, producing a tendon-like structure which may be called
the ‘artificial fundal ligament’ (Fig. 20).

[Illustration: FIG. 20. THE FUNDUS OF A UTERUS. A long fibrous cord
arises from the fundus as a result of hysteropexy performed nearly five
years previously for inveterate retroflexion. Full size.]

In patients in whom the length of the uterus allows its fundus to come
in contact with the abdominal wall without strain, the union may be so
secure that the woman may pass through one or more pregnancies
successfully without disturbing the union, or even stretching it. This I
have proved in twelve instances where some subsequent trouble such as
appendicitis, gall-stones, ovariotomy, cancer of the colon, or the like
has led to a repeated cœliotomy, and has afforded me an opportunity of
examining the condition of the uterus.

In one remarkable case where a small uterus had been securely fixed by
its fundus to the abdominal wall by means of ten thick sutures (the
operation had been performed in a cottage hospital in Yorkshire), the
patient complained of persistent pain, and was sent to me on this
account. I found the sigmoid flexure of the colon caught in one of the
sutures, which accounted for some of the woman’s trouble, but the uterus
was so firmly fixed to the abdominal wall and had been so dragged upon
that it had become a rounded sausage-like organ. Its removal was
followed by immediate relief. Among rare accidents which have followed
this simple operation is tetanus when catgut and wallaby tendon has been
used for the retaining sutures (see p. 107).


REFERENCES

KELLY, H. A. Hysterorrhaphy. _American Journal of Obstetrics_, 1887, xx.
    33.

OLSHAUSEN. Ceber ventrale Operationen bei Prolapsus und Retroversio
    Uteri. _Centralblatt für Gynäkologie_, 1886, x. 698.




CHAPTER IX

OPERATIONS UPON THE UTERUS DURING PREGNANCY, PARTURIENCY, AND PUERPERY


Pregnancy is apt to be complicated with tumours growing in the walls of
the uterus, _e.g._ fibroids, cancer of the neck of the uterus, or cysts
and tumours of one or both ovaries; morbid conditions of the Fallopian
tubes, _e.g._ pyosalpinx, tubal pregnancy; tumours and cysts in the
broad ligament; displaced viscera occupying the pelvis, _e.g._ the
spleen or the kidney; tumours arising in the pelvic bones, _e.g._
osteoma, enchondroma, or sarcoma; and echinococcus cysts and colonies
growing in the omentum, but occupying the pelvis, or arising in the
pelvic tissues.

This is a formidable list, and any one of them may so complicate the
pregnancy that it may be necessary to remove the tumour, and in some
instances to perform Cæsarean section, or even hysterectomy.


CÆSAREAN SECTION

This signifies the removal of a fœtus and placenta from the uterus
through an incision involving the abdominal and uterine walls.

This operation is required when the outlet of the pelvis is too narrow
to permit the transit of a viable child, as in rickets and osteomalacia;
when the vagina is malformed; when the pelvic outlet is narrowed by
tumours growing from the pelvic wall. Occasionally the passage of a
fœtus is barred by tumours growing from the uterus, especially a large
cervix fibroid, or a fibroid growing from the lower segment of the
uterine wall. An ovarian cyst, especially a dermoid incarcerated by the
uterus, may render this operation necessary. The rarest causes are
cancer of the neck of the uterus and cancer of the rectum.

This operation is advocated by some obstetricians in certain cases of
eclampsia and placenta prævia.

=Operation.= When it is known some days beforehand that the patient will
be submitted to this operation, she should be prepared as for
ovariotomy. Often it happens that the operation is undertaken after
labour has commenced, and in circumstances which make time very
precious. Even then the abdomen, pubes, and vulva can be shaved and
thoroughly washed with warm soap and water, and lightly rubbed with
ether and cotton wool.

The instruments required are those given on p. 5.

When the patient is under the influence of ether and the bladder emptied
with the catheter, an incision is made in the linea alba from the
umbilicus to the pubes. The belly-wall of a woman advanced in pregnancy
is very thin, and, unless the surgeon be cautious, the knife will come
in contact with the uterus before he is aware of it.

The uterus lies just under the incision, and the operator ascertains
that it lies centrally (often the uterus is somewhat rotated to the
right or left), and then makes a free incision through the uterine wall
and extracts the fœtus and placenta; as the uterus contracts, he slips
his left hand behind the fundus, and grasps the uterus near the cervix,
and effectually controls the bleeding. The assistant passes a large warm
flat dab into the belly to restrain the intestines and omentum. The
uterine cavity is sponged out, and the finger passed through the os
uteri into the vagina in order to ensure a free passage for blood and
serum.

The incision in the uterine wall may be closed either by a double or a
single set of silk sutures. When two layers of sutures are employed, the
first set involve the mucous and adjacent half of the muscular layer[;]
these sutures should be fairly close together, for they not only bring
the parts into apposition, but they restrain the bleeding. A second row
of silk sutures is now inserted, including the serous coat and adjacent
half of the muscular layer. These threads should not be tied too
tightly, as the tissues of a gravid uterus are soft and easily tear. In
closing the uterine incision the surgeon should not spend time vainly in
endeavouring to stanch the bleeding from the edges of the incision; this
is best effected by dexterously inserting and securing the sutures.

The recesses of the pelvis are carefully cleaned by gentle sponging, and
the parietal incision is closed as after ovariotomy.

The dressing varies with the fancy of the operator; a piece of
sterilized gauze and a square of Gamgee tissue held in position by a
many-tail of flannel firmly applied is all that is necessary.

Although Cæsarean section is one of the simplest operations that can be
performed on the pelvic organs, it formerly had a very high mortality;
but since the principles of asepsis have been thoroughly established the
death-rate from this operation has been so reduced that it varies from 4
to 10% according to the skill of the operator; indeed the results are so
good in the hands of careful and skilful men that on recovery from the
operation the patient may reconceive, and there are conditions in which
the patient is desirous to produce more children with the knowledge that
they must be extricated by Cæsarean section. There are many instances on
record of women being submitted to this operation twice, and some
thrice; and at least two patients have undergone this operation four
times (Sinclair). In view of the fact that a woman after being
submitted to Cæsarean section may reconceive, it has been urged
(especially by Sinclair) that the anterior surface of the uterus should
be attached to the abdominal wall in such a manner as to promote the
formation of adhesions, so that when the patient needs to be submitted
to ‘repeated Cæsarean section’, the adhesions resulting from the primary
operation will so shut off the operation area from the general
peritoneal cavity, that the uterus may be opened and the fœtus and
placenta extracted by a practically extraperitoneal operation. This
question has been discussed in an able and comprehensive paper by
Wallace, and also by Sinclair.

There is one great danger which women run by becoming pregnant after
Cæsarean section, namely, rupture of the uterus. Some cases illustrating
this accident have been reported. This accident has been discussed by
Wallace.

[Illustration: FIG. 21. PORTION OF OVARY AND FALLOPIAN TUBE. The parts
were removed a year after a supposed complete oöphorectomy had been
performed to induce an artificial menopause. This fragment of ovary
maintained menstruation regularly. Full size.]

Although a few writers, particularly Wallace, consider that all Cæsarean
sections should be performed with a view to ulterior pregnancy, this is
not the opinion of the majority, for there are many women who, having
passed such an ordeal once, have no desire to do so again, and ask for
something to be done to prevent its possibility in the future. This
involves what is known as ‘sterilization’.

=Sterilization after Cæsarean section.= When Cæsarean section is
performed the uterus is preserved, and after convalescence the woman is
in a position to reconceive. There are conditions in which she is most
anxious to produce more children even with the risk of having them
extracted by this operation. On the other hand, some women, knowing the
risks, ask that steps may be taken to prevent a recurrence of what they
consider a catastrophe. This appears a simple matter, but it is not so
in reality, for in many instances in which the operator had been under
the impression that he had effected this by ligature of both Fallopian
tubes in continuity, he has been surprised when the woman has again come
under his notice well advanced in pregnancy.

This has happened even when each tube has been ligatured in two places
and a segment of the tube exsected between the ligatures. Bilateral
oöphorectomy has been recommended, but on the whole, when the patient
and her husband wish that further risks should be avoided, the wisest
plan is to perform subtotal hysterectomy instead of Cæsarean section;
moreover it is a difficult matter to completely remove healthy ovaries,
and _it needs only a small portion to maintain menstruation_ (Fig. 21).

The whole of this matter is one that is really a question of ethics, and
the extreme views are represented by Wallace and Sinclair in the papers
to which reference has already been made. The difficulty of effectively
sterilizing women by simply relying on bilateral oöphorectomy is shown
by the well-established cases in which patients have successfully
conceived after bilateral ovariotomy and oöphorectomy.

The youngest patient on whom Cæsarean section has been carried out with
success to the mother and child was thirteen years of age. The operation
was performed by Gache in Buenos Ayres on account of smallness of the
pelvis. Women have recovered after a self-inflicted Cæsarean section.


REFERENCES

DORAN, A. Pregnancy after Removal of both Ovaries for Cystic Tumour.
    _Journal of Obstetrics and Gynæcology of the British Empire_, 1902,
    11, i.

GACHE, S. Opération césarienne sur une fille de 13 ans: Guérison.
    _Annales de Gynécologie_, 1904, p. 601.

HARRIS, R. P. Six self-inflicted Cæsarean Operations with recovery in
    five cases. _Am. Journ. of the Medical Sciences_, 1888, xcv. 150.

SINCLAIR, SIR WILLIAM. Cæsarean Section successfully performed for the
    Fourth Time on the same Woman, with remarks on the production of
    Utero-parietal Adhesions. _Journal of Obstetrics and Gynæcology of
    the British Empire_, 1907, xii. 335.

WALLACE, ARTHUR J. On Repeated Cæsarean Section. Ibid., 1902, ii. 555.


CÆSAREAN SECTION IMMEDIATELY AFTER THE DEATH OF THE MOTHER

It occasionally happens that a woman in whom the course of pregnancy is
nearly complete dies suddenly from disease, such as hæmoptysis,
hæmatemesis, cardiac trouble, or uterine hæmorrhage in the preliminary
stage of labour; or is killed by accident. In some such circumstance
attempts are sometimes made to rescue the unborn child, by performing
Cæsarean section. It is true that such efforts are rarely attended with
success, but in cases where death is very sudden and the surroundings
such as to enable the operation to be performed without delay, the child
may be extracted from the uterus and survive. Successful cases of this
kind are published from time to time.

In order to show how necessary it is to act promptly the following case
may be mentioned:--

A woman in the eighth month of pregnancy was found to be suffering from
cancer of the neck of the uterus. The child was alive. I decided to
perform hysterectomy. The uterus was exposed through a free incision in
the abdominal wall and quickly detached from its cervix. The uterus with
the fœtus inside was handed to an assistant, who quickly extracted the
child. Although the time which elapsed from the complete etherization of
the mother until the extraction of the child from the uterus was 2-1/2
minutes, it required the display of some energy to induce the child to
breathe. This is the first record as far as I know of a child being
delivered alive from a uterus detached from its mother. The woman died
on the fourth day after the operation, and the child on the fourteenth.

Möglich had a successful case. A patient aged forty-one years, with
placenta prævia, died from hæmorrhage, and an asphyxiated fœtus was
promptly extracted by cœliotomy. Prolonged efforts at artificial
respiration were successful, and the child was well five weeks later
(see also Sippel).


REFERENCES

HUGIER, M., and MONOD, M. Cæsarean Operation immediately after the death
    of the Mother. _Lancet_, 1829-30, i. 899.

MÖGLICH. Ueber Kaiserschnitt an der Toten. _Münchener med. Wochensch._,
    1908, lv. 202.

SIPPEL. Sectio Cæsarea in mortua. _Monats. f. Geb. u. Gyn._, 1907, xxvi.
    618.


OVARIOTOMY AND HYSTERECTOMY DURING PREGNANCY AND IN LABOUR

Although the directions in surgical writings are clearly laid down
concerning the course to be pursued when pregnancy and labour are
complicated by an ovarian tumour, the difficulty which often confronts
the operator when he is face to face with the actual case is uncertainty
regarding the nature of the tumour. Although he may begin the operation
under the impression that he has to deal with an ovarian tumour, it may
turn out to be a fibroid, a tumour of the pelvic wall, a misplaced
spleen or kidney, a tubal pregnancy, a sequestered extra-uterine fœtus
(lithopædion), or a calcified hydatid cyst. Thus an expected ovariotomy
may terminate as a Cæsarean section, or as a hysterectomy. In many cases
the surgeon must rely on his own judgment and experience, but it may be
useful to furnish some directions which may help him. It may be useful
also to mention what unexpected conditions are sometimes found. Thus an
experienced gynæcologist like Prof. Olshausen once removed a gravid
uterus under the impression that it contained a cystic fibroid which
would obstruct delivery. When it was examined after removal, the
suspected fibroid proved to be a large sacral teratoma growing from the
fœtus.

=Ovarian tumours and pregnancy.= Before the fourth month of pregnancy,
single and double ovariotomy is attended with a low rate of mortality,
and the risk of disturbing the pregnancy is small. The removal of a
parovarian cyst during pregnancy is more liable to be followed by
abortion than single or double ovariotomy. After the fourth month the
risk is that of an ordinary ovariotomy, but the chances of abortion
increase with each month. It is also a fact that ovariotomy may be
safely carried out between the eighth and ninth months of gestation
without precipitating labour, even when the tumour is incarcerated in
the pelvis.

In many cases in which ovariotomy is urgently indicated during
pregnancy, the pedicle will be found twisted.

When the tumour is situated above the uterus there is rarely any
difficulty in dealing with it, as the pedicle is usually long, but it
will require extra care in applying the ligature, as the tissues, being
unusually vascular and soft, are easily lacerated. Occasionally the
tumour lies in the pelvis below the uterus: in this case the surgeon
carefully insinuates his hand between the pelvic wall and the uterus,
and then gently withdraws the tumour from its incarcerated position.

    CASES IN WHICH OVARIOTOMY HAS BEEN PERFORMED NEAR THE END OF THE
    NINTH MONTH OF PREGNANCY

  +------------+--------+---------+------------------------------------+
  |            |_Result |_Result  |                                    |
  | _Surgeon._ |   to   |   to    |            _Reference._            |
  |            |Mother._| Child._ |                                    |
  +------------+--------+---------+------------------------------------+
  |Pippingsköld|   R.   |Stillborn|_Am. J. of Obstet._, 1880 xiii. 308.|
  |Bland-Sutton|   R.   |  Lived  |_Brit. Med. Jour._, 1895, i. 461.   |
  |Morse       |   R.   |  Lived  |_Trans. Obstet. Soc._, xxxviii. 221.|
  +------------+--------+---------+------------------------------------+

In operating for ovarian cysts complicating pregnancy, the surgeon
should, after removing the cyst, carefully examine the other ovary, for
twin tumours may be present. Berry Hart performed ovariotomy on a woman
in the fifth month of pregnancy, and removed a dermoid of the left ovary
‘enlarged to about the size of a man’s brain by recent hæmorrhage due to
the twisting of a pedicle’. The patient died on the ninth day. A frozen
section was made of the pelvis, and on inspecting the cut surface the
right ovary, converted into a dermoid, was found incarcerated by the
gravid uterus.

Many cases have been published in which ovariotomy has been undertaken
during the late months of pregnancy, or shortly after delivery, and the
surgeons have been astonished to find both ovaries converted into
tumours; in very many instances they were dermoids. Cases of this kind
have been recorded by Knowsley Thornton, F. Page, Cullingworth, Berry
Hart, Malcolm Campbell, and others, including myself. These
observations demonstrate that a woman may have both her ovaries occupied
by dermoids, yet the glands are capable of yielding fertilizable ova.

Campbell relates that Brewis, in performing an ovariotomy during
pregnancy, attempted to conserve some ovarian tissue by resecting the
dermoids; this proved impracticable, and both ovaries were excised. Miss
Ivens records a case in which a woman thirty-five years of age was five
months pregnant and required ovariotomy on account of an incarcerated
ovarian dermoid. In the course of the operation both ovaries were found
to contain dermoids. A tumour was successfully excised from each.
Pregnancy continued undisturbed.


REFERENCES

CAMPBELL, M. Case of Bilateral Ovarian Dermoid Tumour associated with
    Pregnancy. _Lancet_, 1907, ii. 1760.

CULLINGWORTH, C. J. Three cases of Suppurating Dermoid Cyst, of or near
    the Ovary, treated by Abdominal Section. _St. Thomas’s Hospital
    Reports_, 1887-9, xvii. 139.

HART, BERRY. See Clarence Webster’s _Researches in Female Pelvic
    Anatomy_, Edin., 1892, p. 124.

IVENS, MISS F. Pregnancy complicated by Bilateral Ovarian Dermoid Cysts.
    _Brit. Med. Journal_, 1908, i. 625.

PAGE, F. Acute Peritonitis after Confinement; abdominal section; Dermoid
    Disease of both Ovaries; removal; recovery. _Lancet_, 1893, ii. 250.

THORNTON, K. A case of removal of both Ovaries during Pregnancy. _Trans.
    Obstet. Soc._, London, xxviii. 41.

=Ovariotomy during labour.= When an ovarian tumour is discovered during
labour and it impedes delivery, ovariotomy should be performed.

In this condition it follows that the tumour lies in the pelvis; when
the tumour is tightly impacted by the contracting uterus it has happened
that the surgeon has been unable to reach the tumour until he has
emptied the uterus by Cæsarean section. Several operators have had this
difficulty, myself among them. I have added a list of reported cases
drawn from British sources. For this I hope not to be accused of what is
sometimes perhaps facetiously called ‘insularity’. The enormous
population of these islands should furnish material enough to settle the
principles of treatment which should govern these terrible cases of
obstructed labour.

One of the commonest conditions met with in ovariotomy during pregnancy
and labour is to find that the cyst has undergone axial rotation and
twisted its pedicle. The technique in these circumstances is very
simple.

    OVARIOTOMY FOR TUMOURS OBSTRUCTING LABOUR AT TERM

  -----------+--------+--------+---------+------------------------------
             |_Nature |_Result |_Fate    |
  _Operator._|   of   |   to   |   of    |           _Reference._
             |Tumour._|Mother._| Child._ |
  -----------+--------+--------+---------+------------------------------
  Williams   |Cyst    |   R.   |No record|_Trans. Obstet. Soc._, xxvi.
             |        |        |         |  203.
  Spencer    |Dermoid |   R.   |  Lived  |Ibid., xl. 14.
  Boxall[1]  |Dermoid |   R.   |  Lived  |Ibid., xl. 25.
  Bland-     |Dermoid |   R.   |  Lived  |_Lancet_, 1901, i. 382.
    Sutton[1]|        |        |         |
  Sinclair[1]|Cyst    |   R.   |  Lived  |_Lancet_, 1901, i. 158.
  Favell[1]  |Dermoid |   R.   |No record|_Brit. Med. Journal_, 1901, i.
             |        |        |         |  894.
  -----------+--------+--------+---------+------------------------------
      [1] In these cases it was necessary to perform Cæsarean section
          in order to extract the tumour from the pelvis.

[Illustration: FIG. 22. A UTERUS DISTORTED BY FIBROIDS. It contains a
fœtus of four months’ development. Removed by the subtotal operation
from a primigravida, aged 42. Half size.]

=Ovariotomy during the puerperium.= It occasionally happens that a woman
may go through her pregnancy and labour with an unrecognized ovarian
tumour in her abdomen; during the puerperal period it may cause symptoms
which lead to its recognition, because in the course of the labour the
cyst may burst, undergo axial rotation, or suppurate. When a puerperal
woman possesses an ovarian tumour which gives rise to unfavourable
signs, ovariotomy should be resorted to without delay. The operation in
these circumstances is comparatively simple, and such adhesions as may
be present are usually recent and easily overcome.

Single and even double ovariotomy can be performed during puerpery
without in any way interfering with involution of the uterus or
lactation.

In 1896 I was able to collect fifteen recorded cases of double
ovariotomy during pregnancy, and sixteen in which ovariotomy was
performed during the puerperium, or shortly after abortion. Since this
date McKerron has collected the statistics relating to the whole
question of pregnancy and ovarian tumours in a very comprehensive
manner.


REFERENCES

BLAND-SUTTON. _Surgical Diseases of the Ovaries, &c._, London, 1896, 2nd
    Ed. pp. 180-91.

---- The Surgery of Labour and Pregnancy, complicated with Tumours,
    _Lancet_, 1901, i. 382, 452, 529.

MCKERRON, R. G. _Pregnancy, Labour, and Childbed with Ovarian Tumour_,
    London, 1903.


=Fibroids and pregnancy.= In a large number of instances in which
operations have been undertaken when fibroids complicate pregnancy, they
have been performed on an erroneous diagnosis. The tumours when small
and placed laterally simulate ovarian cysts; when large and lying high
in the abdomen they have been mistaken for renal tumours, and when low
in the pelvis they have been regarded as incarcerated ovarian cysts. The
variety of fibroid most likely to lead to operation, under the
impression that it is an ovarian cyst, is an interstitial fibroid which
becomes painful in consequence of undergoing red degeneration. The
difficulty which faces the surgeon in this condition is to decide on a
safe course.

When the tumour is not likely to cause difficulty it may be wise to
close the abdomen. If the tumour is pedunculated and incarcerated, he
may be able to extract the tumour and ligature the pedicle without
disturbing the pregnancy; a big fibroid invading the broad ligament may
be enucleated; a large cervix fibroid will render delivery impossible,
and will necessitate hysterectomy.

A study of many recorded cases in which hysterectomy has been performed
on account of fibroids complicating pregnancy shows that the operation
had been undertaken on account of a great increase in the size of the
tumours, the concurrent pregnancy not being discovered until the parts
were examined after removal.

Hysterectomy may be necessary at any time during pregnancy; after labour
has begun; and during puerpery on account of fibroids. During pregnancy
it is a straightforward operation, the subtotal operation being
preferable. When it is needed during puerpery it is for septic
complications, and there is no greater difficulty in performing
hysterectomy then than during pregnancy, but the risk to the patient
from sepsis is much greater: therefore total hysterectomy with drainage
is advisable.

Fibroids have many times been enucleated from the gravid uterus and the
pregnancy has gone successfully to term.

When pregnancy complicated with fibroids goes to term and the tumour
occupies the neck or the lower segment of the uterus so as to offer an
impassable barrier to the passage of the fœtus, abdominal hysterectomy
is a necessity.

=Red Degeneration.= Among the new things which the surgical treatment of
uterine fibroids has brought to light is a knowledge of that change to
which these tumours are liable, known as ‘red degeneration’.

This increase in our knowledge of the pathology of fibroids is extremely
useful in diagnosis, for red degeneration is especially liable to occur
in fibroids lodged in a pregnant uterus, and, as I pointed out in 1904,
it has the effect of rendering them painful.

One of the most striking features of a uterine fibroid is its
insensitiveness, and equally remarkable is its painfulness and
tenderness when in a state of red degeneration, but these signs are only
exhibited by such fibroids when associated with pregnancy.

Red degeneration, even in an extreme degree, in fibroids occupying the
walls of a non-gravid uterus is, as a rule, painless. It is also curious
that a gravid uterus may contain four or five fibroids, the size of
large potatoes, in its walls, yet only one will exhibit this red
degeneration and become acutely painful, whilst its companions remain as
insensitive as apples. In the early stages of this change the fibroid
exhibits the colour in streaks, but as the pregnancy advances it
permeates the whole tumour. Occasionally in the mid-period of pregnancy
this necrotic change may be so extreme that the central part (sometimes
the whole) of the tumour is reduced to a red pulp.

The suddenness with which this pain comes on may be illustrated briefly
by the following case:--A primigravida, aged 30, two months pregnant,
was seized with sudden pain during a railway journey. Her condition
became so alarming that she left the train at an intermediate station
and placed herself under the care of a doctor whom she knew. A large,
tender, and increasing swelling was found in the abdomen. The doctor
regarded the patient’s trouble as being due to rupture of a tubal
pregnancy. He asked me to see the patient, and I found a large swelling
on the right side of the abdomen reaching as high as the liver. I
considered that some change had taken place in this tumour consequent
on the pregnancy: it was also probable that it might be an ovarian cyst
which had twisted its pedicle. The swelling was very tender. On opening
the abdomen the tumour proved to be a large subserous fibroid undergoing
red degeneration. The gravid uterus contained several fibroids of the
interstitial variety: it was removed. These fibroids exhibited the red
change in streaks.

It is a curious and noteworthy fact that many of the operations
tabulated on pp. 81 and 82 were undertaken on an erroneous diagnosis. In
some the acute pain and tenderness of which the patients complained led
the surgeons to believe that the troubles were due to an ovarian cyst
which had twisted its pedicle, or to the bursting (or abortion) of a
gravid Fallopian tube.

Practitioners and obstetricians are now becoming familiar with the fact
that when a pregnant woman, who has also fibroids in the uterus,
complains of sudden acute pain, it may be due to one of the fibroids
undergoing red degeneration.

[Illustration: FIG. 23. A GRAVID UTERUS IN SAGITTAL SECTION.

The woman miscarried at the seventh month: delivery was obstructed by a
cervical fibroid. The parts were removed by total hysterectomy. The
small fibroid is in the condition of red degeneration (_Museum, R.
College of Surgeons_). Half size.
]

The cause of this change is unknown. Lorrain Smith and Fletcher Shaw,
after an examination of four specimens, three of which were associated
with pregnancy, believe that the change is due to thrombosis of the
vessels of the fibroid. In two tumours they isolated micro-organisms,
_e.g._ _staphylococci_ in one and _diplococci_ in another: the patients
with these tumours exhibited toxic symptoms.

In my early investigations of this disease I often took the tumours to
the bacteriological laboratory with the hope of finding some
micro-organism which would account for the degeneration. The results
were so persistently negative that the search was abandoned. Since
learning that Smith and Shaw had found micro-organisms in two cases I
had the next specimen which came to hand examined, and it happened to be
the fibroid obtained from the acute case described on p. 79. From the
softened parts Mr. Somerville Hastings succeeded in obtaining
_staphylococcus pyogenes aureus_ in pure culture.

The views here expressed in regard to the red degeneration of fibroids
are founded on an examination of thirty-four recent examples.


REFERENCES

BLAND-SUTTON, J. The Inimicality of Pregnancy and Uterine Fibroids.
    _Essays on Hysterectomy_, 1905, 76.

FAIRBAIRN, J. S. A Contribution to the Study of one of the Varieties of
    Necrotic Changes in Fibro-myomata of the Uterus. _Journ. of Obstet.
    and Gyn. of the British Empire_, 1903, iv. 119.

SMITH, J. L., and SHAW, W. F. On the Pathology of the Red Degeneration
    of Fibroids. _Lancet_, 1909, i. 242.

    CASES OF HYSTERECTOMY PERFORMED ON PATIENTS IN LABOUR IN WHICH THE
    OBSTRUCTION WAS DUE TO FIBROIDS

  -----------+--------+-------+----------------+-----------------------
             |_Result |_Fate  |    _Nature     |
  _Operator._|   to   |  of   |       of       |     _Reference._
             |Mother._|Child._|   Operation._  |
  -----------+--------+-------+----------------+-----------------------
  Spencer    |   R.   |   L.  |Cæs. Sect.,     |_Trans. Obstet. Soc._,
             |        |       |  Subtotal Hyst.|  xxxviii. 389.
  Bland-     |   R.   |   D.  |Total Hyst.     |_Trans. Obstet. Soc._,
    Sutton   |        |       |  See Fig. 23.  |  xlvi. 238.
  Morison    |   R.   |   D.  |Cæs. Sect.,     |_Northumberland and
             |        |       |  Total Hyst.   |  Durham Medical
             |        |       |                |  Journal_, July, 1904.
  Acland     |   R.   |   ?   |Cæs. Sect. and  |_Lancet_, 1904, ii.
             |        |       |  Subtotal Hyst.|  948.
  Spencer    |   R.   |   L.  |Cæs. Sect.,     |_Trans. Obstet. Soc._,
             |        |       |  Total Hyst.   |  1906, xlviii. 240.
  Spencer    |   R.   |   D.  |Cæs. Sect.,     |_Trans. Obstet. Soc._,
             |        |       |  Total Hyst.   |  1908.
  Pollock    |   R.   |   L.  |Cæs. Sect.,     |_Trans. Obstet. Soc._,
             |        |       |  Subtotal Hyst.|  1908.
  -----------+--------+-------+----------------+-----------------------

The aim of the surgeon is to save the life of the child as well as that
of the mother. To this end, when the operation is carried out and the
uterus exposed the child is extracted by Cæsarean section. Then in the
majority of cases total or subtotal hysterectomy is performed. This is
sometimes clumsily termed Cæsarean hysterectomy. In some instances the
operator has been content merely to perform Cæsarean section in the hope
that the patient may wish to reconceive.

In order to afford some notion of the frequency with which fibroids
cause trouble to pregnant and parturient women, I have collected
thirty-six cases which have been reported to the London Obstetrical
Society from 1900 to 1908 (both years inclusive), and arranged them in
the subjoined tables: they show in an unmistakable way that pregnant
women with fibroids do often require aid from surgery, and that such
efforts are rewarded with success. There is no condition which
simplifies hysterectomy so much as pregnancy.

    A TABLE OF CASES IN WHICH ABDOMINAL HYSTERECTOMY WAS PERFORMED FOR
    PREGNANCY COMPLICATED WITH FIBROIDS

    These cases are recorded in the _Transactions of the Obstetrical
    Society_, 1900-8, both years inclusive.

  ------------+---------+--------------------+--------+-----------------
              |  _Age   |      _Period       |_Result |  _Reference
   _Recorder._|   of    |         of         |   to   |      to
              |Patient._|     Pregnancy._    |Mother._|   Volume._
  ------------+---------+--------------------+--------+-----------------
  Horrocks    |    ?    |5th month           |   ?    |1900, xlii. 242.
  Routh       |   33    |33 weeks            |   R.   |Ibid., 244.
  Doran       |   40    |5th month           |   R.   |1901, xliii. 178.
  Donald      |   43    |9th month           |   R.   |1901, xliii. 180.
  Donald      |   34    |4th month           |   R.   |Ibid.
  Donald      |   34    |4th month           |   R.   |Ibid.
  Donald      |   41    |4th month           |   R.   |Ibid.
  Routh       |    ?    |8-1/2 months        |   R.   |1902, xliv. 41.
  Doran       |   39    |    ?               |   R.   |1904, xlv. 119.
  Doran       |   30    |4th month           |   R.   |Ibid.
  Doran       |   30    |    ?               |   R.   |Ibid.
  Boyd        |   42    |8th month           |   D.   |Ibid., 106
  Boyd        |   40    |3rd month           |   R.   |Ibid.
  Fairbairn   |   22    |5th week post partum|   R.   |Ibid., 194.
  Doran       |   38    |4th week post partum|   R.   |1904, xlvi. 274.
  Taylor      |   33    |3rd month           |   R.   |1905, xlvii. 333.
  Andrews     |    ?    |3rd day post partum |   R.   |Ibid., 4.
  Lea         |   39    |7th week post partum|   R.   |Ibid., 1
  Boyd        |   42    |4th month, total    |   R.   |1907, xlix. 49.
  Bland-Sutton|   39    |4-1/2 months        |   R.   |1907.
  Dauber      |   31    |3rd month           |   R.   |1908.
  McCann      |   25    |4-1/2 months        |   R.   |Ibid.
  Spanton     |   33    |2-1/2 months        |   D.   |Ibid.
  ------------+---------+--------------------+--------+-----------------

    TABLE OF CASES IN WHICH ABDOMINAL MYOMECTOMY WAS PERFORMED DURING
    PREGNANCY

    From the _Transactions of the Obstetrical Society_, 1900-8, both years
    inclusive.

  -----------+---------+--------------------+---------+-----------------
             |_Age of  |     _Stage of      |         |
  _Recorder._|Patient._|     Pregnancy._    |_Result._|  _Reference._
  -----------+---------+--------------------+---------+-----------------
  Donald     |    31   |3rd month           |    R.   |1901, xliii. 194.
  Walls      |    ?    |          ?         |    R.   |Ibid., 195.
  Routh      |    ?    |5th month           |    R.   |1904, xlvi. 279.
  Spencer    |    41   |9th month           |    R.   |Ibid., 122.
  Malcolm    |    32   |7th week post partum|    R.   |Ibid., 15.
  Doran      |    28   |2nd month           |    R.   |1905, xlvii, 426.
  Vaughan    |    ?    |4th month           |    R.   |Ibid., 427.
  Vaughan    |    ?    |3-1/2 months        |    R.   |Ibid.
  Swayne     |    40   |5th month           |    R.   |1908, l.
  Swayne     |    35   |4-1/2 months        |    R.   |Ibid.
  Williamson |    32   |7th month           |    R.   |Ibid., 73.
  Scharlieb  |    37   |4-1/2 months        |    R.   |Ibid.
  Scharlieb  |    39   |3-1/2 months        |    R.   |Ibid.
  -----------+---------+--------------------+---------+-----------------

=Pregnancy complicated with cancer of the cervix.= When a pregnant woman
comes under observation with cancer of the neck of the uterus in an
operative stage in the early months, hysterectomy should be performed:
in some instances the cervix has been amputated without disturbing the
pregnancy.

In the later stages good consequences follow the induction of labour and
the immediate performance of hysterectomy. Surprising as it may seem, a
uterus immediately after labour can be safely extirpated through the
vagina.

When the cancer is so advanced as to be inoperable, the pregnancy should
be allowed to go to term, and if the cancerous mass offer an impassable
barrier to delivery, Cæsarean section should be performed. This
operation has been found necessary to extract a dead fœtus.

Most surgeons in dealing with operable cases of this complication of
pregnancy remove the parts through the vagina, because in the abdominal
operation the septic cervix is withdrawn through the abdomen; this makes
it extremely difficult to avoid soiling the pelvic peritoneum.

=Concurrent uterine and tubal pregnancy.= This condition may require
operation in three different circumstances:--

1. _Tubal and uterine pregnancy occur simultaneously and the
complication is recognized in the early months._ Here the operation
would be that of oöphorectomy, and the uterine pregnancy may continue
undisturbed to term.

2. _Intra- and extra-uterine gestation with living fœtuses runs
concurrently to term._ This is an exceedingly dangerous, though a rare,
combination. The table on p. 35 shows how deadly a compound pregnancy
is to the mother: it sets forth also the fate of the children.

3. _Uterine pregnancy is complicated by the presence of a quiescent
(sequestered) extra-uterine fœtus._ Many cases have been reported in
which a fœtus of this character has occupied the pelvis, yet the woman
conceived and the child was safely delivered at term; but a sequestered
fœtus may constitute an impassable barrier and require removal
(Operations for Compound Pregnancy, see p. 33).

=Pregnancy complicated by tumours growing from the pelvic walls.= When
the pelvis is occupied by a chondroma, osteoma, or a sarcoma growing
from the innominate bones or the sacrum, or from the fascia of the
pelvis and displacing the gravid uterus, the proper course is to perform
subtotal hysterectomy. If the obstruction is not detected until the
child is viable, and there is no especial call for urgency, interference
should be postponed until near term; the child can then be saved by
Cæsarean section, and the uterus removed.

The operation in such circumstances calls for the exercise of judgment,
but it is rarely difficult. Among interesting tumours complicating
labour and obstructing delivery, special mention may be made of dermoids
and teratomata lying in the hollow of the sacrum. Skutsch has collected
the chief German records.

Echinococcus cysts (hydatids) have grown in the pelvic connective tissue
and obstructed labour. Cases have been reported by Knowsley Thornton,
Küstner, Blacker, and others.


REFERENCES

BLACKER, G. F. Clinical Lecture on Uterine Fibroids complicating
    Pregnancy. _The Clinical Journal_, 1908, xxxi. 309.

KÜSTNER. Kaiserschnitt wegen eines Echinokokkus im Becken. _Zentralbl.
    f. Gynäk._, 1907, xxxi. 1390.

SKUTSCH, F. Ueber die Dermoidcysten des Beckenbindegewebes. _Zeitsch. f.
    Geburts. and Gynäk._, 1899, xl. 353.

THORNTON, J. K. Removal of Hydatids of the Omentum and from the Pelvis.
    _Medical Times and Gazette_, 1878, ii. 565.


OPERATIONS FOR PUERPERAL SEPSIS (METASTATIC BACTERIÆMIA)

Acute septic infection (puerperal) of the uterus, too frequent even in
this antiseptic epoch, is a desperate condition, but attempts have been
made to deal with it by two methods--either hysterectomy, or the
ligature and excision of the thrombosed ovarian veins.

So far as hysterectomy for this condition is concerned, it may be
stated that it has been tried, but with no encouraging measure of
success; it is a very desperate proceeding, and has been occasionally
successful by the abdominal, as well as by the vaginal route. It is
possible that vaginal hysterectomy may now and then be a wise operation
in acute puerperal infection, but better results have been attained by
ligature of the thrombosed pelvic veins, and by drainage of the pelvic
cavity. Some interesting operations, with brilliant results, have been
published by Trendelenburg, Michels, Cuff, Bumm, and others.

In some cases of puerperal pyæmia a careful examination of the patient’s
abdomen has enabled the surgeon to feel the thrombosed ovarian vein, and
in others the vein has been exposed by an incision running from the tip
of the eleventh rib to the spine of the pubes, parallel with Poupart’s
ligament. The muscles are divided and the peritoneum reached; this is
reflected until the thrombosed ovarian vein is exposed and separated
from the ureter. About half an inch below its junction with the renal
vein or the vena cava, as the case may be, it is securely ligatured and
divided; the vein is then slit up and the clot turned out. The
operation, when carried out in this way, is extraperitoneal. In some
instances successful ligature of the thrombosed ovarian vein has been
effected by the usual median incision into the peritoneal cavity.

The object of ligaturing the thrombosed ovarian vein is to prevent the
pathogenic micro-organisms in the clot from entering the circulation.
Bumm reported five cases in which he ligatured these veins. Three of the
patients recovered.

It is more than probable that if operative interference be carried out
on thrombosed ovarian veins before the condition of the patients become
desperate, more of them might be rescued. Success has been attained even
in desperate conditions; for example, Friedemann ligatured these veins
in a woman whose general condition was not only bad, but who also had
extensive bed-sores. She recovered.

T. G. Stevens reported the details concerning a woman who died, of acute
septicæmia, eleven days after a subtotal hysterectomy (by Galabin) for
fibroids. The right ovarian vein was thrombosed from the ligature in the
pelvis to its entrance into the vena cava, and he isolated from the clot
and produced in cultures the _bacillus pyocyaneus_. He also stated that
‘the vein could have been easily dissected out, and possibly the fatal
result might have been averted’.

This operation rests on sound principles, for the ligature of the
ovarian veins prevents the septic blood entering the circulation,
thereby setting up, among other things, endocarditis and pulmonary
embolism.

The great difficulty in dealing with this condition is the selection of
suitable cases. Experience teaches that acute cases are unsuitable. The
best results have been attained in the chronic forms of the disease
where the thrombosis was limited. There is great uncertainty in a given
case as to the extent of the thrombosis and the number of veins
implicated. As has already been mentioned, there are two routes for
gaining access to the thrombosed vessels--the extraperitoneal and the
intraperitoneal. I prefer the intraperitoneal route (cœliotomy), for it
enables the surgeon to deal with the vessels, iliac or ovarian, of both
sides, as well as allowing a thorough examination of the pelvic organs,
and it permits the drainage of any collection of serum or pus found in
the pelvis. From a study of the reported cases it is clear that the best
results are obtained by cœliotomy. The ligature of thrombosed ovarian
veins in chronic puerperal pyæmia promises good results for the future,
but it needs further experience to teach us the kind of case in which it
is likely to be successful.


REFERENCES

BUMM, E. Zur operativen Behandlung der puerperalen Pyämie. _Berliner
    Klin. Wochensch._, 1905, xlii. 829.

CUFF, A. A Contribution to the Operative Treatment of Puerperal Pyæmia.
    _Journ. of Obstet. and Gyn. of the British Empire_, 1906, ix. 517.

FERGUSON, J. HAIG. Abdominal Hysterectomy for Acute Puerperal Metritis
    and Acute Salpingitis. _Obstet. Transactions_, Edin., 1906, xxxi.
    123.

FRIEDEMANN, G. Die Unterbindung der Beckenvenen bei der pyämischen Form
    des Kindbettfiebers. _Münchener Med. Wochensch._, 1906, liii. 1813.

LENDON, A. A. Puerperal Infection, Thrombosis: Ligature of the Right
    Ovarian Vein. _Australian Medical Journal_, 1907, xxvi. 120.

MICHELS, E. The Surgical Treatment of Puerperal Pyæmia. _Lancet_, 1903,
    i. 1025.

STEVENS, T. G. The Bacteriological Examination of a Thrombosed Ovarian
    Vein (following Hysterectomy). _Trans. Path. Soc._, li. 50.

TRENDELENBURG, F. Ueber die chirurgische Behandlung der puerperalen
    Pyämie. _Münchener Med. Wochensch._, 1902, xlix. 513.




CHAPTER X

OPERATIONS FOR INJURIES OF THE UTERUS


Injuries of the uterus fall into six groups:--

1. Gynæcological injuries.

2. Obstetric injuries.

3. Injuries to the pregnant uterus.

4. Injuries to the pregnant uterus in the course of abdominal
operations.

5. Bullet-wounds of the pregnant uterus.

6. Stab-wounds of the pregnant uterus.

=Gynæcological injuries.= The simplest and certainly the commonest
accident is perforation of the uterus with a sound, dilator, or forceps
in the operation of curetting. Many cases are known in which the uterus
has been perforated by clean instruments of this class and the patients
have suffered no inconvenience.

On the other hand, when the sound or the uterus is septic, perforation
of the uterus has been followed by a rapidly fatal peritonitis; indeed,
some of these injuries may prove as lethal as a snake-bite.

Occasionally very serious consequences follow simple perforations by
dilators and curettes; this has induced some gynæcologists to urge that
if, in the course of dilatation and curettage of the uterus, a rupture
or perforation of the uterine wall occurs, it is better to perform a
cœliotomy and assure oneself of the safety of the patient than to hope
that no untoward result will ensue.

This advice is too sweeping. When the perforating instrument is clean,
and there is little or no bleeding, the case may be left to itself; if
untoward signs arise, cœliotomy should be performed. Sometimes a pelvic
abscess occurs as a sequence to the accident, and will require
evacuation through the vaginal fornix, or, perhaps, by means of an
incision in the flank. Verco found a piece of a curette, 2-3/4 inches
long, in an abscess cavity behind the uterus. The patient had been
curetted two weeks previously.

A perforation, or a rent in the uterine wall, in the course of
curetting, is a serious accident when the operator is unaware that such
has happened, and proceeds to flush out the uterine cavity with
poisonous antiseptic solutions, especially perchloride of mercury.
Cases are known in which, under these conditions, the woman has died in
the course of a few hours.

Injuries, in the course of instrumentation of the uterus, are not always
mere perforations; some are wide rents--and this is an especial danger
in removing sessile submucous fibroids (vaginal myomectomy). _A serious
complication of tears or rents of the uterine wall, whether the uterus
is gravid or non-gravid, is extrusion or prolapse of the intestine._ It
is also remarkable that in several reported cases the practitioner has
mistaken the intestines for ‘secundines’, even in unimpregnated uteri,
and has withdrawn them, and even cut lengths of intestine away, before
recognizing his error.

In one case of this kind, where a practitioner had withdrawn and removed
several feet of intestine through a rent in the course of a curettage, I
performed cœliotomy, closed the hole in the uterus, joined the cut ends
of the bowel with sutures, resected the mesentery belonging to the
removed bowel, and thus saved the patient’s life. In another case, where
a practitioner had torn the uterus during curettage and intestine
appeared in the vagina, there was such free bleeding that I found it
prudent to perform subtotal hysterectomy. This patient also recovered.
Successful operations of this kind have also been performed by Werelius
and Nixon Jones.

Palmer Dudley relates that on one occasion, in curetting a recently
gravid uterus, he tore the posterior wall without being aware of it, and
withdrew eight inches of intestine, thinking it to be secundines; he
recognized the error, and pushed the intestine back through the opening
in the uterine wall. The patient recovered, and subsequently had two
successful pregnancies.

These cases show how impossible it is to recommend any hard and fast
lines of treatment. Much depends on the circumstances of the case, the
character of the injury, and above all on the experience and
resourcefulness of the practitioner.

Ruptures or tears of the uterus in the process of instrumental
dilatation or curettage are by no means rare, and they have a high
mortality. Jakob of Munich collected 141 instances of such injuries, and
of these twenty-three died chiefly from septic peritonitis. Among these
injuries seventy-three were inflicted with the curette, nineteen with
the sound, fourteen with forceps (_Ausräumungszangen_), and six were due
to flushing catheters.

=Obstetric injuries.= The uterus is liable, during labour, to be torn,
as a result of its own expulsive efforts, especially when the transit of
the fœtus is hindered or obstructed by narrowness of the pelvic outlet,
tumours, or undue size of the child. This form of injury is called
_spontaneous rupture_, to distinguish it from the rupture due to
midwifery implements. The uterus is frequently torn in the obstetric
manœuvre known as ‘turning’.

The literature relating to this accident is abundant, and the reports
issued from lying-in institutions deal with extensive figures, but
unfortunately the reporters are not in harmony on the principles of
treatment.

There are three methods of dealing with rupture of the uterus:--

1. Treating the patient conservatively, which means at most lightly
packing the part with antiseptic gauze.

2. Performing cœliotomy and stitching up the rent in the uterus.

3. Hysterectomy, preferably by the abdominal route, as this enables the
peritoneal cavity to be cleared of clot.

The only point in which there is any semblance of agreement among
obstetricians is this: in cases of complete rupture, in which the fœtus
and membranes are extruded from the uterus into the belly, cœliotomy is
clearly indicated.

Admirable reports have been published by Walla, Klien, Ivanoff, and
Munro Kerr.

Klien’s is a critical and very valuable study, based upon 347 cases of
rupture of the uterus published in the preceding twenty years. Of these
cases 149 were operated upon, with a mortality of 44 per cent.; 198 were
not operated upon, 96 recovered and 102 died--a mortality of 52 per
cent. Among the unoperated cases some were not treated in any way, and
in these the mortality was 73 per cent., whilst in those treated by
drainage, plugging and irrigation, the mortality was only 37.5 per cent.

When there is dangerous bleeding Klien advises immediate operation.
Lacerations of the vagina make the prognosis unfavourable, and
especially injury of the bladder.

During the last ten years hysterectomy has been so much improved and the
technique so simplified, that the operative treatment of complete
rupture of the gravid uterus will be more frequently undertaken in the
future than it has in the past, and with every prospect of reducing the
heavy bill of mortality at present associated with this grave accident.

Donaldson (1908) reports a remarkable case in which the uterus ruptured
during forceps delivery; 12-1/2 feet of small intestine, detached from
the mesentery, were extruded with the fœtus. Cœliotomy was performed,
the detached intestine cut away, and the proximal end of the bowel
anastomosed into the cæcum. A long rent in the posterior wall of the
uterus was closed with sutures. The patient survived the accident ten
days, and died from sepsis; ‘the entire uterus seemed to be a sloughing
mass.’ Donaldson states that, had he removed the uterus at the time he
operated on the intestine, the patient would probably have survived.

=Injuries to the pregnant uterus.= Some of the most remarkable injuries
inflicted on the gravid uterus are the consequences of attempts to
induce what is technically called criminal abortion, especially when the
abortion is self-induced. Kehr has recorded an example of a desperate
effort of this kind:--A widow, twenty-nine years of age, when in the
fifth month of an illicit pregnancy, fired a revolver bullet into the
uterus through the anterior abdominal wall. Cœliotomy was performed, and
the wound in the uterus closed by suture. The woman aborted on the
fourteenth day, but recovered.

A gravid uterus in the later months of pregnancy is a big organ, and,
like the abdominal viscera generally, may be severely damaged by blows,
kicks from horses or brutal men, butts from animals, such as a calf or a
goat, falls upon the belly, or a fall downstairs, or the woman may be
run over. The treatment to be adopted in these conditions varies widely
with the circumstances. As a general rule it may be stated that the most
satisfactory mode of treatment is cœliotomy; this permits a thorough
examination of the organ, and facilitates removal of effused blood. In
the late stages of pregnancy accidents of this kind entail Cæsarean
section.

Among the most curious injuries of this group are those known as
horn-rips: these are cases in which the pregnant uterus is torn open by
the horn of a bull. An interesting collection of cases illustrating this
accident has been made by Robert P. Harris. Even after very severe
injuries, in some of which the intestines protruded, women have
recovered, and several children survived this terrible mode of delivery.

=Injury to a gravid uterus in the course of an abdominal operation.= In
spite of every care it has happened on many occasions that a pregnant
uterus has been mistaken for an ovarian cyst, the abdomen has been
opened and a trocar plunged into the uterus. In some instances a uterus
in which the pregnancy has advanced as far as the sixth month has been
removed under the impression that it was a large ovarian cyst, and this
accident has happened with a pregnant uterus greatly enlarged in the
somewhat rare condition known as hydramnios. A pregnant uterus is also
liable to be stabbed by an ovariotomy trocar when the condition is
complicated with unilateral or bilateral ovarian cysts. The gravid
uterus has very thin walls and, occasionally, resembles so very closely
an ovarian cyst as to deceive an inexperienced operator.

When the surgeon finds that he has injured a pregnant uterus in the
course of an abdominal operation three courses are open to him, each of
which has been practised with success by surgeons of renown:--

1. Sew up the incision in the uterus.

2. Perform Cæsarean section.

3. Remove the uterus (subtotal hysterectomy).

Several cases have been reported in which injury to a gravid uterus
during ovariotomy has terminated fatally, especially when the surgeon
followed the plan of sewing up the wound in the uterus.

A careful consideration of the reported cases indicates that the best
results follow for the patient when the surgeon performs Cæsarean
section, as the following record shows:--

Sir Spencer Wells had removed a large, multilocular ovarian cyst from
the left side of the patient, when he felt what was supposed to be a
cyst of the right ovary. When tapped it was found to be a gravid uterus,
in which pregnancy had advanced to near the fifth month. Cæsarean
section was at once performed and the patient recovered.

Injuries of this kind are rarely likely to happen now, for the clumsy
ovariotomy trocar is passing out of use.

[Illustration: FIG. 24. DIAGRAM REPRESENTING A GUNSHOT INJURY OF THE
UTERUS. The woman was aged 28, and in the seventh month of pregnancy.
The bullet was extracted from under the skin on the left side, four
inches behind the anterior superior spine of the ilium. The line A B
represents the track of the bullet. (_British Medical Journal_, 1896,
vol. i, p. 332.)]

=Bullet-wounds of the pregnant uterus.= These are very rare, and, like
rupture of the uterus, liable to be complicated with injury of the
intestines; it is for this reason that the canon of surgery applicable
to penetrating wounds of the abdomen should be practised in these
circumstances, and the patient submitted to cœliotomy.

When the gravid uterus is penetrated by a bullet there may be little
bleeding on account of the contracting property of the uterine tissue.
In some instances amniotic fluid stained with blood escapes. In
operating, the anterior as well as the posterior surface of the uterus
should be carefully examined in order to determine if the bullet passed
through this organ. In some instances the fœtus has been injured by the
bullet. When free bleeding follows a bullet-wound of the gravid uterus
the hæmorrhage is usually due to damage of blood-vessels connected with
the intestines.

The best method of dealing with the uterus in such conditions is
undetermined, but a study of the few reported cases indicates that the
best results follow cœliotomy, with suture of the perforated intestine
and the hole or holes in the uterus. The patients usually abort. In
Prichard’s case (Fig. 24) hysterectomy was performed, but the patient
died.

Even in some apparently desperate cases good consequences follow the
conservative operation, as the following reports demonstrate:--

In a case under the care of Albarran, the patient was aged nineteen
years and in the fifth month of pregnancy when shot. There were four
perforations of the small intestines, and the mesenteric artery was
wounded. He resected 20 centimetres of small intestine. A loop of
umbilical cord protruded through the bullet-hole in the uterus; this was
resected and the ends of the cord tied. The patient miscarried a few
hours after the operation, but recovered.

Baudet reported a case in which there were four perforations of the
small intestine: he sutured the wounds in the uterus and the holes in
the bowel; the woman aborted some hours after the operation, but
recovered.

In a case under Robinson’s care the bullet entered the uterus and
penetrated the right shoulder of the fœtus. The patient, who was in the
eighth month of pregnancy, quickly miscarried. The bullet was found in
the débris. The patient not only recovered, but reconceived, and gave
birth to another child in the following year.

=Stab-wound of the pregnant uterus.= Examples of this kind of injury are
rare, but some of the recorded cases are remarkable. Guelliot has
recorded the details of a case in which a pregnant woman was stabbed in
the buttock. The knife passed through the great sciatic notch, and
penetrated the uterus and the child’s skull. The woman miscarried of a
dead fœtus next day. The great sciatic nerve was injured, but the woman
recovered, though she remained lame.

Steele recorded an example where a woman, six and a half months
pregnant, stabbed herself in the lower abdomen with a knife; she was
taken to a hospital and kept at rest until the wound healed. Six weeks
after the injury the woman was delivered of a live male child, normally
developed, but much of the child’s large and small intestines protruded
through an opening in the abdomen. The jejunum was completely severed
as a result of the stab. Steele attempted to deal with this
extraordinary lesion surgically, but the child died a few hours later.


REFERENCES

ALBARRAN. Plaies multiples de l’intestin et de l’utérus gravide par
    balle de revolver. _Bull. et Mém. de la Soc. de Chirurgie de Paris_,
    1895, xxi. 243.

BAUDET, R. Plaies de l’intestin et de l’utérus gravide par balle de
    revolver. _Bull. et Mém. de la Soc. de Chir. de Paris_, 1907,
    xxxiii. 779.

BLAND-SUTTON, J. A Clinical Lecture on the Treatment of Injuries of the
    Uterus. _The Clinical Journal_, 1908, xxxi. 289. On two cases of
    Abdominal Section for Trauma of the Uterus. _The Am. Journal of
    Obstetrics_, 1907, lvi.

BRAUN-FERNWALD, R. VON. Über Uterusperforation. _Zentralbl. f. Gyn._,
    1907, xxxi. 1161.

CONGDON, C. Abdominal Section for Trauma of the Uterus. _The Am. Journal
    of Obstetrics_, 1906, liv. 618.

DONALDSON, H. J. An unusual Obstetric Complication, causing the removal
    of 126 inches of Small Intestine. _Surgery, Gynæcology, and
    Obstetrics_, 1908, vi. 417.

DUDLEY, P. Discussion on Accidental Rupture of the Non-parturient
    Uterus. _Trans. Am. Gyn. Soc._, 1905, xxx. 21.

GUELLIOT. Coup de couteau ayant pénétré à travers l’échancrure sciatique
    jusqu’à l’utérus gravide et jusqu’au fœtus, &c. _Société de
    Chirurgie_, 1886, xii, 337.

HARRIS, R. P. Cattle-horn Lacerations of the Abdomen and Uterus of
    Pregnant Women. _The Am. Journal of Obstetrics_, 1887, xx. 673.

IVANOFF, N. De l’étiologie, de la prophylaxie et du traitement des
    ruptures de l’utérus pendant l’accouchement. _Annales de
    Gynécologie_, 1904, 449.

JAKOB, J. Gefahren der intra-uterinen instrumentalen Behandlungen.
    _Zentralbl. für Gyn._, 1906, xxx, No. 19, 561.

JARMAN, G. W. Accidental Rupture of the Non-parturient Uterus, with
    report of cases. _Trans. of the Am. Gyn. Society_, 1905, xxx. 15.

KEHR, H. Über einen Fall von Schussverletzung des graviden Uterus.
    _Centralbl. für Chir._, 1893, xx. 636.

KERR, MUNRO. On Rupture of the Uterus. _Brit. Med. Journal_, 1907, ii.
    445.

KLIEN. Die operative and nichtoperative Behandlung der Uterusruptur.
    _Arch. f. Gyn._, 1901, lxii. 193.

PRICHARD, A. W. A case of Bullet-wound of the Pregnant Uterus. _Brit.
    Med. Journal_, 1896, i. 332.

ROBINSON, W. S. Death of Fœtus _in utero_ from Gunshot-wound: Recovery
    of the Mother. _Lancet_, 1897, ii. 1045.

STEELE, D. A. K. Stab-wound of Fœtus _in utero_. _Surgery, Gynæcology,
    and Obstetrics_, 1908, vi. 293.

VERCO, W. A. _The Australian Med. Gazette_, 1908, 681.

WALLA, A. VON. Ruptura uteri completa, abdominale Totalextirpation.
    Heilung. _Centralb. für Gynäk._, 1900, xxiv. 497.




CHAPTER XI

THE AFTER-TREATMENT. RISKS AND SEQUELÆ OF ABDOMINAL GYNÆCOLOGICAL
OPERATIONS


The performance of ovariotomy, hysterectomy, and allied procedures is
attended by several risks, immediate and remote, which may spoil the
best-planned and most carefully executed operation. Some of these may be
avoided by careful attention to the details embraced by the phrase
‘after-treatment’.


THE AFTER-TREATMENT OF ABDOMINAL OPERATIONS

The patient is returned to the bed with gentleness and usually lies on
her back, but many anæsthetists prefer to turn the patient on one or
other side for an hour, until there is a fair return to consciousness.
The patient then lies on her back and a pillow is placed under the
knees. Hot-water bottles should not be placed in the bed with the
patient until she is completely conscious, and they are rarely needed.
The healing of blisters caused by hot-water bottles is a slow process.
During the first twelve hours the patient complains of pain, thirst, and
vomiting.

The thirst is in a measure relieved by administering six or eight ounces
of normal saline solution by the rectum an hour after the patient
returns to bed, and repeating it in three or four hours. The patient may
wash her mouth out frequently with water, hot or cold, according to her
fancy, and if there is no vomiting she may swallow a little hot water
from time to time. As a rule, it is better for her to abstain from
swallowing anything for the first eighteen hours; the best way to avoid
vomiting after an anæsthetic is to keep the stomach empty.

There is always some pain after an abdominal operation, partly due to
tension on the sutures, and colic. The injection of normal saline
solution (a teaspoonful of salt to a pint of water) by the rectum often
controls this, but occasionally the pain is so severe that it is
necessary to give a quarter of a grain of morphine hypodermically, or in
a suppository, about twelve hours after the operation, in order to
procure sleep. The routine use of morphine after these operations is
injudicious and rarely necessary.

At the end of twenty-four hours small quantities of barley-water, tea,
or milk and water are given, and if retained they may be taken in
increasing quantities. On the fourth day an enema is given to clear the
bowel, and then the patient will take fish, chicken, &c., and soon get
on to convalescent diet.

When vomiting is very troublesome, it is sometimes necessary to keep a
patient on rectal feeding two or three days.

When there is abdominal distension, this may be relieved by the passage
of a rectal tube at intervals of three hours, and if this fails a
turpentine enema should be given.

Patients should always be encouraged to empty their bladder naturally:
many are unable to pass water whilst lying on their backs. In these
cases the urine is drawn from the bladder by a carefully sterilized
glass catheter. Before passing the catheter, the nurse carefully wipes
away the mucus from the urethral orifice. Cleanliness and care with the
catheter must be enforced: cystitis causes much misery. During the first
few days the quantity of urine passed by the patient is measured, and
recorded in the notebook.

The temperature should be observed every four hours during the first
week and recorded. The first record after the operation is usually
subnormal, and in twelve hours it rises to normal or beyond. During the
first twenty hours it may rise to 100° without causing alarm; beyond
this, if accompanied by a rapid pulse, an anxious face, and distended
belly, it will cause anxiety to the surgeon. A temperature of 101° or
102° unaccompanied by other unfavourable symptoms is not a cause for
alarm, unless maintained.

The state of the pulse is a valuable guide and more trustworthy than the
temperature. When the pulse remains steady and full there is no cause
for alarm. When it increases in frequency to 120 or 130 beats per
minute, and is thin and thready, then there is danger, even if the
temperature is only slightly raised.

On the seventh or eighth day the sutures will require removal.
Occasionally a hæmatoma forms in the wound; and in patients in whom the
operation has been performed for septic conditions, stitch abscesses
will occur. In septic cases the sutures require to remain a few days
longer, to allow the wound to unite more securely.

When oöphorectomy, ovariotomy, or hysterectomy is followed by a
non-febrile convalescence the patient may be allowed to leave her bed on
the fourteenth day, and at the end of another week she may return to her
home or go to the seaside according to circumstances. When the wound has
healed by primary union, and this is usual where aseptic methods have
been followed and buried sutures employed for the fascial and muscular
layer, an abdominal belt is unnecessary. When suppuration has taken
place in the wound and healing has been retarded, especially in a
patient in whom operations have been performed for septic conditions, it
is a useful precaution to advise her to wear a well-made belt. This is
more necessary for women who have to get their living by hard work.


COMPLICATIONS OF ABDOMINAL GYNÆCOLOGICAL OPERATIONS

=Metrostaxis.= After ovariotomy and oöphorectomy, unilateral or
bilateral, blood sometimes escapes from the uterus in the course of the
first week, and simulates menstruation: it sometimes occurs within
forty-eight hours of the operation, and is usually ushered in with a
rise of temperature (100°-101°).

=Bed-sores.= These sometimes give trouble when operations are performed
on elderly or enfeebled patients, especially when they are thin and have
incontinence of urine. With due watchfulness and care on the part of the
nurse a bed-sore ought rarely to occur.

=Post-anæsthetic paralysis.= Paralysis following operations on the
pelvic organs occurs in connexion with the upper and lower limbs; it is
an awkward and avoidable complication. Some of the simplest cases are
those which arise from the pressure upon an individual nerve, such as
the ulnar, circumflex, or musculo-spiral, due to the arm coming in
contact with the sharp edge of a metal operating table. When the
patient’s legs are flexed across the sharp edge of the table and fixed,
as in the Trendelenburg position, during a long operation, the external
popliteal nerve is liable to be pressed upon by the condyles of the
femur. This will lead to paralysis of the muscles supplied by it. In
some instances the paralysis is bilateral. Paralyses of this kind are
identical with what are known as ‘sleeping palsies’. The more serious
paralyses are directly due to the Trendelenburg position, in which there
is a great tendency for the arms to be displaced over the head and hang
downwards or abducted, as this position causes the clavicle to compress
the nerves of the brachial plexus upon the first rib, or the scalenus
anticus muscle, and perhaps, as some observers believe, between the
clavicle and the transverse processes of the fifth and sixth cervical
vertebræ.

Most of the writers on this subject attribute the paralysis more
particularly to drawing the head to one side when the patient lies in
the Trendelenburg position with abducted upper limbs, as it tends to
stretch the lower cervical nerves of the opposite side, especially the
fifth. This stretching is probably a greater factor in producing
paralysis than pressure.

The form of paralysis produced in this way is that known as Erb’s palsy,
and the muscles particularly concerned are the deltoid, brachialis
anticus, biceps, and the supinator longus. Sometimes the spinati are
involved. Occasionally the paralysis is bilateral. A case has been
reported in which there was a total lesion of the brachial plexus,
including the muscles of the shoulder girdle.

The following facts serve to show that stretching rather than pressure
is responsible for this class of paralyses. A patient had undergone a
vaginal operation in the crutch position, when the assistant drew her
along the table by means of his fingers hooked in the axillæ over the
folds of the pectoral muscles: next morning both upper limbs were found
to be paralysed, and they remained in this condition many weeks.

In some of the lighter forms the paralysis passes off in a few days, but
cases are known in which it has persisted for many months, and as it
renders the limb useless for a time it is a serious matter.

Halstead refers to a case of bilateral peroneal paralysis following
salpingectomy in the Trendelenburg posture which disabled a patient for
six months.

On the whole prognosis is favourable, and recovery the rule.

Büdinger has described a case in which the upper limb was paralysed
after an abdominal operation. The patient died some weeks later, and a
clot of blood was found pressing on the surface of the brain at a spot
corresponding to the arm centre.


REFERENCES

BÜDINGER. Über Lähmungen nach Chloroformnarkosen. _Archiv f. klin.
    Chir._, 1894, Bd. xlvii. 121.

COTTON, F. J., and ALLEN, F. W. Brachial Paralysis--Post-narcotic.
    _Boston Med. and Surg. Journal_, 1903, cxlviii. 499.

HALSTEAD, A. E. Anæsthesia Paralysis. _Surgery, Gynæcology, and
    Obstetrics_, 1908, vi. 201.

TURNEY. Post-anæsthetic Paralysis. _Clinical Journal_, 1899, xiv. 185.


=Giving way of the wound.= After cœliotomy the patient runs a risk of
the wound being burst open, and this accident seems particularly liable
to happen in cases where catgut has been selected for the suture
material. Accidents of this kind belong to two categories:--

1. Many cases occur in patients from violent coughing or vomiting, as
the straining causes the knots of the sutures to slip.

2. In feeble patients, and those debilitated by anæmia, diabetes, &c.,
and especially in septic wounds, the union of the edges of the incision
unite very slowly; if the sutures are taken out on the eighth day, as
is the custom, the wound is liable to burst asunder. This accident is
prone to occur in patients whose abdominal wall has been greatly
distended by a large tumour, and especially by pregnancy. On the whole
the accident is more prone to complicate Cæsarean section than any other
operation on the pelvic organs, and cases have been reported in which
there has been a repetition of the accident. The largest collection of
case-reports in which the wound has burst open after cœliotomy has been
made by Madelung; a perusal of his paper shows that it is an accident
with a high mortality. It is a fact that cases of this kind are rarely
published, and from inquiries I find that it is of common occurrence. It
has certainly diminished since surgeons have widely adopted the method
of securing the wound with buried suture, but this is not always a
preventative. The complication which makes the accident so unfortunate
for the patient is the protrusion of the intestines.

In dealing with this condition the surgeon carefully and gently cleans
the extruded intestines and omentum with sterilized water, returns them
into the abdomen, and resutures the wound.


REFERENCES

MADELUNG, O. Ueber den postoperativen Vorfall von Baucheingeweiden.
    _Verhandlung. d. Deutschen Gesellsch. f. Chir._, Berlin, 1905,
    xxxiv, 2. Theil, p. 168.


=Hæmorrhage.= However carefully an operation may be conducted or
whatever material may be employed for ligatures, there is a liability of
bleeding after the patient has been returned to bed. Severe internal
bleeding is usually due to the slipping of a ligature from an ovarian
pedicle, or a uterine artery: it may come from a vaginal artery,
especially in total hysterectomy, and occasionally from a vessel in an
adhesion which has been missed in the course of the operation, for
oozing which is scarcely appreciable when a patient is collapsed may
become very free when reaction occurs.

Severe internal bleeding is manifested by very obvious signs: pallor,
cold skin, rapid but feeble pulse, restlessness, and sighing
respiration. When these symptoms are manifested the wound must be
reopened, the blood and clot removed, and the bleeding point secured. It
often happens, where the bleeding is due to the slipping of a ligature
from the uterine or ovarian artery, that by the time the surgeon reopens
the wound the patient is so bloodless that there is difficulty in
determining the source of the bleeding. In very bad cases it is a wise
plan to arrange for an assistant to perform the intravenous infusion
whilst the surgeon deals with the bleeding vessel. (See Vol. I, p.
405.)

Intravenous injection is the best method of treating patients when the
loss of blood has been great. It is unwise to transfuse more than three
pints into the veins, or the lungs will become waterlogged and the
patient will be later in great peril. When the loss is moderate in
amount and the patient is not greatly enfeebled, a pint or more of
saline solution may be poured into the abdomen before closing the
incision, and this may be supplemented by the administration of six or
more ounces of the solution by the anus at two-hourly intervals until
the force of the circulation is restored.

In some instances the subcutaneous injection of normal saline solution
may be employed. A suitable region is the loose tissue under and around
the breasts. When this method is adopted the skin should be rendered
antiseptic, otherwise troublesome abscesses and cellulitis will arise in
the subcutaneous tissue at the situation where the saline solution has
been injected.

=Intrapelvic hæmorrhage.= For many years I have maintained that two
factors which have enabled hysterectomy to vanquish oöphorectomy in the
treatment of uterine fibroids are _rigid asepsis_ and _perfect
hæmostasis_. In the early days of intrapelvic surgery there used to be
much discussion on the subject of free blood in the pelvic cavity: some
practical surgeons urged that it was harmful and would induce
peritonitis, and others took the opposite view. From my own observations
I came to the conclusion that effusions of blood in the abdomen were
often quickly absorbed, but that this was not invariable; and that
post-operative collections of blood were very liable to become septic,
especially when drainage was employed. I also pointed out that the large
effusions of blood in the abdomen due to tubal abortion, or to the
rupture of a gravid tube, are often attended with fever, and in some
instances the temperature rises to 103°. In such cases, when operative
interference is undertaken, the deliquescent clot present in the pelvis
often gives off a musty odour. Much light has been thrown on this
condition by Dudgeon and Sargent, who have specially investigated the
bacteriology of intraperitoneal effusions. These observers have isolated
from intraperitoneal effusions of blood a white staphylococcus, which
makes its appearance in the blood within a few hours of being effused,
and they are of opinion that the febrile disturbances so frequently
found after effusions of blood into the peritoneal cavity are due to the
presence of this organism.

Apart from the pathological importance of these observations there is a
point of practical value connected with them. The white staphylococcus
will infect sutures and give rise to stitch-abscesses in the wound; in
view of this fact it behoves the surgeon who has to deal with a stale
effusion of blood in the pelvis and evacuates it by an incision through
the abdominal wall, that in closing the incision he should employ
through and through sutures, and not attempt to suture it layer by
layer. I have noticed the same tendency to stitch-abscess in cases of
diffuse pelvic inflammation due to infection by the gonococcus.

=Pneumonia.= This is a serious and not infrequent sequel of cœliotomy,
especially when it concerns diseased conditions in the upper half of the
abdomen: pneumonia occurs frequently as a sequel to ovariotomy,
hysterectomy, and allied operations, and occasionally has a fatal
ending. It may arise from inhalation, or may be due to the dorsal
position (hypostatic pneumonia), or it may arise from infection.

Inhalation pneumonia is not uncommon, and although it is often
attributed to the anæsthetic, especially ether, it is doubtless due to a
combination of causes, such as a cold room, undue exposure of the body,
septic teeth, the chilling effects of ether on the tissues of the lung,
and occasionally to a dirty face-piece belonging to the ether or
chloroform apparatus.

Hypostatic congestion of the lungs is liable to occur in the aged and in
debilitated patients; it is a complication in such cases always to be
guarded against.

Embolic pneumonia is the most serious form, and occurs as a sequel to
operations for septic conditions, such as pyosalpinx, suppurating
ovarian cysts, septic fibroids, and post-operative sepsis; it is also
associated with thrombosis, especially when the pelvic veins contain
septic clot.

In the preceding section attention was drawn to the appearance in
intra-abdominal blood-effusions of a white staphylococcus: such
collections of blood are prone to decompose and cause the temperature to
rise.

On several occasions in which blood has been effused freely into the
pelvic cavity, either as a consequence of tubal pregnancy, or as a
sequel to an operation, such as an abdominal myomectomy, and the blood
has been allowed to remain, or it has been inefficiently drained, the
patients have died from septic pneumonia.

In cases of septic thrombosis the patients run a definite risk from
pulmonary embolism. When the embolus is large the patient sometimes dies
in a few minutes (see p. 101); but even in cases where the embolus is
too small to promptly destroy the patient’s life, its lodgment in the
lungs entails in some instances a very serious illness, and occasionally
a fatal termination.

=Parotitis.= Septic parotitis, or, as it is sometimes called,
symptomatic or secondary parotitis, to distinguish it from mumps, is an
occasional sequel to abdominal operations of all kinds. Careful
observations have shown that parotitis is more common after operations
for septic conditions, and, although it occasionally occurs after
operations which run an afebrile course, the conditions underlying it
are mainly septic in character.

Septic parotitis is distinguished from mumps in the following points:--

It occurs as a complication of some other affection, is in itself
non-contagious, and occasionally suppurates. There are two views held in
regard to its etiology: some hold that it is due to direct infection of
the duct (Stenson’s) of the parotid gland by micro-organisms from the
mouth, whilst others maintain that the path of infection is mainly by
the blood-stream.

Two able investigations have recently been published in regard to this
condition, in which one writer (Bucknall) supports the view that it is
an ascending affection from the mouth, and the other (Tebbs) brings
forward evidence that the elements of infection reach it by the
blood-stream.

Lequeu has seen many cases of post-operative parotitis, and at his
suggestion Verliac and Morel investigated the condition in the
laboratory. They came to the conclusion that this variety of parotitis
originates in the ducts of the gland.

When parotitis complicates post-operative convalescence, it is almost
entirely confined to septic cases: it may occur within two days of the
operation or as late as the thirtieth day. It is more common between the
sixth and tenth days, and its advent is accompanied by much disturbance.
The parotid swells and becomes painful and tender; the skin over it is
red and often brawny. These signs are accompanied by fever, malaise, and
depression of spirits. In mild cases they subside in a few days, but in
severe cases rigors occur, with high fever and suppuration.

The mild cases are best treated with warm fomentations, frequently
changed. If suppuration occurs, the pus will need to be evacuated by a
scalpel, but incisions in a suppurating parotid gland should be carried
out with careful regard to the branches of the facial nerve (pes
anserinus), and the large vessels intimately associated with it.

The surgeon need not be in a great hurry to use the scalpel in these
cases, for it seems occasionally as if the skin would slough, and yet
when it is incised no pus escapes. This septic parotitis is deceptive in
the red and brawny appearance of the skin covering the swollen gland,
and the misleading sense of fluctuation. In many instances the
inflammatory products escape by way of the parotid duct.

Septic parotitis is an unpleasant and painful complication of an
abdominal operation, but it is rarely dangerous and has only had a fatal
termination in very exceptional cases.

=Thrombosis.= After operations on the pelvic organs, thrombosis
occasionally occurs in the iliac, femoral, and saphena veins,
accompanied by fever, pain, especially in the course of the long
saphenous vein, and œdema of the limb. It is noticed most frequently
about the twelfth day after operation.

In some patients the thrombosis is confined to the superficial veins of
the calf and thigh, but when the femoral and internal iliac veins and
the associated lymphatics are involved, the œdema is of a solid kind.
Apart from the danger which ensues from the detachment of a fragment of
clot and its arrest in the pulmonary artery, this complication is often
very serious for the patient, for it entails a long confinement to bed,
a tedious convalescence, and the œdema of the limb will sometimes
persist for many weeks or months, in spite of topical applications,
careful bandaging, or judicious massage.

Post-operative thrombosis was formerly fairly common after hysterectomy
for fibroids and in the later stages of malignant disease of the uterus.
Its frequency after operations for fibroids was attributed to the
profound anæmia in patients who had severe and exhausting metrorrhagia.
I am convinced that it is due to sepsis. In several instances I have
caused the clot found in thrombosed veins to be examined
bacteriologically, and pathogenic microscopic organisms have been
isolated. I am also satisfied that in some cases of thrombosis of the
veins of the thigh, especially those limited to the saphenous veins, the
clotting spreads from the superficial veins of the hypogastrium which
are infected from the abdominal incision.

=Pulmonary embolism.= In perusing the clinical histories of a series of
cases of ovariotomy, hysterectomy, myomectomy, and, indeed, after almost
any surgical operation, here and there a record may be read to this
effect: ‘The patient appeared to be doing well after the operation, when
she sat up, laughed and chatted with the nurse, then suddenly fell back
and died in a few minutes.’

Anything more tragic than this it is difficult to conceive, and, as a
rule, after such a sad occurrence, the relatives are so distressed that
they rarely permit an examination of the body. Death in such
circumstances is usually attributed to embolism of the pulmonary artery.
In some instances this is an assumption, but there are many in which an
embolus has been demonstrated, and a few in which the source has been
detected.

Post-operative embolism of the pulmonary artery is an important matter
for surgeons interested in the operative treatment of uterine fibroids,
for it follows such operations more frequently than any other. In order
to afford some notion of the relative liability of patients to this
accident after subtotal and total hysterectomy for fibroids, I have
gathered the following statistics, which are interesting as showing an
extraordinary variation in the practice of different operators:--

Baldy ascertained that among 366 operations for fibroids in the Gynecean
Hospital, Philadelphia, there were thirteen sudden deaths attributed to
pulmonary embolism.

In the Middlesex Hospital between the years 1896 and 1906 (both years
inclusive) there were 212 abdominal hysterectomies performed for
fibroids. Three of the patients died from pulmonary embolism. Spencer,
in eighty-five total hysterectomies, had two deaths from pulmonary
embolism. R. Lyle, in eight cases of subtotal hysterectomy, had one
sudden death.

Mallet collected the records of 1,800 cœliotomies: there were six deaths
attributed to embolism, and of these, three followed operations for
uterine fibroids. Chas. P. Noble, in forty-two vaginal myomectomies,
lost two patients, one from septic endocarditis, the other from
embolism; in the latter case the fibroid was gangrenous.

Olshausen, from the year 1896 to the end of 1905, performed 366
hysterectomies for fibroids; twenty-seven of these patients died. Five
of the fatal cases were due to embolism.

Since 1894 I have performed more than a thousand operations of various
kinds for fibroids, and have lost one patient from pulmonary embolism.
This happened in 1900. The woman was forty-five years of age and
profoundly anæmic from profuse and long-continued menorrhagia. Twelve
days after subtotal hysterectomy she asked to be pillowed up in bed;
this was done, when she suddenly slipped down the bed in agony and died
in fifteen minutes. At the post-mortem examination the right pulmonary
artery was found plugged with a thick clot. No thrombosed vessels were
found in the pelvis.

The symptoms of pulmonary embolism may occur at any period from the hour
of the operation up to the thirtieth day. In the majority of patients
embolism happens about the twelfth day. The symptoms supervene with
great suddenness and seem to be preceded by movement, such as sitting
up, getting out of bed, and especially straining during defæcation.
Withrow tells of a patient who was attacked whilst ‘putting on her
clothes to leave the hospital’. She died in twelve hours. Reclus, at a
meeting of the Société de Paris, 1897, mentioned that a patient quitting
the hospital, apparently convalescent from hysterectomy, fell dead in
the courtyard from pulmonary embolism. In one remarkable instance a
patient complained of sciatic pain fifteen days after hysterectomy. In
order to afford relief the surgeon flexed the patient’s thigh on her
abdomen and then suddenly extended it. This dislodged a clot, and the
woman was seized with the symptoms of pulmonary embolism and died in
forty-seven minutes. At the post-mortem examination the pulmonary
artery was found occluded with clot and the ovarian vein contained a
thrombus (Byron Robinson).

It is important to note that these fatal cases of pulmonary embolism
occur when they are least expected, and it is an unusual sequence in
patients with obvious thrombosis of the femoral and saphenous veins.

The most constant symptoms are urgent dyspnœa accompanied by great
distress; in some instances the patient becomes pallid and in others
cyanotic. Death may follow in a few minutes; in less severe cases it is
delayed several hours, the patient remains conscious, but suffers severe
mental agony.

A pulmonary embolism is not necessarily fatal, for a woman after a
pelvic operation may complain of sudden pain in the chest, urgent
dyspnœa, exhibit great mental distress, and in a short time spit up
sputum mixed with blood. In a few hours the urgent symptoms subside and
in two or three days pass away, and the patient recovers. I have seen
five examples of this mild form of pulmonary embolism after
hysterectomy. One of the patients appeared to suffer from a succession
of small pulmonary emboli.

[Illustration: FIG. 25. THE PULMONARY ARTERY AND ADJACENT PART OF THE
LUNG AND TRACHEA. The artery is completely occluded by a clot derived
from a thrombus in the right auricle. (_Museum of the Middlesex
Hospital._) Three-quarter size.]

Somerville Hastings refers to a woman thirty-six years of age, anæmic
from profuse, long-continued menorrhagia due to a uterine fibroid, who,
whilst waiting in the hospital for hysterectomy, was seized with
pulmonary embolism and died three hours later. An embolus occupied the
pulmonary artery, resembling a blood-clot found in the left common and
internal iliac veins. Hastings also states that in a patient who died
from pulmonary embolism, after an operation, a thrombus occupied the
right cardiac ventricle, and he thought it possible that this
intraventricular clot furnished the embolus (Fig. 25).

We must bear in mind that individuals apparently in good health die
suddenly in the street, in the armchair, in a bath, or even during
sleep: it is a fair assumption that some of the instances of sudden
death occurring during convalescence from surgical operations may be due
to failure of the heart absolutely unconnected with the operation. It
is, however, undeniable that thrombosis of the pelvic veins after
ovariotomy, or hysterectomy, is a source of fatal emboli. At present
there is very little evidence available as to the cause of the
thrombosis, but it can scarcely be doubted that sepsis, it may be only
of a mild type, is responsible for some of the cases.

A careful consideration of the matter reveals beyond any doubt that
pulmonary embolism occurs much more frequently after hysterectomy or
fibroids than after any other operation, and it is especially liable to
happen in women who are profoundly anæmic from profuse and prolonged
menorrhagia. This indicates that long-continued and irregular losses of
blood induce some change in the composition of this important fluid,
which favours its coagulation.

It has been suggested that the practice of keeping patients strictly
confined to bed for two or three weeks after hysterectomy and allied
operations is responsible for the thrombosis which is the source of
these fatal emboli. Some American surgeons act on this suggestion and
insist on their patients getting out of bed a few days after such
operations. This method does not commend itself to British surgeons. In
my own practice I make it a rule, even in the most favourable
conditions, to keep the patients confined to bed for two weeks. No
patient is allowed up until her temperature has been normal for at least
three days. The consequences of this practice appear to be justified,
for in more than a thousand hysterectomies, only one of my patients lost
her life in consequence of pulmonary embolism.

In cases of embolism of the pulmonary artery, death does not always
occur immediately, but may be postponed for an hour or more after the
lodgment of the embolus.

Trendelenburg is of opinion that it might be possible to remove this
clot by direct surgical intervention. After careful consideration of the
matter he carried out this operation on a woman aged sixty-three years;
he raised an osteoplastic flap on the left side of the thorax, exposed
the conus arteriosus, and intended to withdraw the clot, by means of a
specially constructed pump, through a slit in its walls. The patient
died from excessive bleeding before the clot could be extracted; the
operation was hindered by an adherent pericardium.

Trendelenburg has carried out this operation on a man forty-five years
of age. This patient was tabetic and sustained a spontaneous fracture of
the femur. One month later he was seized with urgent dyspnœa and signs
clearly indicating the lodgment of an embolus in the pulmonary artery.
Trendelenburg exposed the heart, opened the pulmonary artery, and by
means of polypus forceps succeeded in withdrawing 34 centimetres of
clot. The incision in the artery was carefully closed with sutures. The
man improved considerably as the result of the operation, but died
thirty-seven hours later. At the post-mortem examination the left and
right branches of the pulmonary artery contained an embolus. From the
surgical point of view there are no reasons why such a bold example
should not be repeated with success.

When patients who are profoundly anæmic from menorrhagia due to fibroids
undergo hysterectomy, it is a useful measure to give them twenty grains
of citrate of sodium twice daily in order to diminish the abnormal
tendency of the blood to coagulate in the vessels. Certainly this drug
should be administered if there is the least evidence of thrombosis.

=Foreign bodies left in the abdomen.= Every writer on ovariotomy and
kindred operations insists on the importance of exercising the utmost
personal vigilance in counting instruments and dabs before, and
immediately after, an abdominal operation in order to avert the dangers
which ensue when instruments, dabs, gauze, or drainage tubes are
accidentally left in the abdominal cavity. Before the era of antiseptic
surgery nearly all the patients in whom foreign bodies were left in the
abdominal cavity died. In several instances the surgeon has discovered,
on counting the sponges and instruments after the operation, one or more
to be missing, and, failing to find them in the room, has reopened the
wound and recovered the missing article. In many lucky cases, a sponge
or compress has given rise to an abscess, and, the wound reopened, the
sponge presented at the opening. Often a compress of cotton-wool or
gauze has slowly ulcerated into the rectum and been discharged through
the anus.

When things of this kind are left in the abdomen the risks are not so
great now as in pre-antiseptic days, but they cause much discomfort and
anxiety as well as suffering: moreover, such an accident entails
reopening the wound and occasionally a serious operation for the removal
of the missing article, and as a recent decision in a Court of Law fixes
the responsibility on the operator, there is always the possibility of
an action at law with all its vexations and the liability of being
mulcted in damages.

The behaviour of foreign bodies left in the abdomen is curious and also
interesting from the great length of time which metal instruments will
sometimes remain without causing very urgent symptoms, and the tendency
they exhibit to penetrate adjacent viscera.

Among the early cases Sir Spencer Wells reported one in which a pair of
forceps was found in a patient’s bladder who died a month after
ovariotomy. Olshausen mentions that a pair of forceps was passed by the
rectum nine months after ovariotomy, and Terrillon tells of a pair of
pressure forceps which remained eight months in the belly and came out
close to the navel. One of the most remarkable instances is recorded by
MacLaren, in which a pair of forceps was left in the abdomen in the
course of a hysterectomy. Two years later, a swelling formed in the
right iliac region; this was explored through an abdominal incision, and
the hæmostatic forceps represented in Fig. 26 was found embedded in the
omentum; the forceps had ulcerated into the cæcum and the blades were
lodged in the vermiform appendix. The patient recovered.

In order to illustrate the diminished risks run by patients when the
instruments and dabs used in operations are thoroughly sterilized,
reference may be made to a case recently reported by J. E. F. Stewart
(Australia), in which he removed a pair of pressure forceps which had
remained in the abdomen for ten years and a half. The patient, who had
been more or less an invalid since the primary operation, had suffered
from attacks of acute pain, constipation alternating with diarrhœa, and
pains in the lower limbs. The instrument, which measured 5 inches long
and 2-1/2 across the handles, was lying point downwards in the pelvis,
and the ring handles could be felt through the belly-wall before the
operation: it had made its way into the small intestine.

[Illustration: FIG. 26. A PAIR OF PRESSURE FORCEPS: this instrument had
remained in the abdomen two years after hysterectomy. The forceps had
ulcerated into the cæcum and the blades had lodged in the vermiform
appendix. (_After MacLaren._)]

The tendency for a foreign body, whether hard like forceps, or soft like
gauze pads, to erode its way into the intestine is very remarkable. Thus
Gifford operated on a patient with intestinal obstruction; an impacted
mass was felt in the ileum, it was extracted through an incision in the
gut and proved to be a pad of cotton-wool enveloped in gauze. She
recovered. Three months previously this woman had undergone abdominal
myomectomy.

Another source of risk to patients is the practice or habit of packing
the pelvic recesses with strips of gauze temporarily, either with the
hope of controlling oozing, or to serve as a drain. I have long
abandoned this habit. The disadvantage of gauze stuffing which needs
consideration in this section is the risk that some portion, or the
whole of it, is sometimes left in the wound. Examples are known where
long strips of ‘gauze stuffing’, sometimes amounting to a yard or more,
have been passed through the anus a year after the operation. Many
intractable sinuses have had a forgotten piece of gauze as the cause of
their persistence.

A woman had cœliotomy performed for peritonitis, the consequence of
criminal abortion; she had a long convalescence due to an intractable
sinus. Eventually the patient was thought to have tuberculous disease of
the appendages, and a mass, formed mainly by the Fallopian tube, was
removed. The walls of the tube were intact, but when slit open the tube
was found to contain a small gauze tampon (Kouwer).

The isolated records relating to foreign bodies left in the abdomen are
very numerous. Thus Wilson in 1884 was able to collect twenty-eight
cases from periodical literature and personal reports from friends. An
interesting discussion took place on the reading of a paper on this
subject before an American gynæcological society, by R. W. Waldo, and
the number of cases related by the members is astonishing and refer to
such things as sponges, dabs, forceps, a strip of iodoform gauze ‘a yard
wide and two yards long’, a pair of spectacles, and ‘an operating-room
towel’, which were left in the abdominal cavity.

The most comprehensive collection of records relating to foreign bodies
left in wounds of all kinds has been made by F. von Neugebauer; they
amount to 195.


REFERENCES

GIFFORD, G. T. _British Medical Journal_, 1907, ii. 1042.

KOUWER, PROF. _Zentralbl. für Gynäk._, 1907, xxxi. 1447.

MACLAREN, A. _Annals of Surgery_, 1896, xxiv. 365.

NEUGEBAUER, F. V. _Monatsschriften für Geburtsh. u. Gyn._, 1900, Bd. xi,
    821, 933. _Zentralbl. für Gynäk._, 1904, xxviii. 65.

STEWART, J. E. F. _Australian Medical Gazette_, 1906, xxv. 446.

WALDO, R. W. _American Journal of Obstetrics_, 1906, liv. 553.

WILSON, H. P. C. _Trans. American Gynecological Society_, 1884, ix. 94.


=Tetanus.= This dread complication of wounds occasionally occurs after
ovariotomy, and during the ‘reign of the clamp’ it was especially
frequent in Germany (Olshausen). Cases have been reported in England,
and tetanus has been noticed to affect patients who have been
ovariotomized in rooms recently plastered.

Since Kitasato demonstrated the bacillary origin of tetanus poison, and
showed that the bacillus can be transported by dust, knowing its
liability to attack suppurating wounds, we can understand that when the
pedicle of an ovarian cyst was secured by a clamp and allowed to slowly
slough away, more or less exposed to air and dust, it offered a nidus
for the tetanus bacillus.

Tetanus, however, has not quite disappeared as a sequel to operations on
the pelvic organs, for in 1902 a case was reported by Dorsett in which a
patient died of this disease after hysteropexy, and the tetanus bacillus
was detected in some wallaby tendon employed to suspend the uterus.
Tetanus has also been traced to infected catgut employed in
cholecystotomy (1905).

Ed. Martin reported the occurrence of tetanus after vaginal fixation of
the uterus and colporrhaphia anterior. Cumol-catgut was employed.

Menzer has recorded a similar case which occurred in Dührssen’s Klinik
(1901). The ligatures were of catgut.

Mallet refers to two post-operative deaths from tetanus. One patient had
undergone an operation for bilateral pyosalpinx and the other had a
fibroid of the uterus complicated with an ovarian cyst. There was an
interval of eighteen months between the two fatal cases. Catgut was
employed as the ligature material.

In practice it is important to remember that tetanus arises from
infection: hence all instruments which have been in contact with this
disease must be sterilized, and this should be effected by submitting
them to prolonged boiling.

Tetanus occurs as a rare sequel to miscarriage and normal labour. Kraus
and von Rosthorn have reported some carefully investigated cases of this
kind.


REFERENCES

DORSETT, W. B. Two fatal cases of Tetanus following Abdominal Section
    due to Infected Ligatures, &c. _Am. Journ. of Obstet._, 1902, xlvi.
    620.

MALLET, G. H. Some Unusual Causes of Death following Abdominal
    Operations. Ibid., 1905, li. 515.

MARTIN, ED. Postoperativer Tetanus (with references). _Zent. f. Gyn._,
    1906, xxx. 395.

MEINERT. Drei gynäkologische Fälle von Wundstarrkrampf. _Arch. für
    Gyn._, 1893, xliv. 381.

MENZER. Tetanus Infection after Vaginal Fixation of the Uterus.
    _Zeitsch. f. Geb. u. Gyn._, 1901, xliv. 517.

OLSHAUSEN, R. Tetanus nach Ovariotomie Billroth-Lücke’s. _Handb. der
    Frauenkrankheiten_, 1877-9, ii. 367.

TAYLOR, H. Tetanus after Hysterectomy. _Am. Journ. of Obstet._, 1908,
    lvii. 574.


=Injury to intestines.= Intestines great and small are very liable to
injury in the performance of intrapelvic operations. Unless care is
taken in opening the abdomen, the intestines are apt to be cut,
especially when there has been chronic peritonitis, as in tuberculous
and gonococcal infections, which cause the small intestine to adhere to
the parietal peritoneum investing the anterior abdominal wall. Where
cœliotomy is being performed a second or third time, through or near the
original cicatrix, it is necessary to proceed with extreme caution for
fear of cutting an adherent coil of gut.

Intestine is also liable to be torn in separating adhesions from the
tumour, and great care is necessary when cysts are firmly adherent to
the floor of the pelvis, for in separating them the rectum runs a great
risk of being damaged.

In removing tumours to which the vermiform appendix adhered it is
necessary to be careful and avoid mistaking it for an adhesion, for
there is reason to believe that this structure has been divided and its
nature overlooked; an accident of this sort leads usually to fatal
peritonitis.

It has happened, in the course of removing very adherent ovaries and
tubes from the floor of the pelvis, that in transfixing the pedicle a
coil of ileum has also been transfixed with the needle and tied to the
stump. This accident is not likely to happen now that the Trendelenburg
position is almost universally employed.

In sewing the abdominal incision the intestines have been pricked with a
needle, and in some instances the bowel has been accidentally included
in the sutures and sewn to the abdominal wall. On one occasion while
securing a very long incision with through and through sutures, while
passing the needle through the abdominal wall, it broke, and the broken
end came with great force against the anterior wall of the stomach and
tore a hole in it. This I secured at once with suture and the accident
had no bad consequences.

An unrecognized wound of the bowel in the course of a pelvic operation
is almost certainly fatal. Accidental injuries, such as punctures and
cuts, require immediate suture, and I have never known any harm follow.
On the other hand, ragged tears in thickened and inflamed bowel require
careful consideration in order to spare patients the inconvenience and
distress of fæcal fistulæ.

In regard to small intestine a very small opening may occasionally be
safely secured with fine silk, but in most cases it is wiser, if the
bowel is thickened and inflamed around the hole, to resect well wide of
the damaged portion and join the cut ends (circular enterorrhaphy).

Holes low down in the rectum are difficult to suture securely. These
should be treated by drainage, using a wide rubber drain; the
convalescence will be tedious, but the fistula will close.

It is useful to remember that if the rubber tube be too long it may
enter the hole in the bowel and thus maintain the fistula. On one
occasion I was asked to close a fæcal fistula which had followed an
oöphorectomy. This fistula persisted five years. At the operation I
found a hole in the sigmoid flexure with its margins adherent to the
opening in the parietes, so that the tube passed directly into the
bowel. The gut was detached and the opening closed with sutures, and it
gave no further trouble.

If, in the course of an ovariotomy or hysterectomy, the surgeon
discovers a cancerous stricture in the colon or cæcum he should resect
the affected section, if it permits of this treatment; otherwise lateral
anastomosis should be performed. (See Vol. II.)

=Intestinal obstruction.= It is difficult to estimate with any approach
to accuracy the relative frequency of intestinal obstruction after
operations on the uterus and its appendages; nevertheless the danger is
real. The obstruction may be acute or chronic: it may occur within
thirty hours of the operation or be delayed for months or years. The
causes may be arranged under five headings:--

1. Adhesions to the abdominal wound.

2. Adhesions to the pedicle, stump, or a raw surface in the pelvis.

3. Strangulation around an adventitious band.

4. Obstruction due to an overlooked cancer in the colon.

5. Strangulation in a sac formed by a yielding cicatrix.

The form of intestinal obstruction with which we are most concerned here
arises shortly after the operation and in the course of convalescence;
it may be caused by adhesions to the abdominal incision, the pedicles,
raw surfaces in the pelvis left after the removal of adherent cysts and
tumours, and the cervical stump of a subtotal hysterectomy.

The subject is one of importance, for the complication is fairly common
in the practice of some surgeons, and is one which it is very necessary
to recognize, for, unless measures of relief are undertaken promptly,
the patient surely dies.

From a careful study of the matter I have come to the conclusion that
acute intestinal obstruction is more frequent after ovariotomy than
after hysterectomy, and this is due to the fact that the stump or
pedicle left after the removal of an ovarian tumour lies higher in the
pelvis, and in closer relation to ileum and jejunum, than the cervical
stump left after the removal of the uterus. This view also receives
support from the fact that acute intestinal obstruction following
hysterectomy is more frequent in the practice of those surgeons who
perform subtotal hysterectomy improperly, and leave a large piece of the
neck of the uterus sticking up like a median post in the floor of the
pelvis. As far as I can judge from the scanty records relating to this
complication after hysterectomy, it is the sigmoid flexure of the colon
which is most commonly adherent to the cervical stump. The best way of
avoiding this accident is to remove the supravaginal cervix so freely
that, when the peritoneum is closed over the incision in the floor of
the pelvis, there is nothing visible except a narrow thin line of suture
at the base of the bladder.

The only rational method of treating acute intestinal obstruction
following operations in the pelvis, is to promptly reopen the abdomen
and set free the adherent coil of gut. Operations of this kind after
hysterectomy are more often successful than when they are a sequel to
ovariotomy, and this is, I think, due to the fact already mentioned,
that when intestinal obstruction follows ovariotomy or oöphorectomy, the
obstruction arises in the small intestine and is usually very acute and
more dangerous; whereas after hysterectomy the obstruction affects, as a
rule, the sigmoid flexure of the colon, and though it may be fairly
acute, is not nearly so dangerous, and gives far better results to
operative treatment.

=Perforating ulcer of the stomach and small intestine.= A rare cause of
death after ovariotomy or hysterectomy is a perforating ulcer of the
stomach or jejunum. Since 1887 I have seen three cases. In each instance
the patient died from septic peritonitis. Rosthorn lost a patient from
perforating ulcer of the stomach after hysterectomy. Olshausen states
that he has seen at least four examples of this accident.[2]

[2] Bland-Sutton, J. On Perforation of the Stomach and Small Intestine
as a Sequel to Ovariotomy and Hysterectomy. _Journ. of Obstet. and Gyn.
of the British Empire_, 1909, xv.

=Injuries to the bladder.= This viscus has been injured in a variety of
ways during operations on the pelvic organs. An overfull bladder has
been mistaken for an ovarian cyst and been punctured with a trocar
before the mistake was discovered. When tumours are impacted in the
pelvis the bladder is often pushed up into the hypogastrium; this
happens with bilateral ovarian tumours, incarcerated fibroids, and
especially with large cervix fibroids. When the bladder is pushed up,
care should be exercised in making the abdominal incision, or it will be
cut. Punctures and incisions in the bladder should be immediately closed
with sutures of fine silk.

The bladder is liable to be injured in the performance of subtotal and
total hysterectomy, especially in the latter operation when separating
it from the neck of the uterus. In the subtotal operation the risk
arises chiefly in suturing the peritoneal flaps over the cervical stump,
for the bladder is liable to be punctured with the needle as it lies
close to the anterior flap.

=Injuries to the ureter.= Since the vulgarization of hysterectomy,
injuries of the ureters have become common; nearly all are inflicted in
cases where the neck of the uterus is removed, as in total abdominal
hysterectomy, and in vaginal hysterectomy, because the vesical segments
of these ducts come into close relationship with it.

British surgical and gynæcological periodical literature contains very
little that concerns ureteral injuries, but it is only necessary to look
into the pages of the _Zentralblatt für Gynäkologie_ to find ample
evidence that the integrity of the ureters is frequently sacrificed to
modern pelvic surgery.

Blau published statistics from Chrobak’s Klinik in Vienna showing that
in the interval January, 1900, to January, 1902, the ureters were
injured fifteen times. In total hysterectomy seven times; in the course
of ovariotomy on three occasions.

Sampson stated that from August, 1889, to January, 1904, the uterus was
removed 156 times for cancer of its neck at the Johns Hopkins Hospital,
Baltimore, and the ureters were injured nineteen times. The injuries
were of various kinds, such as ‘ligating, clamping, cauterizing,
cutting.’

In abdominal hysterectomy for fibroids the risk of injuring a ureter is
not great. Thus Deaver writes that in the course of 250 abdominal
hysterectomies he injured the ureter once, but the accident entailed the
death of the patient.

I have performed hysterectomy on 1,000 occasions and injured the ureter
once; my patient had a narrow escape for life and lost a kidney.

I have been present on five occasions when a ureter was injured. Four of
the operations were for the removal of the uterus on account of
fibroids, and one was an ovariotomy. Four of the patients died.

The injuries to which the ureters are liable in the course of
hysterectomy are as follows:--

1. One or both ureters have been included in the ligatures applied to
the uterine arteries.

2. One or both ureters have been cut or completely divided with
scissors, or knife, in removal of the uterus.

3. A segment of a ureter 7 centimetres in length has been accidentally
exsected.

4. One or both ureters have been compressed by clamps applied to
restrain bleeding in the course of vaginal hysterectomy, and
subsequently sloughed.

5. Ureters exposed in the course of ‘radical’ operations for cancer of
the neck of the uterus often slough.

6. A ureter is sometimes transfixed by a needle and thread when sewing
the layers of the broad ligament together in the course of a subtotal
hysterectomy.

The most dangerous injury to the ureters occurs in the course of a
subtotal hysterectomy, especially if it is not recognized at the time of
the operation. In such circumstances the urine will slowly leak into the
connective tissue of the broad ligament and form an extravasation
extending into the loin.

In some cases the fluid will leak directly into the pelvis, and a sinus
will form in the abdominal wound and allow the urine to escape; this may
be the first intimation that a ureter has been injured, whereas when a
ureter has sustained damage in the course of a total abdominal or a
vaginal hysterectomy, the leakage of urine along the vagina will quickly
apprise the surgeon of the accident.

There is another form of injury to the ureter which should be mentioned.
Occasionally a fibroid, but more often a cyst or tumour arising from the
base of the broad ligament, will involve the corresponding ureter and
carry it upwards in such a way that, when the layers of the broad
ligament are reflected, the ureter will be found crossing the crown of
the tumour like a strap. In such a case the pressure has usually exerted
a banal influence on the kidney, and it is often in the condition known
as sacculation. In a case under my own care in which I attempted to
remove a malignant tumour of the broad ligament, and in which the ureter
ran over its upper pole in this way, thinking it was an adhesion,
traction was made upon it, and the ureter came away with a portion of
the renal pelvis. At the post-mortem examination the kidney was merely a
thin-walled sac with purulent contents.

In all cases in the course of an abdominal hysterectomy it is useful for
the surgeon to inform himself of the condition of the kidneys. Whilst
performing a subtotal hysterectomy, one of the fibroids burrowed deeply
between the layers of the left broad ligament; when all the bleeding was
checked, I looked carefully to determine that the ureter was safe, and
found it kinked by the ligature applied to the corresponding uterine
artery; it was at once removed. On palpating the kidneys I found the
right kidney small, and shrunken, and useless. Fortunately the woman
recovered.

The method of treating an injured ureter varies greatly and will depend
not only on the extent of the damage, but also on the time at which it
is recognized. For example, if the surgeon recognizes the injury in the
course of the operation, he will be able to deal with it at once. This
we may term _immediate_ treatment. The more difficult cases are those in
which the injury is unrecognized at the time of the operation and only
becomes obvious in the course of convalescence; the treatment in such
circumstances may be called _secondary_.

The primary treatment of an injury to a ureter in the course of a pelvic
operation will depend in a large measure on the ability, judgment, and
experience of the surgeon, as well as on the extent of the injury. For
example, if the ureter be partially divided, the opening may be closed
with sutures of thin silk; when the duct is completely divided, the cut
ends may be invaginated, the upper into the lower, and retained in
position by suture. When five or more centimetres of the ureter have
been accidentally exsected, none of these methods is applicable; in such
circumstances several plans have been tried. Of these the simplest is
ligature of the proximal end with the hope of inducing atrophy of the
kidney; in several recorded instances this has proved successful. The
surgeon who adopts this method should satisfy himself that the patient
has another kidney, and that it is, as far as he can ascertain at the
time, healthy. Some surgeons who have divided a ureter have promptly
removed the corresponding kidney; others have secured the proximal end
in the upper angle of the abdominal incision and removed the kidney
subsequently.

[Illustration: FIG. 27. THE RELATION OF PARTS AFTER RICARD’S OPERATION
OF URETERO-CYSTO-NEOSTOMY (after Lutaud). A, the proximal end of the
ureter with the mucous membrane reflected. B, the walls of the bladder,
showing the mode of fixing the ureter to its walls. 1 and 2, sutures.]

It has been suggested that when a portion of a ureter has been resected
and the proximal end cannot be engrafted into the wall of the bladder,
it should be turned into the cæcum or the sigmoid flexure, according to
its position, and thus preserve to the patient the kidney and save her
the distress of a urinary fistula. This method has not found favour with
practical surgeons. The most promising procedure consists in engrafting
the proximal end of the cut ureter into the bladder. This is known as
uretero-cysto-neostomy, an operation which has been made the subject of
a valuable thesis by Dr. Lutaud. This thesis appears to have been
inspired as a result of two successful operations performed by Ricard.
The principle of this method is as follows:--

The abdomen is opened by the usual median subumbilical incision, and the
peritoneum covering the damaged duct is incised and its proximal end
exposed: the mucous membrane of the ureter is reflected like a cuff. An
opening is made in the bladder wall in a situation convenient for making
the junction, and two centimetres of the ureter are allowed to project
freely into the vesical cavity, ‘à la façon d’un battant de cloche.’ The
ureter is secured by sutures to the vesical mucous membrane, and to the
muscular coat of the bladder. The sutures should be of thin catgut and
must not perforate the bladder or the ureteral walls. The bladder itself
near the junction should be attached by sutures to the adjacent
peritoneum to prevent dragging (Fig. 27).

Lutaud significantly points out that we know little of the subsequent
fate of ureters which have been engrafted into the bladder. The
immediate results have been successful, but there is good reason to
believe that when a ureter has been engrafted into the bladder, its
walls become sclerosed by a chronic ureteritis, and its lumen is
gradually stenosed. These changes take place slowly and cause little or
no discomfort in connexion with the kidney or the bladder, so that they
pass unnoticed.

If the opinion expressed by Lutaud, that the ureter becomes stenosed
after uretero-cysto-neostomy, is found to be a constant, or even a
frequent, sequel to the transplantation of a ureter into the bladder, it
will cause surgeons to be careful, and not follow too literally the
advice given by some writers to the effect that in performing the
‘radical operation’ for cancer of the cervix, if the ureters are
implicated these ducts may be divided and their proximal ends engrafted
into the bladder.

Lockyer, in removing a burrowing fibroid, wounded the bladder and
divided the right ureter; he sutured the vesical incision and removed
the right kidney. During the twenty-four hours following the operation
there was anuria. The abdomen was reopened and then it was found that
the left ureter had also been divided. The proximal end of this ureter
was engrafted into the bladder through the wound which had been already
sutured. Convalescence was disturbed by a urinary fistula. The woman
recovered and reported herself in good health three years later.

It has happened that after nephrectomy for the cure of a ureteral
fistula, the sequel of a ‘radical operation’, the remaining ureter
became thoroughly blocked by recurrent growth and the patient died from
anuria.

In the cases where the injury to a ureter has been overlooked in the
course of the operation many difficulties arise before the true
conditions are appreciated. In some instances they soon become obvious;
for example, Purcell in 1898 performed an abdominal hysterectomy, next
day the patient had complete anuria. The abdomen was reopened
fifty-eight hours later; a distended ureter was easily recognized behind
the ligatures applied to the right and left uterine artery
respectively. The ligatures were removed, the swelling quickly subsided,
and urine reached the bladder. The woman recovered.

When a ureter is injured in the performance of total hysterectomy, urine
escapes by the vagina, and at first there may be some doubt whether the
leak is due to an injury to the bladder or to the ureter. In such
conditions the quantity of urine voided from the bladder is compared
with that which escapes from the vagina; if the quantities are equal, or
nearly equal, the leak is in a ureter. A more reliable method is to
inject a solution of methylene blue into the bladder through the
urethra. If the coloured fluid escapes from the vagina, the leak is in
the bladder; if not, it is in the ureter. When a vaginal leakage occurs
a few days after a vaginal hysterectomy, it is probably due to necrosis
and sloughing of a ureter, or the duct may have been included in a
ligature which has separated by sloughing.

Noble, in 1902, published an interesting series of injuries to the
ureter. One of these is of great value, because it proves that a ureter
may be accidentally ligatured and give rise to no symptoms.

A woman of thirty-three years of age was submitted to vaginal
hysterectomy for cancer of the neck of the uterus, complicated with
pregnancy. She died four days after the operation, and at the
post-mortem examination the left ureter was found occluded with a
ligature. The ureter and pelvis of the kidney were distended with urine.

The urine voided during the four days amounted on the first day to 480
c.c. (16 oz.); second day, 780 c.c. (26 oz.); third day, 1,440 c.c. (48
oz.); fourth day, 960 c.c. (32 oz.). These quantities would lull
suspicion in regard to any patient, but the facts of the case are
sufficient to raise suspicions of another kind, namely, that it is
possible and probable that a ureter has been ligatured in the course of
an operation, and the patient has recovered without any one having any
suspicion that such an accident has happened.

As soon as the surgeon clearly establishes the existence of a ureteral
fistula he is beset with the necessity of deciding which duct is the
seat of damage. Some years ago, when it was the practice to remove the
kidney for a persistent ureteral fistula, the decision involved the
surgeon in a grave responsibility, for the removal of the wrong kidney
could only be regarded as a catastrophe for the patient. Morris has
recorded a case in which this actually happened. A woman had total
hysterectomy performed for a cervix fibroid by a gynæcologist; in the
course of the convalescence a ureteral fistula was recognized, and as
this failed to close spontaneously, a surgical colleague performed
nephrectomy, and next day found to his chagrin that he had removed the
kidney belonging to the uninjured ureter. Serious accidents of this
kind are less likely to happen now, because the surgeon can avail
himself of the cystoscope and ureteral catheter; with these instruments
it is possible, not only to decide with certainty which ureter is
injured, but also to determine the position and extent of the damage.
See also Vol. III.

It is important to remember that every ureteral fistula does not require
an operation. It is always advisable, when it has been clearly
established that a woman has a leaking ureter, to wait a little,
certainly six weeks, for many fistulæ of this kind will gradually close.
In describing such a case, Jonas draws attention to a cystoscopic sign
of some value. He performed a total hysterectomy for fibroids, and on
the tenth day the nurse reported the escape of urine by the vagina. The
daily output of urine from the bladder, which had averaged 50 ounces,
fell to 25 ounces. On cystoscopic examination, urine could be seen
issuing from the right ureteral orifice; at first the left orifice could
not be seen, but on careful watching a movement was detected similar to
the contraction of a ureter discharging urine, but no fluid came from
the opening. This is known as _leergehen_ (empty contraction), and it
indicates that there is a lateral opening, but not complete interruption
in the continuity of the ureter. Such a case should have an opportunity
of healing spontaneously. This happened in Jonas’s patient.

Weibel states that a ureteral fistula due to necrosis after a radical
operation for cancer of the uterus usually occurs in the second week.
The earliest day is the seventh, and the latest the eighteenth day after
operation. The majority of these fistulæ heal in from three to twelve
weeks. If a fistula persist for more than three months spontaneous
healing is not to be expected. A ureteral fistula is a serious matter
for the patient. Blacker has had three cases after total hysterectomy.
In one the kidney was removed on account of septic changes. The second
had an attack of suppression of urine lasting twenty-four hours; it
passed off, the patient recovered and the fistula healed. The third died
eight weeks after the hysterectomy with symptoms of pyæmia; a small
abscess had formed near the site of the fistula.

=The fate of ligatures.= When a ligature is satisfactorily applied to a
pedicle the tissue on the distal side of the ligature is isolated from
the circulation. The fate of this tissue and of the ligature has been
the subject of much speculation.

It is a matter of common observation that when animal tissues are cut
off from the circulation, they atrophy; but if pathogenic
micro-organisms gain access to such parts, suppuration ensues. In due
course, through the activity of the living cells, the dead tissues are
detached from the living, a process termed sloughing.

When a piece of healthy tissue is removed from the body and immersed in
a sterile solution, and absolutely isolated from the atmosphere,
decomposition is indefinitely postponed, but as soon as unsterilized air
is allowed access to it, putrefactive changes ensue. The pedicle after
ovariotomy is in an air-tight chamber, and if the tissues included by
the ligature are healthy, and the silk employed for the purpose is
absolutely aseptic, this pedicle, when returned into the abdomen,
resembles the piece of tissue isolated from contact with the atmosphere.
No septic changes occur, but aggressive leucocytes attack the silk and
may, in course of time, effect its removal, even the knots. For this
desirable result three conditions require to be fulfilled: (1) the
ligatured tissue must be aseptic; (2) the ligature should be absolutely
sterile; and (3) air or intestinal contents must be excluded.

These conditions may be prevented in many ways. The tissues included in
the ligature are not always free from infective organisms, especially
the Fallopian tube, which is usually included in the ligature, and this
structure, especially in cases where oöphorectomy is performed for
inflammatory diseases, often contains septic microbes; this endangers
the ligature and leads to the formation of pus, with its complications,
sloughing of the pedicle and abscess. The tissues may be healthy and
aseptic, but the ligature may have been imperfectly sterilized, or
become contaminated by assistants, or even by the hands of the surgeon
during its application.

The operation may have been conducted aseptically and the tissues be
healthy, but the ligature becomes infected by the admission of air as a
result of drainage, or implication of the bowel or bladder.

I made a careful study of the fate of silk sutures employed in pelvic
surgery extending over many years, and came to the conclusion that, even
under favourable conditions, silk ligatures disappear very slowly. The
silk used to secure an ovarian pedicle may, in very favourable
circumstances, disappear in twelve months, but the knots require nearly
double that time. The piece of silk which encircles the Fallopian tube
is apt to behave in a curious way; in 1898 I removed an ovarian cyst the
size of a fist, and tied its slender pedicle with thin silk. Although
the recovery was uneventful, the patient complained during many weeks of
cramp-like pains on the side from which the cyst was removed. These
pains gradually subsided, and ten months later, during menstruation, the
patient noticed on the napkin a tiny loop of silk, which she saved. This
was the loop of silk which secured the Fallopian tube; it had ulcerated
into the tube and been conducted into the uterus and escaped. I have
since had a like condition, the loop making its appearance three weeks
after an ovariotomy. It has been established by experiments on the long
uterine cornu of rabbits, that an encircling ligature will ulcerate
through, leaving the lumen of the cornu intact. Clinical observations
regarding ligatures applied to Fallopian tubes in the performance of
Cæsarean section for the purpose of preventing pregnancy prove that this
is a useless measure (see p. 71), for these tubes in many instances have
recovered their patency, and pregnancy has recurred. It is a fair
inference that the ligature ulcerates into the lumen of the tube, which
then heals behind it, without stricture of the canal. A similar
condition of things sometimes arises after Cæsarean section, especially
when the uterine incision is closed by two layers of sutures. Those
sutures which involve the endometrium will ulcerate into the uterine
cavity and cause irregular slight losses of blood until they escape.

It is important to emphasize the fact that silk sutures in uterine
tissue will, in some instances, remain unabsorbed for many years. A
patient who had been submitted to Cæsarean section in 1903 came under my
care four years afterwards for the removal of the tumour which caused
obstruction; the sutures used to close the uterine incision were
visible, and a microscopic examination showed that each silk suture was
enclosed in a fibrous tissue sheath (Fig. 28).

The fact that silk sutures will resist absorption for such a long period
has an important practical bearing, because so long as pathogenic
micro-organisms are denied access they remain inert, but if any septic
condition arises in their neighbourhood, and these sutures become
involved, they will give rise to abscesses and sinuses as surely as if
they had been buried but a few days.

[Illustration: FIG. 28. A UTERUS IN SAGITTAL SECTION. Showing silk
ligatures which had been introduced in the operation of Cæsarean section
four years previously. (_Museum, Royal College of Surgeons._) Full
size.]

Patients often suffer great distress and annoyance on account of
abscesses and sinuses due to septic ligatures, and a sinus will persist
as long as the ligature remains. Abscesses and sinuses resulting from
troublesome ligatures may escape in many directions; the most common
spot is at the lower angle of the abdominal incision; the rectum is
another channel of escape, and also the bladder. When a ligature makes
its way into the bladder it will set up cystitis and serve as a nucleus
for a vesical calculus. In an unusual case recorded by Edebohls, double
oöphorectomy was performed for uterine fibroids; a year later the
ligature on the left side escaped through the vagina; six months later
he performed abdominal hysterectomy. The vermiform appendix was adherent
to the stump on the right side; it was removed, and a silk ligature
tied in a complicated knot was found in it, making its way towards the
cæcum.

On one occasion a woman, who had been submitted to subtotal hysterectomy
in the Antipodes, suffered from frequent micturition and fœtid urine;
she came under my care. On dilating the urethra, it was found that the
cervical stump had ulcerated through the posterior wall of the bladder
and projected freely into the vesical cavity, bristling with thick silk
ligatures encrusted with phosphatic deposit. The ligatures were removed,
the urine soon became acid, and the vesical discomfort quickly subsided,
in spite of the anomalous position of the cervical stump.

Until surgeons fully realized the importance of thoroughly sterilizing
the silk employed for the pedicles in ovariotomy, it was quite common
for the silk loops to ulcerate through the bladder wall and set up
cystitis.

Many cases have been reported in which a loop of silk, effecting an
entrance into the bladder in this fashion, has formed the nucleus of a
phosphatic calculus.

=Post-operative kraurosis.= In a small proportion of patients (perhaps
not more than one per cent.) who have undergone bilateral ovariotomy,
oöphorectomy, or hysterectomy, the vulva undergoes the peculiar atrophic
changes which are characteristic of the condition known as _kraurosis
vulvæ_. This change, so far as my observations go, is chiefly seen in
patients who have been submitted to these operations after the fortieth
year of life. The cause of these changes is unknown. The condition is
troublesome and inconvenient in married women, but spinsters rarely
complain of it. Post-operative kraurosis is as rebellious to treatment,
and its causation as inexplicable, as kraurosis occurring independently
of operation.

=The cicatrix.= Although the employment of buried sutures has made
abdominal incisions more secure in the process of healing, and renders
them firmer after union, and thus reduces the chances of a yielding
scar, and saves the patient the inconvenience of an abdominal hernia or
the annoyance of wearing an abdominal belt, it renders the patient
liable to another discomfort, namely, stitch-abscess. This complication
arises from a variety of causes--for example, imperfect sterilization of
the suture material, or of the patient’s skin preceding the operation.
The sutures may be soiled by the hands of nurses and assistants, or the
fingers of the surgeon. All these things may be safeguarded, but the
operation may have been required for the removal of infected cysts, or
pelvic peritonitis: in these cases it is wise not to bury sutures.

Troublesome buried sutures should be removed. In many instances this is
easy of accomplishment, and in others it requires patience and often
perseverance, even when the patient is under an anæsthetic. The simplest
implement for removing a buried suture is a crochet-hook.

The disadvantage of stitch-abscesses, apart from the inconvenience they
cause patients during their convalescence, is that they often cause the
scar to yield at that spot, and necessitate the wearing of an abdominal
belt. If the hernia is of small extent, and especially when it is
situated near the lower angle of the scar, it is difficult to fit a belt
which will restrain it without the use of perineal bands or straps. In
such cases a truss, on the principle of those employed for inguinal
hernia, is more satisfactory than a belt.

Occasionally a scar forms a raised hard red keloid band, and causes some
anxiety to the patient. These keloid scars shrink and whiten in the
course of a year or eighteen months.

=Cancer of the cicatrix.= Several cases have been recorded in which,
after the removal of an ovarian adenoma, a new growth, described as
‘cancer of the cicatrix’, has formed in the scar. These growths are
probably due to the soiling of the wound at the time of operation with
epithelial fragments from the tumours.

After abdominal hysterectomy for cancer of the body of the uterus, or
its cervix, the abdominal wound may become infected with this disease,
and in cases where exploratory cœliotomy has been performed for diffuse
cancerous disease of the peritoneum the cicatrix is liable to become
permeated by malignant disease also.


REFERENCES

BALDY, J. M. The Mortality in Operations for Fibroid Tumour of the
    Uterus. _Trans. Am. Gynæcological Association_, 1905, xxx. 450.

BARTLETT, W., AND THOMPSON, R. L. Occluding Pulmonary Embolism. _Annals
    of Surgery_, 1908, xlvii. 717.

BLACKER, G. F. _Lancet_, 1909, i. 395.

BLAND-SUTTON, J. Hunterian Lecture on Thrombosis and Embolism after
    Operations on the Female Pelvic Organs. _Lancet_, 1909, i. 147.

BLAU, A. Ueber die in der Klinik Chrobak bei gynäkologischen Operationen
    beobachteten Nebenverletzungen. _Beiträge f. Geb. u. Gyn._, 1903,
    Bd. vii. 53.

BUCKNALL, R. The Pathology and Prevention of Secondary Parotitis (with
    Literature). _Med.-Chir. Trans._, 1905, lxxxviii. 1.

DEAVER, J. B. Hysterectomy for Fibroids of the Uterus. _Am. Journ. of
    Obstetrics_, 1905, lii. 858-74.

HASTINGS, S. A Preliminary Note on Embolism in Surgical Cases. _Archives
    of the Middlesex Hospital_, 1907, xi. 78.

JONAS, E. Temporary Uretero-vaginal Fistula after Panhysterectomy for
    Fibroid of the Uterus. _Am. Journ. of Obstetrics_, 1907, lvi. 731.

LEQUEU. Sur les parotidites post-opératoires. _Bull. et Mém. de la Soc.
    de Chir. de Paris_, 1907, T. xxxiii. 1044.

LUTAUD, P. _Sur un procédé d’urétéro-cysto-néostomie dans le traiment
    des fistules urétéro-vaginales et urétéro-cervicales._ Paris, 1907.

LYLE, RANKEN. A Series of Fifty Consecutive Abdominal Sections. _Journal
    of the British Gynæcological Society_, 1906-7, xxii. 120.

MALLET, G. H. _Am. Journ. of Obstetrics_, 1905, li. 516.

MORRIS, H. Lectures on the Surgery of the Kidney. _British Medical
    Journal_, 1898, i. 1039.

NOBLE, C. P. Clinical Report upon Ureteral Surgery. _American Medicine_,
    1902, iv. 501.

---- Myomectomy. _New York Medical Journal_, 1906, lxxxviii. 1008.

OLSHAUSEN, R. Veit’s _Handbuch der Gynäkologie_, 1907, 2nd Ed., Bd. i.
    715.

PURCELL, F. A. The Risks to the Ureters when performing Hysterectomy,
    &c. _Journ. Brit. Gyn. Soc._, 1898-9, xiv. 174.

ROBINSON, B. Sudden Death, especially from Embolism, following Surgical
    Intervention. _Medical Record_, 1905, lvii. 47.

SPENCER, H. R. Discussion at Exeter on Uterine Fibroids, &c. _British
    Medical Journal_, 1907, ii. 452.

TEBBS, B. N. Symptomatic Parotitis. _Med.-Chir. Trans._, 1905, lxxxviii.
    35.

TRENDELENBURG, F. Zur Herzchirurgie. _Zentralbl. für Chir._, 1907, No.
    44, 1302.

---- Ueber die chirurgische Behandlung der puerperalen Pyämie.
    _Münchener Med. Wochenschr._, 1907, xxxiv. 1302.

WEIBEL, W. Das Verhalten der Ureteren nach der erweiterten abdominalen
    Operation des Uteruskarzinoms. _Zeitsch. f. Geb. u. Gyn._, 1908,
    lxii. 184.




                            SECTION I

                   OPERATIONS UPON THE FEMALE
                         GENITAL ORGANS


                             PART II

                 VAGINAL GYNÆCOLOGICAL OPERATIONS

                                BY

           JOHN PHILLIPS, M.A., M.D. (Cantab.), F.R.C.P.

      Professor of Obstetric Medicine, King’s College, London
  Obstetric Physician and Gynæcologist to King’s College Hospital




CHAPTER XII

PREPARATION OF THE PATIENT FOR PERINEAL AND VAGINAL OPERATIONS:
OPERATIONS FOR INJURIES TO THE PERINEUM AND PELVIC FLOOR


PREPARATION OF THE PATIENT

In operations upon the perineum and vagina, the same scrupulous
precautions against sepsis should be taken as in abdominal section.
Before proceeding to practical details, it will be useful to consider a
few points regarding the distribution of bacteria in these parts. Not
only the ordinary bacteria of the skin, but also those from the rectum,
and, under certain conditions, from the urine and the vaginal secretion
abound on the perineal and vulval surfaces. The healthy virgin vagina
may be considered free from pathogenic organisms, harbouring only the
harmless vaginal bacillus of Döderlein. After sexual congress the vagina
contains pathogenic organisms, and in conditions such as carcinoma of
the cervix and body of the uterus, and in all forms of vaginitis, many
varieties of bacteria are present in great numbers.

The normal uterus is germ-free; in fact the external os uteri may be
said to divide the bacteria-free from the bacteria-containing area of
the genital canal. But in carcinoma and in the various forms of septic
endometritis, the uterus not only contains many pathogenic bacteria, but
acts also as a continual source of infection to the vagina and external
genital organs. It follows, therefore, that this area may be exceedingly
difficult to render sterile, and in certain conditions this is indeed
impossible. None the less, every effort should be made to attain this
object; for even if the organisms cannot be entirely removed, yet their
numbers can be considerably reduced, and it must be remembered that the
action of septic organisms is, to a great extent, directly proportionate
to their numbers.

The same general principles apply to the preparation of patients for
operations on the perineum and vagina as for operations on other parts
of the body. Very particular attention, however, must be paid to the
bowels; nothing is more prejudicial to the success of an operation, or
more annoying to the operator, than to have the area of operation
soiled by an escape of fæcal matter from an imperfectly emptied lower
bowel. The aperient should be given at least 24 hours before the time of
operation. A copious soap-and-water enema should follow after the usual
interval, and, an hour or two beforehand, the lower bowel should be
thoroughly washed out with a gentle stream of warm water.

[Illustration: FIG. 29. PATIENT PREPARED FOR OPERATION. In lithotomy
position with crutch applied, Auvard’s speculum inserted, and volsella
attached to the anterior lip of the cervix uteri. Kelly’s pad is omitted
for sake of clearness. (_From a photograph._)]

The external genitals should be shaved, and washed with ethereal soap
solution and hot water the day before the operation, then douched with a
1-2,000 solution of perchloride of mercury, and a compress, soaked in
the same solution, laid over the vulva. After the enema has acted, and
after the final wash-out, the washing and douching should be repeated
and a fresh compress applied.

If there is any vaginal discharge, the vagina should be douched out
three times a day for two or three days previous to the operation, with
an antiseptic such as 1-4,000 perchloride of mercury, or 1% formalin.
The healing of a perineal wound is considerably impaired if it be
continually bathed in an unhealthy vaginal discharge.

When the patient is on the table and under the anæsthetic, the external
parts should again receive a thorough final disinfection, and, in
addition, the vagina should be thoroughly swabbed out with ethereal soap
solution, by means of swabs on holders. A final douching with 1-2,000
perchloride of mercury completes the process.

In all cases of vaginal hysterectomy for carcinoma, particular attention
must be paid to the preliminary disinfection of the vagina by means of
douching for two or three days before the operation. The vagina is
swarming with various kinds of bacteria, and by careful attention to
these principles the risk of sepsis will be materially diminished.

After the above preparations have been carried out, the patient is
anæsthetized and placed on the table in the lithotomy position, the legs
being kept well apart and fixed by means of a crutch. The buttocks are
brought well to the edge of the table, and a Kelly’s pad may be placed
beneath them. The legs should be encased in sterilized towels or linen
stockings, and towels placed on the hypogastrium (Fig. 29).


OPERATIONS FOR THE REPAIR OF COMPLETE LACERATION OF THE PERINEUM

Under the term _colporrhaphy_ (suture of the vagina) is included any
operation in which denudation and subsequent suturing of one or both
walls of the vagina is carried out. Anterior colporrhaphy includes the
various operations devised for cystocele; posterior colporrhaphy, the
procedures carried out for incomplete rupture of the perineum
(colpo-perineorrhaphy), prolapse of the pelvic floor, and to produce
narrowing of the vagina.

The appearance of the parts in this condition is quite characteristic
(Fig. 30); the laceration of the recto-vaginal septum appears as a
triangular space with its apex upwards, its sides equal, and its base
formed by the retracted sphincter ani (Fig. 32). The separated ends of
the sphincter are seen as two slightly depressed circular spots at the
base of each side of the isosceles triangle _a_, _a_{1}_. The object of
the operation is to adapt these two ends, repair the recto-vaginal rent,
and re-form the perineal body. There is often much irregular scar tissue
about the opening, which may cause additional difficulty at the
operation.

The instruments necessary are six Spencer Wells artery forceps, long
dissecting forceps with hooked points, a pair of sharp-pointed angular
and a pair of sharp-pointed curved scissors (see Fig. 31), flat curved
needles and Schauta’s needle-holder (Fig. 73).

The preparatory treatment consists in regular gentle purgation daily for
a week, dieting, rest in bed for three days, and antiseptic vaginal
douches of lysol (1 drachm to the quart).

[Illustration: FIG. 30. COMPLETE LACERATION OF THE PERINEUM. (_From a
photograph._)

  _a_, _a_{1}._ Ends of torn sphincter ani.
  _cli._ Clitoris.
  _l.i._ Labium internum.
  _m.v._ Mons Veneris.
  _p.c._ Preputium clitoridis.
  _sph._ Sphincter ani.
  _ur._ Urethral orifice.
]

=Operation.= The patient is placed in the dorsal position on a Kelly’s
pad, and after the usual purification, _denudation_ is commenced. The
skin over the circular depressions corresponding to the ends of the
severed sphincter (Fig. 30, _a_, _a_{1}_) is seized with the dissecting
forceps and slightly raised. This portion of skin on either side is
removed by means of the scissors, thus baring the ends of the sphincter
and opening up the cellular tissue.

The point of one blade of the scissors is now buried in the cellular
tissue at this bared spot on the operator’s right side, and is carried
along the free torn edge of the recto-vaginal septum between the deep
and superficial tissues until the apex of the laceration is reached. A
similar incision is made on the opposite side.

The triangles of the vaginal flap are now raised by means of
catch-forceps and the scissors passed carefully into the cellular
tissue, and the recto-vaginal septum is split transversely, producing a
raw surface somewhat the shape of a butterfly in outline (Fig. 33). A
median extension of the denudation is made in an upward direction for
another inch in length to form a supporting column. This flap may, if
the tissues are sufficiently redundant, be removed along the line
running at its base. The raw surface should be swabbed over carefully,
and any bleeding points secured by ligatures. Large venous sinuses are
very often opened, and, should the bleeding recur after the adaptation
of the flaps, the operation will inevitably fail.

[Illustration: FIG. 31. LONG-HANDLED SHARP-POINTED SCISSORS CURVED ON
THE FLAT.]

Closure of the recto-vaginal rent is first carried out by interrupted
sutures, as is seen in the semi-diagrammatic drawing (Fig. 32). The
threaded needle in a holder is passed from the rectal side of the flap
through the flap on to the raw surface, then over the rent on to the raw
surface of the other side; it finally finds its exit again on the rectal
side of the flap. Four or more sutures may be passed in this way, a
final one bringing the cut ends of the sphincter ani together. Each
suture should be tied and the ends cut short before the next one is
inserted, and the knots will lie just beneath the mucous membrane of the
rectum.

[Illustration: FIG. 32. COMPLETE LACERATION OF THE PERINEUM.
Semi-diagrammatic drawing of a ruptured recto-vaginal septum, indicating
the method of passing the sutures for its repair.

  _r.m.m._ Rectal mucous surface.
  _sph._ Torn end of sphincter ani.
  _v.m.m._ Vaginal mucous surface.

The arrows indicate the direction of the sutures.
]

We have now a large butterfly raw surface to deal with. The extension
corresponding to the head is first of all dealt with by four or more
separate sutures (Fig. 33, _a_). The large raw surface is now reduced in
size by the passage of a deeply buried suture (Fig. 33, _b_); those used
in the preceding manœuvres are best of silk. The buried suture should be
catgut, and is passed in a spiral direction, as is seen in the diagram;
the area of the raw surface is very much reduced by it (Fig. 33, _b'_).

The parts to be brought together will now present the appearance shown
in Fig. 33, B, and they are approximated by means of silk sutures, which
are entered on the skin surface on one side, passed beneath the raw
surface, and made to emerge on the skin surface on the opposite side.
Four to six of these may be inserted.

[Illustration: FIG. 33. COMPLETE LACERATION OF THE PERINEUM. In A the
‘butterfly’ surface has been denuded and the recto-vaginal rent repaired
(_c_).

  _a._ Sutures passed through the sustaining column, but not tied.
  _b._ The ‘buried’ spiral suture passed but not tied.

In B is shown the oval raw surface left to be brought together by
sutures (_d_) after the buried suture (_b'_) has been tied.
(_Diagrammatic._)
]

Great care must be taken to see that no bleeding points are left
unsecured, and a current of hot 1 in 4,000 perchloride solution should
be allowed to play over the surface, after which the sutures are tied.
Each suture should be left about an inch and a half long in order to
facilitate removal later on. A gauze drain should be passed into the
vagina and an antiseptic gauze pad placed over the perineum.

[Illustration: FIG. 34. LACERATION OF THE PELVIC FLOOR. The double
triangular surface has been denuded. (_Semi-diagrammatic, from a
photograph._)

The sutures, 1-5, on the operator’s right side are passed and tied;
those on the left are passed but not tied.

  _a._ Anus   _c._ Cervix   _h._ Site of hymen.
  _p_{1}-p_{3}._ Sutures passed through the quadrilateral denuded surface.
  _r._ recto-vaginal wall.
  _s._ Speculum (Pozzi’s anterior retractor).
  _t_, _t._ Tenacula.

The arrow denotes the direction in which the sutures are passed.
]

=After-treatment.= The patient’s knees should be tied together, the
urine drawn off by a catheter every six hours for the first 48 hours,
and the wound kept as dry as possible. Throbbing and pain in the
perineum with slight rise of temperature are generally indicative of
suppuration taking place either between the flaps or along the sutures.
A smart purge should be given on the morning of the third day and daily
afterwards. If there are any scybala left in the rectum it is better to
inject a little warm olive oil into it through a catheter before the
bowels are expected to act.

The patient should be allowed to get up on the twenty-first day. There
should be proper control of flatus and motions from the date of
operation.


OPERATION FOR LACERATION OF THE PELVIC FLOOR

The objects of this operation are twofold: first, to secure the torn
ends of the levator ani to the lateral vaginal sulcus and perineum; and,
secondly, to draw up or lift the pelvic floor, which is more or less
depressed.

The patient is placed in the lithotomy position and a retractor is
inserted in the anterior cul-de-sac in order to elevate the anterior
vaginal wall: Fig. 34 shows the appearances then seen. The left
forefinger or some gauze packing is placed in the rectum and a double
triangular space is denuded by means of sharp-pointed scissors, the base
line of the double triangle being formed by the hymen. Two tenacula are
inserted as indicated in the drawing (Fig. 34, _t_, _t_). The mucous
membrane is now removed from the M-shaped space, great care being taken
to penetrate deeply into the lateral sulci. After all bleeding has been
arrested in the usual manner, the sutures should be passed. On the
left-hand side of the figure these are indicated as inserted, not tied,
whereas on the right they are tied and cut. Subsequently the somewhat
quadrilateral raw surface which is left is brought together by five deep
sutures, and the operation is complete. A Y-shaped cicatrix will be the
result.

[Illustration: FIG. 35. REPAIR OF A LACERATED PERINEUM, WITH NON-UNION
OF THE SPHINCTER ANI, BEFORE A PLASTIC OPERATION. (_From a photograph._)

  _a._ Ununited sphincter ani.
  _b_, _c._ Buried ends of torn sphincter.
]

=Cases in which the perineum is apparently intact, but in which the
sphincter is not united= (Figs. 35, 36).

These are the cases in which a complete laceration of the perineum is
apparently completely healed after operation, but the patient finds that
she has incontinence both of flatus and fæces.

On inspection of Fig. 35 this will be well explained. The patient is
lying on her back in the lithotomy position: _a_ represents the
sphincter which has been torn through; the two cut ends, _b_ and _c_,
are represented by two dark circular, somewhat depressed spots. The
rectal orifice gapes; there is no sphincteric power present. The
perineum anterior to the anus is firmly healed.

=Operation.= The most certain and effectual method in these cases is to
split up the healed perineum antero-posteriorly and treat the case as
one of complete laceration of the perineum (see p. 128). This has been
carried out in the case represented in the illustration (Fig. 35), and
Fig. 36 shows the result: the patient entirely recovered power over the
sphincter ani and the sustaining power of the pelvic floor was much
improved.

[Illustration: FIG. 36. REPAIR OF A LACERATION OF THE PERINEUM AFTER A
PLASTIC OPERATION. (_From a photograph._)

  _a._ Repaired sphincter ani.
  _b._ Anus.
  _s._ Resutured perineum.
]




CHAPTER XIII

OPERATIONS UPON THE URETHRA AND BLADDER


EXTIRPATION OF A URETHRAL CARUNCLE

=Indications.= A urethral caruncle is a bright red, tender tumour,
usually on the posterior portion of the urethral orifice.

The symptoms requiring interference are pain on micturition,
dyspareunia, bleeding and discomfort on movement, and, occasionally,
retention of urine which is probably due to apprehension of pain rather
than to any mechanical obstruction.

=Operation.= To be effectual this must be thorough, and may take the
form of deep cauterization with a Paquelin’s cautery, or excision. The
latter operation consists in excising a wedge-shaped piece of the
posterior wall of the urethra containing the caruncle. Free bleeding
will usually take place, which must be controlled by means of hæmostatic
forceps. The edges of the wound are brought together by fine silk or
catgut sutures, which must be passed completely through the raw surfaces
to prevent recurrent hæmorrhage.

The _after-treatment_ consists in keeping the wound as clean and dry as
possible.


OPERATIONS FOR INCONTINENCE FOLLOWING LABOUR

This is probably due to injury to the pelvic floor and the anterior
fibres of the levator ani, producing a backward displacement of the
urethra.

=Operation.= The operation recommended by Dudley consists of first
denuding the vaginal mucous membrane over a horseshoe-shaped space
between the clitoris and the urethral orifice and then drawing the
urethra forward with sutures passed through the anterior portion of the
orifice and inserted near the clitoris. It will then be seen that the
urethra is carried forward nearly an inch. The raw edges are brought
together in the usual manner by catgut or silk sutures.

The author’s experience of this operation has been unsatisfactory on the
whole, and he has obtained better results by the wearing of a ring
pessary.


OPERATIONS FOR VESICO-VAGINAL FISTULA

=For simple vesico-vaginal fistula.= This condition is fortunately very
rare at the present time. Many operations have been devised for this
condition, but the original one recommended by Sims, with subsequent
modifications, appears to the author to be most efficient and applicable
to the large majority of varieties of this condition.

[Illustration: FIG. 37. AUVARD’S SELF-RETAINING SPECULUM.]

[Illustration: FIG. 38. KNIVES FOR FRESHENING THE EDGES OF A
VESICO-VAGINAL FISTULA.]

[Illustration: FIG. 39. TOOTHED FORCEPS FOR USE IN VESICO-VAGINAL
FISTULA.]

=Preparatory treatment.= The chief object is to obtain a healthy
condition of the fistulous edges, which are nearly always inflamed,
thickened, and covered by urinary deposits, usually of a phosphatic
character. These are best removed by means of a soft sponge or
cotton-wool, and the raw edges treated with a weak solution of nitrate
of silver (gr. ij to the ounce). Hot vaginal douches of lysol solution
(ʒj to a quart) should be given night and morning, and the parts freely
smeared with vaseline to protect them from the action of the irritating
urine. Any cicatricial tissue which may be present around the fistula
should be treated by submucous division.

[Illustration: FIG. 40. EMMETT’S HOOK.]

=Operation.= The instruments necessary are: a Sims’s or Auvard’s (Fig.
37) speculum; two flat spatulæ; three long-handled knives (Fig. 38), one
with a long haft and a short straight narrow blade, and the others with
angular blades (right and left); two long-handled, sharp-pointed, curved
scissors (right and left); an Emmett’s hook for making counter-pressure
(Fig. 40); toothed forceps (Fig. 39) and tenaculum; six Spencer Wells’s
forceps; Schauta’s needle-holder (Fig. 73) with short curved needles.

[Illustration: FIG. 41. SIMS’S OPERATION FOR THE REPAIR OF A
VESICO-VAGINAL FISTULA.

  _a._ Bladder mucous membrane.
  _b._ Vaginal wall.
  _c._ Suture passed but not tied.
  _d._ Section of denuded surface.
  _e, e_{1}._ Liberating incisions.
  _f._ The fistula.
]

The patient is placed in the lithotomy position. A strip of mucous
membrane is then removed from the whole of the vaginal edge of the
fistula by means of an angular knife. In the original operation Sims
(Fig. 41) made the surface oblique, but Simon (Fig. 42) considered the
raw surface should be at right angles to the mucous membrane. The blade
of the knife should not wound the vesical mucous membrane.

After the bleeding has ceased, the sutures, which may be of silk or
catgut, are passed by means of the needle through the pared edge of the
fistula on one side, passing across the fistula, and piercing the raw
surface on the opposite side. The entry of the needle should be made
about 1/4-1/3 of an inch from the raw edge (Fig. 44). Emmett’s hook,
shaped like a button-hook, is useful to produce counter-pressure against
the needle point. The sutures are tied, and milk is injected into the
bladder to test the accuracy of the union.

As a rule, fistulæ are bounded by rather scanty and inelastic walls,
owing to the presence of cicatricial tissue; it is therefore more
advantageous not to remove any tissue in order to produce a raw surface,
or as little as possible. To fulfil this condition, the method of
_dédoublement_ or flap-splitting, as practised by Walcher, may be
carried out (Fig. 43, A, B, and C).

[Illustration: FIG. 42. SIMON’S OPERATION FOR THE REPAIR OF A
VESICO-VAGINAL FISTULA. Letters as in the preceding figure.]

The patient is placed, as before, in the lithotomy position, and the
cervix is pulled down, while the edges of the fistula are kept steady by
a volsella on either side. The margin of the orifice is then split all
round to a depth of from a quarter to half an inch. Vesical and vaginal
mucous membrane flaps are thus produced, giving a large raw surface
without any loss of substance. The sutures are passed as shown in Fig.
43, C.

=After-treatment.= This is very simple: if the patient is able, she
should pass water, either in the dorsal or genu-pectoral position,
otherwise a catheter should be passed every six hours.

_Modifications of this operation_ have been devised, more especially for
the larger fistulæ: they will be briefly mentioned.

1. Repair by turning up vaginal flaps to form the base of the bladder is
recommended by A. Martin of Berlin. He first frees the adherent edges of
the fistula and then raises the flaps from the vaginal wall and brings
them over the opening, suturing them carefully together. By this method
the mucous membrane of the vagina forms the new lining to the bladder,
and the exposed raw surface a new anterior vaginal wall. The edges of
this latter denuded surface are united by sutures, as in the operation
of colporrhaphy.

2. Closure of the fistula by detaching the bladder from the vagina and
suturing it independently is described and practised by Mackenrodt.

[Illustration: FIG. 43. REPAIR OF A VESICO-VAGINAL FISTULA BY
DÉDOUBLEMENT.

  A. The flap-splitting stage.
  B. The flaps separated and the suture passed.
  C. Suture tied, approximating the flaps.
    _a._ Bladder mucous membrane.
    _b._ Vaginal wall.
    _c._ Suture.
    _e, e_{1}._ Liberating incisions.
    _k, k_{1}._ Flap-splitting incisions.

In A the flap-splitting is seen in section (_k, k_{1}_); in B the flaps
have been everted towards the bladder and vagina respectively and the
suture passed. In C this suture has been tied; liberating incisions, _e,
e_{1}_, have been made on the vaginal surface to prevent tension in the
wound.
]

The patient is placed in the lithotomy position, and the fistula is
exposed: the cervix is drawn downwards and backwards by means of a wire
loop or tenaculum, and the urethral prominence held with a pair of
hooked forceps. An incision is then made in the median line extending
across the fistula and through the vaginal walls down to the bladder, in
this way exposing the entire base of the bladder. The edges of the
fistula are then split so that the bladder and the vaginal walls are
separated. The two vesical flaps are now carefully and separately
sutured by catgut and the edges of the vaginal wound are brought
together as much as possible: if necessary, the fundus of the uterus
may be used to assist in closing the opening.

=For vesico-utero-vaginal or juxta-cervical fistula.= In this affection
the cervix is involved, and it must therefore be carefully
differentiated from the vesico-vaginal variety, in which the cervix is
intact.

[Illustration: FIG. 44. REPAIR OF A VESICO-VAGINAL FISTULA. _Sims’s
Operation._ The edge of the fistula has been denuded and the sutures
have been passed.

  _a.v.w._ Anterior vaginal wall.
  _cl._ Clitoris.
  _s_{1}, s_{11}._ Retractors.
  _sp._ Posterior speculum.
  _t._ Tenaculum.
  _u._ Orifice of urethra.
  _v.v.f._ Vesico-vaginal fistula.
]

In operating upon such cases the chief difficulty will be found in
denuding the surfaces necessary for the introduction of the sutures,
owing to the density of the cicatricial tissues, which are always
present. This is best overcome by drawing the cervix forcibly downwards
and backwards and incising the anterior cul-de-sac; the bladder wall
with its fistulous opening is then dissected off the anterior surface of
the cervix and carefully sutured independently of the cervical
laceration; the latter is treated by suture in the usual way (see p.
128). In the deeper forms of juxta-cervical fistula, the above technique
is impossible, and suprapubic incision and suture of the bladder must be
substituted.


RECTO-VAGINAL FISTULA

This condition may be defined as an opening between the rectum and
vagina through which flatus, or fæces, or both, may pass from the former
into the latter; it is chiefly the result of an imperfect union
subsequent to an operation for complete perineum laceration. It may also
be caused by the rupture of a pelvic abscess or by the spread of primary
malignant disease of the rectal wall.

=Operation.= If the sphincter ani is incompletely united, it will be
found much the most satisfactory proceeding to divide the healed
portions of the perineum and make a complete perineal laceration; this
may then be treated as described above (see p. 128).

If, however, the sphincter is intact and serviceable the fistula should
be pared and the edges brought together by silk sutures. It is not
infrequently necessary to perform a temporary colostomy (see Vol. II) in
order to divert the fæcal contents of the bowel during the process of
healing.


OPERATIONS FOR CYSTOCELE

In cystocele there is prolapse of the anterior vaginal wall and the
corresponding area of the posterior bladder wall. Cystocele often
complicates rectocele and prolapsus uteri, and operation upon it is
often carried out in combination with colpo-perineorrhaphy.

=Operation.= The operation for the cure of this affection is very
simple, and may be performed:--

(1) By denuding an oval space over the swelling and bringing the raw
edges together.

(2) By Stoltz’s operation, which is really purse-string suture.

The instruments necessary are a bladder sound, two tenacula,
sharp-pointed angular scissors, a needle-holder and fine silk.

(1) The parts are exposed with a Sims’s or Auvard’s speculum and a
volsella, or silver wire is passed through the cervix, by means of which
traction downwards and backwards may be exerted. The cystocele itself is
fixed by tenacula, and, with the sound in the bladder, an oval incision
is carried completely round the base of the cystocele. The whole area
contained in this incision is denuded by knife or scissors, care being
taken to avoid wounding the bladder mucous membrane.

Any bleeding having been controlled, a spiral buried suture, as in the
operation for perineorrhaphy (see p. 128), is passed antero-posteriorly,
thus reducing the size of the raw area and making a solid support in the
median line. The raw edges are then brought together by sutures. The
catheter should be passed every eight hours for three days, and then the
patient should be allowed to micturate on her hands and knees.

(2) _Stoltz’s operation._ The instruments necessary are: a No. 8 male
bladder sound; two tenacula; hooked forceps; sharp-pointed angular
scissors, and a needle-holder (Schauta’s for preference).

The patient is placed in the lithotomy position and the parts are
exposed by means of an Auvard’s speculum. A silver wire or tenaculum is
passed through the posterior lip of the cervix, by means of which
downward and backward traction may be exerted. Four points must be
selected: two lateral (Fig. 45, 1, 1'), fixing the external boundaries
of the surface to be denuded; one immediately behind the orifice of the
urethra (2); and a fourth in front of the cervix (3). These four points
should be capable of close approximation. They are carefully joined by
curved incisions so that the area to be denuded is almost oval in shape.
The bladder sound is now passed, and the mucous membrane of the vagina
kept on the stretch by pressure on its point. The process of denudation
should be carried out with a scalpel or pointed curved scissors. It will
be found that bleeding rarely gives any trouble. The point of the needle
threaded with silk is inserted on the operator’s right side of the
urethral orifice and a little below it; it pierces the mucous membrane
on the left side of the median line, and again appears upon the surface.
By an in-and-out stitch all the way round the circle which has been
pared, the point finally issues on the operator’s left side of the
urethra and below it: by traction on these two ends the edges of the
denuded surface are drawn together and the prolapsed bladder is sutured
in its normal situation. A puckered cicatrix results. This method is
valuable for prolapsus uteri when combined with the operation of
posterior colporrhaphy.

[Illustration: FIG. 45. STOLTZ’S OPERATION FOR CYSTOCELE. The oval
surface has been denuded and the circumferential suture passed but not
tied.

  1,1',2,3. The four points first selected as boundaries for denudation.
  _s._ Suture, the arrows denoting the direction in which it is passed.
  _sp._ Retractor.
  _t._ Tenaculum.
  _u._ Urethral orifice.
]




CHAPTER XIV

OPERATIONS UPON THE VULVA AND VAGINA


OPERATIONS UPON BARTHOLIN’S GLANDS

The glands of Bartholin, or the vulvo-vaginal glands, are two racemose
structures about the size of a pea, lodged between the layers of the
triangular ligament, one on each side of the orifice of the vagina.
Their ducts open a little in front of the fossa navicularis, on each
side of the vaginal orifice, in the groove between the attached border
of the hymen and the labium minus.

=Removal of a cyst of Bartholin’s gland.= These cysts really arise in
the ducts rather than in the gland itself. The orifice of the main duct
is very liable to become blocked from inflammation of the vulva, and
leads to the formation of a single cyst varying in size from a cherry to
an orange. Less common is the blocking of the secondary ducts, wherefrom
a collection of small cysts results. The cyst forms a characteristic
tense ovoid or pyriform swelling in the posterior third of the labium
majus. The chief symptoms the patient complains of are discomfort in
walking and pain on coitus.

=Operation.= The best procedure is complete excision of the cyst. A
longitudinal incision is made over its cutaneous surface, and the cyst
carefully dissected out, together with the gland itself: care must be
taken not to perforate the vaginal mucous membrane stretched over the
inner surface of the cyst. Brisk bleeding from vessels at the base of
the cyst, usually follows from the cavity which contained the cyst and
this must be carefully arrested, otherwise a large hæmatoma may result.
The cavity is closed by five or six interrupted catgut sutures, passing
deeply through its sides and floor, so as to ensure complete closure. A
gauze drain may be inserted and retained for twenty-four hours.

The method of incising the cyst, swabbing its interior with undiluted
carbolic acid, and packing it with gauze is not to be recommended, for
cure is neither so rapid nor so certain as in excision.

=Incision of an abscess of Bartholin’s gland.= Abscesses arise by
infection passing into the gland along the ducts, and are a very
frequent accompaniment of gonorrhœa. The orifice of the duct can usually
be seen red and prominent, and may exude pus if pressure be made over
the abscess-sac. Sometimes the abscess bursts and spontaneous recovery
may follow, but it is very liable to recur, for infection lurks among
the smaller ducts and is carried to a fresh part of the gland, and the
process may continue until the whole gland has been thus destroyed.

=Operation.= The abscess must be freely incised and all pockets and
septa broken down. It is stuffed with iodoform gauze, which is changed
daily, and the cavity is allowed to granulate up from the bottom. If the
abscess recurs, or if it consists only of a small collection of pus
surrounded by brawny œdema, the whole gland should be excised.


OPERATIONS FOR ATRESIA OF THE HYMEN AND THE VAGINA

Occlusion of the hymen is the commonest form observed. The vagina
becomes slowly distended with blood, forming an elastic pelvic swelling
(hæmato-colpos) upon which the uterus is, so to speak, perched. Later in
the course of the disease, this organ itself (hæmato-metra) and the
Fallopian tubes (hæmato-salpinx) may become affected similarly.

=Indications.= In atresia of the hymen symptoms only commence after
puberty; there is then congenital amenorrhœa with periodic pelvic pain
and gradual formation of a pelvic swelling. On inspection the hymen is
distended and the blood-tumour above it gives a bluish tint to its
surface.

=Operation.= After administration of an anæsthetic, careful palpation of
the tubes should be made _per rectum_: if they are distended it is
better to open the abdomen, ligature and remove them; if not, the hymen
should be incised by means of a crucial opening and the characteristic
tarry fluid allowed to escape: no hypogastric pressure should be used.

Irrigation and packing with gauze may be resorted to as after-treatment,
but are considered unnecessary by a large number of operators.

Atresia of the vagina may be congenital or acquired. In the latter case
the condition results from contraction of adhesions developed from
damage done during labour; or it may follow acute septic vaginitis, the
introduction of acids or irritating materials to produce abortion, or as
a sequel to typhoid fever.

Treatment is by slow dilatation with Hegar’s bougies over an extended
period of time; relapse is common.


DILATATION OF THE VULVAL ORIFICE

=Indications.= This is done for vaginismus due to a pathological spasm
of the levator ani and resulting in more or less complete obstruction to
coitus.

=Operation.= Under an anæsthetic the vulval orifice should be thoroughly
dilated by means of the thumbs, and for some days subsequently
graduated Sims’s ‘vaginal rests’ (Fig. 46) should be inserted twice
daily and worn for twenty minutes at a time. This treatment may be
necessary for a fortnight or longer. In many cases of dyspareunia the
cause will be found to be due to a thick, fleshy, and unruptured hymen
or to tenderness about the remnants of that organ. Under these
circumstances, exsection is the better plan to pursue. The hymen is
seized with a pair of toothed forceps and removed with curved scissors
along its entire base of attachment. Free bleeding often occurs from the
raw surface, which must be controlled by ligatures. The two almost
parallel cut edges must then be carefully brought together either by
continuous or interrupted suture.

[Illustration: FIG. 46. SIMS’S VAGINAL REST.]


COLPOTOMY OR VAGINAL CŒLIOTOMY

By colpotomy is meant making an opening into the peritoneal cavity
through the vagina; the operation is known as anterior or posterior
colpotomy, according to whether the opening is made through the anterior
or posterior fornix.

Colpotomy has certain _advantages_ over abdominal section. There is less
interference with the peritoneum and intestines, and therefore less
shock; if pus is present, there is less risk of infecting the general
peritoneal cavity, and better drainage; there is no abdominal scar, and
therefore no risk of hernia; lastly, there are certain pathological
products which can be more easily reached by this route. The operation
is difficult in a nullipara, where the vagina is narrow, and easier in a
multipara, where the vagina is more capacious, and it is still easier if
the cervix can be drawn down as far as the vaginal orifice.

A serious _disadvantage_ is that, during the course of the operation, it
may be found impossible to deal adequately with the conditions for which
the operation is being performed; in the case of a tumour, for instance,
its size, position, or the presence of adhesions may render it necessary
to complete the operation by the abdominal route. Further, in more than
one instance, the abdomen has had to be opened after the completion of
the operation on account of bleeding, the source of which could not be
dealt with by the vagina.

Therefore, before deciding upon the removal of a tumour by colpotomy,
all the above points must be taken into consideration.

=Indications.= When the above conditions are fulfilled, colpotomy is
suitable for:--

(i) The evacuation of collections of pus or blood in Douglas’s pouch.

(ii) The removal of fibro-myomata, ovarian tumours of small size, and
early tubal pregnancies.

(iii) The drainage of collections of pus or the removal of the
appendages in cases of acute inflammation where immediate operation is
necessary.

(iv) Conservative operations upon the Fallopian tubes or ovaries.

(v) A preliminary to the performance of vaginal hysteropexy.

(vi) Those cases in which the patient’s general condition is
unfavourable to the performance of exploration by the abdominal route.

Anterior colpotomy is more suitable for removing small tumours growing
from the anterior wall of the uterus, or for conservative operations on
the ovaries. Posterior colpotomy is more suitable for removing inflamed
appendages, and for evacuating collections of pus or blood from
Douglas’s pouch.

[Illustration: FIG. 47. POZZI’S RETRACTORS.]

Posterior colpotomy has been used for many years for the opening of
abscesses and hæmatoceles in Douglas’s pouch. The anterior operation is
of more recent date, and its relative advantages and disadvantages and
the indications for its use have not yet been definitely agreed upon by
the majority of gynæcologists. Taking all things into consideration, the
disadvantages of colpotomy seem to outweigh its advantages, and, except
for the evacuation or drainage of collections of blood or pus behind the
uterus, the operation may be said to have few indications.

=Anterior colpotomy.= A posterior Pozzi’s (Fig. 47) or Péan’s retractor
is passed into the vagina, and the cervix is seized with a volsella and
drawn downwards and backwards. A sound passed into the bladder defines
its lower limit. A T-shaped incision is now made through the vaginal
mucous membrane, the transverse portion just below the point to which
the bladder has been found to extend (Fig. 48, _b_). This incision
should pass completely through the vaginal mucous membrane, but no
further, and should extend across the whole width of the anterior
surface of the cervix. Some operators use a simple longitudinal or a
transverse incision. The vaginal mucous membrane is now carefully pushed
upwards with the pulp of the finger until the lower limit of the bladder
is defined. Great help is gained at this stage by the use of the bladder
sound. On pushing up the vaginal mucous membrane still further the
peritoneum is reached, and is recognized by its white glistening
appearance, and by the fact that its two opposed surfaces glide freely
over one another under the finger. The next step is to open the
peritoneum: it is picked up with catch-forceps, and a small transverse
incision is made into it with a pair of scissors; the finger is passed
through, and the incision is extended on either side, care being taken
not to pass too far outwards for fear of injuring the ureters or uterine
vessels.

[Illustration: FIG. 48. ANTERIOR COLPOTOMY.

The patient is in the lithotomy position, the speculum is passed and the
cervix pulled down by a tenaculum. The T-shaped incision has been made.

  _b._ Outline of bladder.
  _c._ Cervix.
  _cl._ Clitoris.
  _l.m._ Labium minus.
  _sp._ Speculum.
  _u._ Urethral orifice.
  _v,v',v''._ Volsella.
]

After the peritoneum has been opened, the pelvic organs can be carefully
examined with the fingers, and the purposes for which the operation has
been undertaken can be proceeded with. The next step usually consists in
drawing out the fundus of the uterus, by which much more room and much
better access to the pelvic organs is gained. To accomplish this, the
uterus is caught with a volsella in the middle line, as high up as
possible, and drawn downwards and forwards. If necessary, a second
volsella is applied above the first, and so on, until the uterus is
delivered. A very complete examination of the appendages can now be
made, for the tubes and ovaries can be drawn out of the wound and
examined directly.

When the object of the operation has been attained, and all the blood
has been carefully removed by swabs, the next and final step consists in
closing the peritoneal and vaginal wounds. The uterus is replaced, and
the peritoneal incision is closed by a single layer of catgut sutures;
the vaginal incision is similarly dealt with. The vagina is cleared from
blood-clot and gently irrigated with an antiseptic solution. A gauze
plug is inserted lightly, and the patient is put back to bed. The
catheter should be used every six or eight hours for the first
twenty-four hours.

=Posterior colpotomy.= A posterior speculum is passed and the cervix
drawn downwards and slightly forwards with a volsella. A transverse
incision is then made through the vaginal mucous membrane at the
junction of the posterior fornix with the cervix. This exposes the
peritoneum more or less easily, and this structure is picked up with
catch-forceps, and a transverse incision made into it with scissors; a
finger is passed through this, and the incision is extended on either
side. The pelvic organs can now be explored and the tubes and ovaries
drawn down and examined. The peritoneal and vaginal incisions are then
closed by separate layers of catgut sutures.

[Illustration: FIG. 49. MARTIN’S TROCHAR FOR PELVIC ABSCESS.]

_To open a collection of pus in Douglas’s pouch_, the best method is to
pass a pair of sinus-forceps, with the blades closed, into the most
prominent part of the swelling. The blades are then opened and the
forceps withdrawn. The finger passed into the abscess cavity gently
breaks down any adhesions. The cavity is then irrigated with hot salt
solution and a drainage tube inserted, which projects just outside the
vulva: the lower end of the tube should be carefully packed around with
cyanide gauze. The tube should be changed every day and the vagina
douched with an antiseptic. Another method is to plunge a Martin’s
trochar (Fig. 49) into any softened spot in the swelling and then
withdraw the needle, leaving a blunt dilating forceps to extend the
opening.

In opening an abscess, the most stringent precautions against sepsis
should be observed. The vagina must be most carefully prepared
beforehand, by rubbing over with swabs and ethereal soap, and by a
subsequent copious douche of 1 in 1,000 perchloride of mercury:
otherwise continual reinfection of the abscess cavity occurs, and
healing is much delayed.

=Lateral colpotomy--Paravaginal section.=

=Indications.= The object of the operation is to increase the amount of
room in the vagina in certain cases of vaginal hysterectomy in elderly
virgins, or in women who have a small vagina.

=Operation.= The same preliminaries are carried out as before. The
incision is carried completely round the cervix at its junction with the
vagina. The lateral margin of the vulva is then held tense, and an
incision is made, beginning at the circumcervical incision running down
the lateral vaginal wall, through the margin of the vulva and on to the
skin externally, ending at a point midway between the perineum and the
ischial tuberosity, _i.e._ about 1-1/2 inches to the side, and in front
of the perineum; the incision may be lateral only or bilateral. In
sewing up, it is important to reunite the cut edges of the levator ani,
or pelvic weakness will result.




CHAPTER XV

OPERATIONS UPON THE UTERUS


PASSAGE OF THE UTERINE SOUND

This is an operation which is much less frequently resorted to than
formerly, owing partly to the risks of sepsis attending its performance
and partly to the greater perfection of the bimanual examination.
Passing the uterine sound should always be looked upon as a surgical
operation. The facts learnt by the use of the sound are: (1) the length
and direction of the uterine cavity; (2) the condition of the
endometrium: bleeding as a rule follows withdrawal in fibro-myomata and
endometrial disease; (3) whether a fibroid growth is projecting into the
uterine cavity, and if so, how much.

[Illustration: FIG. 50. THE PASSAGE OF THE UTERINE SOUND. _Introduction
of the point into the external os uteri._]

[Illustration: FIG. 51. THE PASSAGE OF THE UTERINE SOUND. _Commencement
of the tour de maître._]

The sound may be passed in the dorsal position (Fig. 61), the cervix
being held by a volsella and exposed by means of a posterior speculum,
or in the left lateral position, the method usually adopted in the
consulting room. In the latter the right index-finger is passed up to
the anterior lip of the cervix, the sterilized sound is taken in the
left hand with its concavity backwards and its bulbous end is slid
gently along the palmar surface of the finger in the vagina until the os
uteri externum is reached; through this it should be passed for about a
quarter of an inch (Fig. 50). The instrument should now be steadied by
the thumb and the two distal joints of the second finger of the right
hand, and its subsequent movements controlled by the left (Fig. 51).

[Illustration: FIG. 52. THE PASSAGE OF THE UTERINE SOUND. _Completion of
the tour de maître._]

[Illustration: FIG. 53. THE PASSAGE OF THE UTERINE SOUND. _Entry of the
sound into the uterine cavity._]

If the uterus is in a state of retroversion, the bulbous end will
gradually enter the uterine cavity by pressing the handle of the sound
forward and at the same time giving an upward and slightly backward
impulse to its tip; the rough surface of the handle will be found to be
looking towards the sacrum. Should the uterus be anteverted, the handle
is held in the left hand as before and passed through an arc of a circle
by raising the handle and turning it forward until it lies beneath the
symphysis pubis, in the median line (_tour de maître_) (Fig. 52). The
rough surface of the handle now looks anteriorly and the bulbous end is
pressing against the internal os uteri; now bring back the handle
directly to the perineum and it will glide into the uterine cavity (Fig.
53).

_Difficulties_ to be met with will be: (1) An acutely anteflexed uterus;
if traction is made on the cervix with a volsella the canal is
straightened and the difficulty overcome. (2) Spasmodic contraction of
the internal os uteri; this soon passes off with a little steady
pressure. (3) A fibroid may project into the lumen of the canal. (4)
Congenital or acquired stenosis of the external os uteri.

When there is a septic discharge from the vagina, the sound should be
passed in the dorsal position and through a speculum.


REPOSITION OF A CHRONIC UTERINE INVERSION

=Indications.= Chronic inversion of the uterus, with severe hæmorrhage
and bearing-down pain. The uterine fundus presents in the vagina and
simulates a fibroid polypus in process of extrusion.

=Operation.= This is most likely to be successful if continuous pressure
be brought to bear against the inverted fundus while an attempt is made
simultaneously to dilate the contracted cervix.

The patient is placed under an anæsthetic in the dorsal position and the
whole hand is passed gradually into the vagina. The tips of the fingers
and thumb should be pressed into the circular space at which the flexion
of the walls of the body on the cervix has occurred. With the palm of
the hand upward pressure is made, counter-pressure being exerted by the
other hand over the lower hypogastrium. Reduction usually begins by a
slight dimpling of the inverted fundus.

[Illustration: FIG. 54. CHRONIC UTERINE INVERSION. Aveling’s repositor
in place with elastic cords A, B, and C, in action.]

A more scientific method of exerting continuous pressure is by the
application of Aveling’s sigmoid repositor and elastic cords (Fig. 54).
This instrument consists of a vulcanite cup into which is secured a
steel S-shaped rod terminating below in a loop. The cup is made of
various sizes and should always be smaller than the inverted fundus over
which it fits.

After it has been applied, the instrument is carefully packed round with
gauze to keep it in place. Two elastic bands in front and two behind are
fastened by one end to the steel loop and by the other end to an
abdominal belt. By this means constant and direct pressure is obtained
on the fundus uteri in the direction of the pelvic axis.

Pain is usual and must be relieved by morphine. The cup usually elevates
the fundus and corrects the inversion in about twenty-four hours, but as
much as three days has been occupied in the process.


CURETTING THE UTERUS--CURETTAGE

The term ‘curetting’ is applied to the operation of scraping away the
lining membrane of the uterus, either for the relief of some
pathological condition or for diagnostic purposes.

The endometrium is not removed in its entirety by curetting, for the
uterine glands dip down to a slight extent between the muscle fibres of
the uterine wall. The endometrium is removed as far down as the muscular
coat, and, consequently, those parts of the glands lying amongst the
muscular fibres are left intact.

=Indications.= These may be divided into the cases in which the
operation is (1) Remedial and (2) Diagnostic in nature.

The diseased states of the endometrium are many and their exact
pathology is still under discussion. It is, therefore, more practical to
consider _the remedial indications for curetting_ from the point of view
of symptoms.

(i) _Uterine hæmorrhage_ is the chief symptom which calls for curetting.
The causes of the hæmorrhage may be _certain forms of endometritis_.
Thus hæmorrhage is a prominent symptom of the so-called ‘hypertrophic
glandular endometritis’, a diffuse overgrowth or adenomatous condition
of the endometrium, probably the after-result of a previous
inflammation. There is one form which gives rise to specially profuse
hæmorrhage--the ‘polypoid’ or ‘villous’ form, which arises usually in
women over forty years of age.

The hæmorrhage from _fibro-myoma of the uterus_ may require removal of
the endometrium in order to relieve the bleeding temporarily at any
rate. When milder measures fail, curetting is of great service in
arresting the profuse menorrhagia which so often accompanies
_subinvolution of the uterus_.

Certain cases in which the actual cause of the hæmorrhage is not evident
are relieved by curetting; amongst these are such conditions as
arterio-sclerosis of the uterine vessels.

(ii) _A leucorrhœal discharge_ is another symptom for which curetting is
sometimes indicated.

It may be called for when the endometrium is congested and œdematous
from such conditions as displacements of the uterus and chronic
subinvolution.

It is better not to curette for a purulent uterine discharge; extension
of the infection may be caused and give rise to pyosalpinx.

(iii) _Sterility._ Curetting should follow dilatation, in the hope that
the new endometrium formed may afford a better nidus for the ovum.

(iv) _Frequent abortion in the early months._ Curetting often cures this
by removing the diseased endometrium.

(v) _Inoperable carcinoma of the cervix._ Removal of the redundant
portions of the growth by the curette, followed by cauterization or
other measures, relieves the hæmorrhage and foul discharge. Great
caution must be exercised, lest the peritoneum or bladder be opened into
by the curette and the sufferings of the patient thereby increased.
Cells of the disease may also be pushed into the pelvic lymphatics;
considerable febrile disturbance may also follow the operation. In this
condition a blunt curette (Fig. 60, B) may be gently used; the same
instrument is safest in abortion up to the eighth week of pregnancy;
after this date it is better to use the fingers only.

[Illustration: FIG. 55. VOLSELLA FOR FIXING THE CERVIX.]

[Illustration: FIG. 56. HEGAR’S DILATORS (THREE SIZES) FOR DILATATION OF
THE CERVIX UTERI.]

Fragments removed by the curette are subjected to microscopical
examination _for diagnostic purposes_. The various conditions which may
have to be diagnosed are:--

1. Carcinoma of the body of the uterus.

2. Retained products of conception.

3. Tuberculosis of the endometrium.

4. Chorio-epithelioma malignum.

=Operation.= The following instruments are required: a volsella (Fig.
55); a self-retaining weighted speculum (Fig. 37); uterine dilators
(Figs. 56, 57); a uterine sound; a Bozemann’s tube (Fig. 58); Budin’s
celluloid catheter (Fig. 59); and one or other flushing curettes.

There are many varieties of curettes, and each has its own adherents.
The most generally useful is Murray’s sharp flushing curette, which has
a groove for the recurrent flow (Fig. 60, A). There are many varieties
of blunt curettes. The model depicted in Fig. 60, B, enables the
operator to clear out the uterine cornua and is of the best shape.

The patient is placed in the lithotomy position and the various
antiseptic precautions already described are carried out. A speculum is
passed and the cervix is steadied by a volsella applied to the anterior
lip.

The cervix is first dilated up to a suitable degree for the passage of
the curette; up to No. 12 Hegar is usually sufficient. The curette is
now taken and passed into the uterus. In performing the operation a
definite plan should always be followed so as to ensure that no part of
the uterine cavity is missed. The curette is passed up to the top of the
fundus uteri with its cutting edge directed to the posterior wall. It is
then drawn downwards with steady pressure to just below the internal os.
It is then again passed upwards and the manœuvre repeated with just
sufficient change of direction to ensure the curette passing over fresh
tissue. This is repeated until the whole of the posterior wall has been
thoroughly dealt with from side to side. The anterior wall and sides of
the uterus are then treated in turn in the same way. Finally the fundus
is curetted by a lateral movement of the instrument, especial attention
being paid to the Fallopian tube angles, which are very apt to escape
the curette.

[Illustration: FIG. 57. METAL BOUGIES FOR DILATATION OF THE CERVIX.

  _a._ As used by the author.
  _b._ Ends of bougies considered unsuitable.
]

A rasping or grating sound indicates that the endometrium over a given
part has been removed and that the muscular walls have been reached. In
spite of the most careful attention it is very difficult to remove the
endometrium completely. If a uterus be scraped, as it is thought,
thoroughly, and be examined _post mortem_, strips of mucous membrane
will often be found untouched, showing the difficulties of complete
removal.

[Illustration: FIG. 58. BOZEMANN’S DOUBLE-CHANNELLED TUBE.]

[Illustration: FIG. 59. BUDIN’S CELLULOID CATHETER.]

[Illustration: FIG. 60. A, MURRAY’S FLUSHING CURETTE; B, BLUNT CURETTE.]

After the operation an intra-uterine douche of 1 in 2,000 perchloride of
mercury or some other suitable antiseptic is given with a Bozemann’s
tube or Budin’s catheter. If a flushing curette has been used, this of
course has already been done. After the douche, some application may be
made to the interior of the uterus: the best is iodized phenol (liquid
carbolic acid, 2 parts; tincture of iodine, 1 part). To do this the
interior of the uterus is first dried with a Playfair’s probe armed with
cotton-wool; another similar probe is then taken, dipped into the
solution, and passed into the uterus. The vagina is protected by
inserting a plug of cotton-wool into the posterior fornix. The uterus is
then lightly packed with ribbon gauze. If there is hæmorrhage, the
packing should be firmer, and a vaginal tampon should be placed in below
the cervix. The packing should be removed in twenty-four hours. The
patient may get up at the end of a week and resume her ordinary duties
in a fortnight.


DILATATION OF THE CERVIX

=Indications.= Dilatation may be performed:--

    (i) As a means of diagnosis.
   (ii) As a preliminary to the use of the curette or to
        removal of intra-uterine growths.
  (iii) As a method of cure for spasmodic dysmenorrhœa.

_Contra-indications_ to the rapid method of dilatation of the cervix are
very few: a recent attack of peri- or parametritis would certainly be
one, but when the effects of a salpingitis have quieted down there seems
very little reason against its use. Where carcinoma of the body of the
uterus is known to exist, and in old age, it should only be resorted to
with the greatest caution, if at all.

=Methods=:--

  (_a_) Rapid dilatation by means of graduated metal bougies.
  (_b_) Gradual dilatation by means of tents.
  (_c_) Combined gradual and rapid dilatation.

In a large majority of cases rapid dilatation is the operation selected.
Its one disadvantage is that when a great degree of dilatation is
necessary, or when the operation is performed too rapidly, the cervix is
liable to be torn, an event which is especially liable to occur when the
tissues of the cervix are rigid. These lacerations are longitudinal in
direction and in the neighbourhood of the internal os uteri. They
sometimes result in hæmorrhage, which can easily be controlled by
plugging the cervical canal. Unless strict asepsis be maintained, these
lacerations of course form a channel for infection of the pelvic
cellular tissue.

It is obvious that dilatation will be easier to perform, and laceration
less liable to occur, if the cervix is in a softened condition--a
physiological state which is always present during pregnancy and labour.
Efforts should therefore be directed, when possible, to ensure a soft
state of the cervix before performing rapid dilatation.

Immediately after the cessation of a period, the cervix is soft and
somewhat patent, and advantage may be taken of this fact. The
introduction of a glycerine tampon two hours beforehand produces a
certain amount of softening. But nothing ensures so much softening as
the introduction of a tent into the cervix about twelve hours previous
to the rapid dilatation.

It is therefore recommended in all cases, where possible, to perform
dilatation by this latter means, viz. a combination of the gradual and
rapid methods.

=Rapid dilatation= by means of graduated metal bougies. Hegar’s original
dilators (Fig. 56) were solid vulcanite bougies, graduated from 1 to 26,
the numbers corresponding to the diameter of the bougie in millimetres.
Each was 5-1/4 inches in length, the handle measuring 1-1/2 inches and
the bougie the remainder. The bougie formed a slight curve and tapered
off to a blunt point.

These bougies were rather short and too sharply pointed, and they could
not be sterilized by boiling. To overcome these disadvantages, uterine
dilators are now made about the same length as a male catheter, with a
sharper curve than Hegar’s original one, and a blunter point; the larger
sizes are of hollow metal for the sake of lightness. There are many
varieties of dilator, each with minor differences as to length, curve,
handle, and shape of the point.

[Illustration: FIG. 61. DILATATION OF THE CERVIX. The patient is in the
lithotomy position. Auvard’s speculum has been inserted, a volsella
attached to the anterior cervical lip and a bougie passed. (_From a
photograph._)

  _d._ Right hand inserting bougie.
  _s._ Speculum.
  _v._ Volsella.
]

The author uses metal bougies. These have somewhat the shape of the
ordinary uterine sound, are thirty-five in number, and graduated in
size. Like the sound, the upper portion is bent at an angle of about
160° with the solid handle, a circular shallow depression indicating the
2-1/2 inch mark in the smaller numbers; in the larger this is not
considered necessary.

=Operation.= Instruments: an Auvard’s self-retaining weighted flushing
speculum; a volsella; a Bozemann’s tube or Budin’s catheter; a uterine
sound; and a set of dilators.

The patient is anæsthetized and placed in the lithotomy position with
the legs supported by a crutch. Strict asepsis must be observed; the
labia must be shorn of long hairs; this is followed by cleansing of the
vagina and a vaginal douche, and finally the vulva is washed with
antiseptic lotion. The speculum is passed and held by an assistant, but
if self-retaining, as in Fig. 61, the assistant is not necessary: a
sound is then inserted to ascertain the length and direction of the
uterine cavity. If anteflexion be present, the anterior lip of the
cervix should be seized with the volsella and fixed by slight traction.
If retroversion or retroflexion be present, then the posterior lip
should be fixed. Traction by the volsella tends to straighten out the
uterine canal, and thus makes the passage of the bougies easier. The
bougies are now passed in order, commencing with the size which will
pass easily. The bougie is passed by means of the right hand into the
cervical canal until the internal os uteri is reached; resistance will
now be felt. Firm and continuous pressure in the proper direction must
be made, and in a short time the resistance gives way, and the bougie
will pass into the uterine cavity. An interstitial fibroid produces a
tortuous channel and much difficulty will often be experienced in
passing a bougie in such a case. It will be found on attempting to
withdraw the instrument that it is grasped by the internal os uteri; in
the course of one to five minutes this spasm will relax, and only then
should the bougie be withdrawn. The next in size should be ready and
introduced in the same manner, and the succeeding ones are inserted
until the required dilatation is produced. Sterilized vaseline or
glycerine of perchloride of mercury may be smeared over the point of the
dilator to facilitate its passage. Each succeeding bougie should
increase in size by not more than 1 mm.: occasionally a case is met with
where this seems too large a difference, and it is really better to have
them made with a 1/2 mm. difference. As a preliminary to the use of the
curette, dilatation up to No. 12 Hegar is necessary. The index-finger
can be introduced into the uterine cavity after the passage of No. 19 or
20 Hegar, while full dilatation up to No. 26 is required for any
operation with scissors or the écraseur on intra-uterine growths.

It is evident that the degree of dilatation for exploratory purposes
will be governed by the diameter of the operator’s finger, or rather of
its second joint, and this varies very much in different people. By
means of the finger a uterus can be explored in which the cavity is much
longer than the operator’s finger, if the viscus be forced down on to
the finger by the pressure of the other hand above the symphysis pubis.
The operator must not be satisfied until he has felt the whole extent of
the uterine wall, especially the two cornua, which are favourite seats
of disease. After completion of the operation it is well to give an
antiseptic intra-uterine douche by means of a Bozemann’s tube. The
uterus and cervix should be lightly packed with sterile ribbon gauze, 1
inch wide; the free end is left projecting through the os uteri. The
packing should be removed in twenty-four hours, and an antiseptic douche
given.

=Difficulties and dangers.= The difficulty due to non-dilatability is
overcome by means of the preliminary use of a tent. The complication
produced by a fibroid, altering the direction of the uterine canal, has
been mentioned. Extreme anteflexion or retroflexion gives trouble during
the passage of the earlier numbers, but as dilatation is effected this
disappears.

The dangers are:--

1. Laceration of the cervix.

2. Rupture of the uterus.

3. Sepsis and its sequelæ.

4. Hæmatoma between the layers of the broad ligament.

_Laceration of the cervix_ has been referred to: it begins as a rule at
the internal and extends towards the external os uteri; it may be deep
or superficial, and is recognized as a sulcus into which the finger can
be passed from above downwards: rarely, laceration into the peritoneum
may take place.

_Rupture of the uterus_ is liable to occur when the uterine wall has
been weakened by the changes which accompany the completion of the
menopause, or has been infiltrated by carcinoma, or, more rarely, by
vesicular mole.

_Sepsis_ may occur from absorption through a laceration if asepsis has
not been maintained: it may lead to an attack of pelvic cellulitis or
even septicæmia.

If the uterus is fixed or not freely mobile, and the condition is
complicated by any tubal or ovarian disease, great care must be
exercised in manipulation.

=Gradual dilatation= by tents. There are three varieties of
tents--sponge, laminaria, and tupelo.

Sponge tents should never be used, for they are extremely difficult to
render sterile.

The commonest and the safest to use, because they can be most easily
sterilized, are laminaria tents, made from sea-tangle (_Laminaria
digitata_). These are cylindrical rods, which expand evenly, from
imbibition of moisture. Tupelo tents are larger than laminaria and
expand more rapidly.

To use tents that are not absolutely sterile is to court disaster, and
in former times they were responsible for many fatalities from sepsis.
The best way to keep laminaria and tupelo tents is in a solution of 1 in
1,000 corrosive sublimate in absolute alcohol. They may be kept in this
for an indefinite period, and so are always ready for use.

=Contra-indications.= All septic states of the uterus and cervix, for
the retention of pent-up discharges is very likely to lead to local or
general infection. Tents should never be used then in such conditions as
carcinoma of the body of the uterus, sloughing polypus, acute
endometritis and cervicitis.

=Method of introduction of a tent.= The patient is placed in the lateral
or lithotomy position and a vaginal douche given. A Sims’s speculum is
passed and the cervix seized and drawn down with a volsella so as to
straighten the cervical canal. The direction and length of the uterine
cavity is ascertained by passing the sound. The most suitable size of
tent is now selected, and, being held in a special form of tent
introducer or suitable pair of forceps, is passed into the cervical
canal, well past the internal os uteri. The end should project slightly
into the vagina. The vagina should then be douched again and lightly
packed with sterilized gauze. The patient must remain in bed.

The tent should be left in position for twelve to fifteen hours, when it
will have exerted its full action. The action of tents is twofold: it
causes (1) dilatation, and (2) softening of the cervix, the softening
being accompanied by an abundant secretion of mucus from the cervical
glands.

=Method of removal.= Tents are removed by traction on the silk thread
attached to the vaginal end. The part of the cervical canal which exerts
the greatest resistance to the dilating action is the internal os uteri,
and after the tent has been removed a well-marked constriction is always
to be seen at this point. If there is much resistance to removal by
reason of the tent being gripped at the internal os, it should be taken
in a pair of forceps and gently pulled and levered out.


OPERATIONS FOR HYPERTROPHY OF THE CERVIX

This is a congenital condition and there is no thickening of the mucous
membrane and underlying tissues; hence the diameter of the cervix is not
increased. The operation best adapted for the treatment of this
condition is the wedge-shaped incision, recommended by Marckwald (Fig.
62).

=Operation.= The cervix is split bilaterally into an anterior and
posterior portion by means of scissors, and out of each portion is
excised a wedge-shaped piece of tissue, leaving a deep groove. The
sutures are passed as in Fig. 62, and the raw surfaces are brought
together.

_Circular amputation_, as carried out by Hegar, is more suitable for
supravaginal elongation of the cervix, the result of prolapsus uteri.

The patient is anæsthetized and placed in the lithotomy position and the
cervix is pulled down by a volsella and amputated transversely by a
knife or scissors. A certain amount of retraction of the stump takes
place, producing an inversion of the vaginal wall. The raw surface
remaining must be covered by uniting the vaginal and cervical mucous
membranes. Sutures are passed in the following manner: a short stout,
straight needle, threaded with a loop of silk, is passed from the
vaginal mucous membrane, across and beneath the raw surface of the
stump, and emerges on the mucous membrane of the cervix (Fig. 63). From
eight to ten of these sutures are passed at regular intervals and tied.
The sutures are removed on the tenth day and the patient should be kept
in bed for fourteen days.

[Illustration: FIG. 62. MARCKWALD’S OPERATION FOR CONGENITAL HYPERTROPHY
OF THE CERVIX. The wedge-shaped portions have been excised and the
sutures passed but not tied.

  _a,p._ Anterior and posterior lip of cervix before exsection.
  _e.o.u._ External os uteri.
  _i.o.u._ Internal os uteri.
  _s,s'._ Sutures.
]

[Illustration: FIG. 63. HEGAR’S OPERATION FOR SUPRAVAGINAL ELONGATION OF
CERVIX. The cervix has been removed and four sutures passed but not
tied.

  _c.m.m._ Cervical mucous membrane.
  _s._ One of the sutures.
  _sp._ Speculum.
  _v.m.m._ Vaginal mucous membrane.
]


TRACHELORRHAPHY.

=Indications.= This operation is performed for the repair of certain
forms of laceration of the cervix. It was formerly practised in every
case in which a laceration occurred: it is now only permissible in cases
in which there is extroversion of the mucous membrane with certain
symptoms, such as hæmorrhage or free leucorrhœal discharge accompanied
by backache on exertion and general ill health. It was formerly
considered that there was a direct relation between cervical laceration
and cancer, but further inquiry has failed to corroborate this view.

The instruments required are: a Sims’s or Auvard’s speculum;
long-handled, angular-bladed knives (right and left); Emmett’s scissors
(right and left) (Fig. 64); toothed dissecting forceps; short stout
needles with sharp triangular points, straight or very slightly curved.

=Operation.= As it is usually found that subinvolution is present and
kept up by the laceration, it is best to perform a preliminary curettage
(see p. 154) before proceeding to the operation proper.

[Illustration: FIG. 64. EMMETT’S SCISSORS (LEFT) FOR TRACHELORRHAPHY.]

The patient is placed in the lithotomy position and an Auvard’s speculum
is inserted. A piece of stout silver wire or a tenaculum is passed
deeply through the anterior and posterior lips of the cervix; steady
traction can be made through these and the uterus kept fixed while
denudation and suturing are carried out. Should marked extroversion be
present, with hypertrophy of the cervical glands, the curette should be
freely applied to the diseased surface.

The uterine sound is passed to mark the situation of the internal os
uteri, and an antero-posterior linear piece of lining membrane, about a
quarter of an inch in breadth, must be allowed to remain untouched. This
is necessary to prevent total occlusion of the cervical canal when the
denuded flaps are sutured (Fig. 65).

_Denudation._ The right half of the anterior and posterior lips of the
cervix (upper and lower from the operator’s point of view) are first
pared by means of the angular knives and scissors, great care being
taken to see that the deep angle of the reflexion is not overlooked. The
other side is then treated in a similar manner. The tissues will be
found extremely hard and resistant, especially if there be much
cicatrization about the angle of the laceration.

_The passage of the sutures_ (Fig. 65). The short stout,
triangular-pointed needle is first doubly threaded with silk or stout
chromicized catgut so that a loop of three to four inches in length is
produced. The needle and the silk suture are passed as in Fig. 65, two
on either side.

[Illustration: FIG. 65. TRACHELORRHAPHY. The patient is in the lithotomy
position. The left half of the cervix has been denuded and two sutures,
_a_, _a'_ and _b_, _b'_, passed. The right half is intact, but the
method of passing the needle _n_ is indicated.

  _ant._ Anterior lip of cervix.
  _post._ Posterior lip of cervix.
  _t,t._ Tenacula.
  _o.u.i._ Os uteri internum.
  _sp._ Speculum.
  _w._ Wire.
]

The triangular-pointed needle must be held in Schauta’s specially strong
holder (Fig. 73), and should be made to pierce the cervix near the raw
surface on one lip, and pushed through the tissues immediately below
this to emerge on the strip of unpared cervix already mentioned. It is
then carried across the sulcus and is made to emerge through the
opposite lip of the cervix. A stout wire is now hooked into the loop and
pulled through the needle track. When the two wire sutures are inserted
on either side, the flaps are brought together and the wires twisted
together.

=Results.= Primary union is the rule, and the wire sutures may be
removed at the end of the tenth or twelfth day. The cervix has the
appearance observed in the nullipara, and may lead to complications in
any ensuing labour from difficulty of dilatation.

Dührssen modifies Emmett’s operation by a flap-splitting procedure
which, however, does not appear to possess sufficient advantages to
warrant its general introduction.


VAGINAL FIXATION (Hysteropexy)

This operation consists in the fixation of the retroverted fundus uteri
in an anteverted position, by suturing it to the anterior vaginal
cul-de-sac.

=Indications.= These are somewhat uncertain, and the field of utility of
the operation is rapidly becoming more limited. Advocates of this
procedure recommend it for backward displacement of the uterus with or
without adhesions. It is considered specially applicable to cases in
which slight retroversion is complicated by moderate prolapsus. The
results which have so far obtained do not appear to be so good as those
resulting from the use of a well-fitting pessary.

=Operation.= The technique recommended by Dührssen appears to be the
most satisfactory, and is as follows: The patient is anæsthetized and
placed in the dorsal position with the knees supported by a Clover’s
crutch. After purification of the parts (see p. 126) the cervix is
pulled down as far as possible by means of a volsella: a curettage is
then carried out as a preliminary measure (see p. 154). If cervical
hypertrophy is present, amputation by Marckwald’s method (see p. 160)
should be performed, as an elongated cervix acts as a preventive to
satisfactory anteversion of the uterus. A transverse or T-shaped
incision is now made as in vaginal hysterectomy (see p. 169), and the
cellular tissue pushed up by the index-finger until the peritoneum is
reached. The peritoneum is now seized with a volsella and cut through,
and the edges sutured to the lips of the vaginal wound. The uterine
fundus is then anteverted by means of a sound: by pressing the handle of
the instrument towards the perineum the fundus is brought into the
wound. By means of a rectangular curved needle a stout silk suture is
passed through the anterior wall of the fundus as high up as possible:
the vaginal flaps are not included, as the suture is to be used for
traction only. The uterus is now forcibly pulled down and two other
sutures are introduced in the same manner higher up. Three sutures of
catgut are passed through the uterine wall, including the vaginal and
peritoneal flaps. The silk traction sutures are now withdrawn and the
permanent ones tied. The vaginal wound is carefully sutured by means of
fine silk.

=Difficulties and dangers.= The risks of the operation are peritonitis
and wounding of one or both ureters or the bladder wall. Absolute rest
for fourteen days is necessary and no local after-treatment is called
for.




CHAPTER XVI

OPERATIONS FOR NEW GROWTHS OF THE UTERUS


Uterine growths include primary malignant disease and fibro-myomata; the
former should be treated by exploration and subsequent vaginal
hysterectomy (see p. 168), while the latter should be dealt with
according to their relations and attachments to the uterine wall.

[Illustration: FIG. 66. PEDUNCULATED FIBROID POLYPI IN VARIOUS STAGES OF
EXTRUSION. (_From drawings made at time of operation._)]


OPERATIONS FOR UTERINE FIBRO-MYOMATA

Fibro-myomata may present themselves to the operator in one of the
following forms:--

1. As a fibroid polypus still intra-uterine or presenting through a
naturally dilated and thinned-out cervix (submucous pedunculated).

2. As sessile growths presenting by their lower segments at the os
uteri, which may be closed, or may be in varying degrees of dilatation
(submucous sessile).

3. As tumours incorporated in the uterine wall (interstitial).

=Operations for pedunculated tumours.= _If a fibroid polypus be still
intra-uterine_ (Fig. 66) the proper treatment is to dilate the cervix
(see p. 156), and, if the pedicle be sufficiently thin, to seize the
growth with a pair of stout polypus forceps and twist it off by a slow
rotary movement of the handles. Should the pedicle be thicker than the
finger, the use of the wire écraseur is advisable. This is a scientific
snare, with a loop of pianoforte wire and a handle or wheel by which it
can gradually be tightened, causing the wire to slowly cut through the
stalk of the growth (Fig. 67).

[Illustration: FIG. 67. WIRE ÉCRASEUR.]

The cervix is steadied with a volsella and the loop of the écraseur is
shaped and bent to the size and position of the fibroid. The instrument
is then passed into the uterine cavity and the noose pushed over the
tumour up along the pedicle. The wire loop is then tightened up by means
of the handle or wheel, and the wire cuts its way through and separates
the growth from the uterine wall. It is somewhat dangerous to put any
traction on the tumour before its separation, as is recommended by some
writers, as the uterine wall itself may become somewhat inverted and the
wire loop may cut through into the peritoneal cavity.

_If the fibroid polypus has passed through the external os uteri_,
treatment is more simple. Slight traction may be made upon it by means
of forceps, and the pedicle severed with scissors; no hæmorrhage takes
place, owing to the retraction of the stump.

=Operations for sessile tumours.= In submucous sessile fibroids (Fig.
68) in which the lower segment of the uterus is somewhat thinned out and
dilated, operative interference may be as follows: Preliminary
dilatation of the cervix by bougies may be necessary. The capsule of the
tumour is then incised with a sickle-shaped knife and the growth is
enucleated by means of the finger or a blunt spoon. In some cases mere
incision of the capsule is sufficient, and the uterus expels the growth
later on.

Another method of treating these cases is by the operation of
_morcellement_, which consists in removing the tumour piecemeal by means
of specially made forceps.

The instrument used by the author consists of a strong pair of forceps
somewhat like those used in lithotomy, with the two distal ends notched
with sharp teeth like a volsella. A portion of the tumour is seized
between these two blades, and partly cut and partly twisted off. With
patience and care the whole tumour may be thus removed. In one case the
author was enabled to remove two large growths, each filling a pint
measure. This operation is specially suitable in women in whom an
abdominal operation is to be avoided.

=Operations for interstitial tumours.= Interstitial fibroid tumours, if
not above the size of a small fœtal head, should be treated by vaginal
hysterectomy (_vide infra_); if large, by hysterectomy by the abdominal
route (see p. 36).

[Illustration: FIG. 68. SUBMUCOUS FIBRO-MYOMATA, CAPABLE OF TREATMENT BY
MORCELLEMENT. (_From drawings made at time of operation._)]

=Vaginal hysterectomy.= By vaginal hysterectomy is meant removal of the
whole uterus by the vagina, with or without the appendages. The
advantages that the vaginal operation possesses over abdominal
hysterectomy are, there is less disturbance of peritoneum and
intestines, less shock, and no abdominal scar or risk of subsequent
hernia. The operation is limited to uteri not exceeding in size the head
of a full-time fœtus.

=Indications.= (i) Malignant disease of the uterus (fundus or cervix) in
an early stage: chorio-epithelioma malignum.

(ii) Certain cases of fibro-myoma of the uterus.

(iii) Certain cases of inflammatory disease of the uterine appendages
complicated by recurrent attacks of local perimetritis.

(iv) Other conditions, such as intractable uterine hæmorrhage, usually
due to uterine myo-fibrosis, and, as a last resort, severe
dysmenorrhœa.

It has also been advised for irreducible chronic inversion of the
uterus, and for severe procidentia uteri. No case of the former has
occurred in the author’s experience in which the operation was found
necessary. In the latter condition the operation is not to be
recommended, the almost certain result of the procedure being prolapse
of the vaginal walls and the intestines (enterocele).

=Vaginal hysterectomy for carcinoma.= The only cases suitable for
operation are early ones, in which the disease is still confined to the
uterus itself, which should be freely mobile in all directions. No signs
of infection of the surrounding cellular tissue and vaginal walls should
be present. It cannot be too strongly insisted that all cases should be
thoroughly examined under anæsthesia to settle this point before
operation is decided upon. Rectal examination is most important to
estimate the condition of the sacro-uterine ligaments, the cervix being
pulled down so as to place them on the stretch.

Occasionally, cases of carcinoma of the cervix are seen, in which the
cellular tissue immediately surrounding the cervix is apparently free
from disease, but if search be made further outwards, a hard, fixed mass
is found plastered, as it were, on to the side of the pelvis, indicating
advanced disease of the lymphatic glands, or cellular tissue at the
outer part of the broad ligaments. Such cases are hopeless for
operation.

If the disease is in the sloughing stage, and there is foul discharge,
Paquelin’s cautery should be applied to the diseased surface, followed
by vaginal douches of formalin (ʒj to the pint), or some other efficient
antiseptic, given three times a day for three days prior to operation.
The operation consists of three main stages:--

  (_a_) Separation of the cervix from the vagina, pushing up of the
      bladder and ureters, and opening the anterior and posterior
      peritoneal pouches.

  (_b_) Removal of the uterus by ligaturing and dividing the broad
      ligaments.

  (_c_) Treatment of the peritoneal and vaginal flaps thus left.

First of all, the growth, if of the cervix, should receive careful
preliminary attention, for it constitutes a continuous source of
infection, not only by means of septic organisms, but also of cancer
cells, which may become implanted in the wound and cause early
recurrence. The cervix is drawn down with a volsella and all visible
growth is burnt away with the Paquelin cautery, until apparently healthy
tissue only is left. The cervix is then completely closed by the
application of a volsella or three or four stout silk sutures, passing
through both anterior and posterior lips. The ends of the sutures may be
left long if preferred and serve as tractors.

After these preliminary measures against infection have been completed,
the removal of the uterus is proceeded with. A posterior speculum,
Auvard’s or Pozzi’s, is passed, and the cervix is drawn downwards and
somewhat backwards by traction on the volsellum or the long ends of the
silk sutures. A sound is passed into the bladder to define its lower
limit. A transverse or T-shaped incision (Fig. 48) is now made through
the vagina at the level of the cervico-vaginal junction in front. This
constitutes the anterior incision, and the transverse portion should
extend completely across the anterior aspect of the cervix, passing
through the whole thickness of the vagina, but no further.

[Illustration: FIG. 69. GALABIN’S BROAD-LIGAMENT NEEDLE (RIGHT).]

[Illustration: FIG. 70. JESSETT’S BROAD-LIGAMENT NEEDLE.]

The knife is now laid aside, and the operator proceeds to push up the
vagina and bladder from the anterior aspect of the cervix with the
index-finger or a winged director, until the anterior peritoneal pouch
is reached. This is at once recognized by its glistening white
appearance and by the manner in which its opposing surfaces glide over
one another.

This part of the operation must be conducted very cautiously for fear of
injury to the bladder: the pulp of the finger only must be used in the
separation. The frequent use of the bladder sound is very useful at this
stage, as it is quite easy to wound this viscus laterally. Bleeding from
the divided twigs of the vaginal vessels often obscures the field of
operation and renders the separation of the bladder troublesome: it well
repays the operator to stop all bleeding after making the vaginal
incision.

The peritoneum is next picked up and opened with scissors. The anterior
fold of peritoneum may sometimes be more easily reached after the bases
of the broad ligaments have been ligatured and divided, thus allowing
the uterus to be drawn down more readily, and making the peritoneum more
accessible. An anterior retractor is then passed to keep the bladder out
of the way.

[Illustration: FIG. 71. VAGINAL HYSTERECTOMY. The patient is in the
lithotomy position, the vaginal incisions have been made and the
peritoneal cavity opened. The left broad ligament is exposed, and a
Galabin’s needle threaded with silk is being passed from before
backwards on to the index-finger of the operator’s left hand inserted
into the peritoneal cavity. (_Semi-diagrammatic, from a photograph._)

  _a, a_{1}, a_{11}_. Retractors.
  _c._ Cervix.
  _p._ Supravaginal cervix denuded of its coverings.
  _ut._ Uterine artery.
  _b.lig._ Broad ligament.
  _n._ Galabin’s needle.
  _v._ Volsella.
]

A second incision similar to the first is now made across the posterior
aspect of the cervix at the level of the cervico-vaginal junction, more
or less cellular tissue is traversed, and the posterior peritoneal pouch
is opened. By joining the ends of these two incisions the cervix is
completely separated from the vagina.

The uterus is now suspended in the pelvis by the attachments of the
broad ligaments only; the next step consists in ligaturing and dividing
these. The cervix is drawn over towards the patient’s right side by an
assistant, so as to expose the base of the left broad ligament.
Additional space is gained by drawing aside the left wall of the vagina
by means of a retractor. By passing the left index-finger behind the
broad ligament the tube and ovary can be easily felt, and if necessary
the bent finger can pull them down for inspection; the finger is then
placed beside the cervix below and behind the base of the broad
ligament. A Galabin’s or Jessett’s (Fig. 70) needle, carrying a stout
silk suture, is passed through the ligament from before backwards, on to
the tip of the finger (Fig. 71).

[Illustration: FIG. 72. VAGINAL HYSTERECTOMY. _Final stage._ The uterus
has been removed, and the peritoneal flaps are in process of suture.

  _a, a_{1}, a_{11}, a_{111}._ Retractors.
  _f, f'._ Spencer Wells forceps attached to the anterior
       and posterior vaginal flaps.
  _p._ Circular orifice left open in the peritoneal flaps
       for insertion of gauze drain.
  _sp._ Stump of left broad ligament with bundle of
       ligatures (_l_).
  _cl._ Clitoris.
  _l.m._ Labium majus.
  _u._ Urethra.
]

The ligature should be passed about one-third of an inch up the broad
ligament. It is then tied tightly and the ends left long and drawn
aside. The segment of broad ligament included in the ligature is divided
as near the uterus as is justifiable; in carcinoma of the cervix at
least half an inch from the disease should be allowed. Care must be
taken at this stage to avoid injury to the ureters; these lie about one
inch distant from the cervix; consequently all ligatures must be passed
as near the cervix as possible compatible with being clear of the
disease.

A second ligature is now passed through the broad ligament above the
first and then a third, and more if necessary. The second generally
includes the uterine artery, which can always be recognized by its
strong pulsation under the finger; the third ligature will control the
Fallopian and ovarian arteries. After the arteries on the left side have
been secured and divided, attention is directed to the right broad
ligament. The cervix is drawn over to the left side, the fundus
delivered, and the upper portion of the right broad ligament is dealt
with in a similar manner, but from above downwards. If the ovaries and
tubes are diseased, they can now be removed by piercing the pedicle and
tying the stump in the usual way.

[Illustration: FIG. 73. SCHAUTA’S NEEDLE-HOLDER.]

The uterus having been extirpated, the next step consists in dealing
with the wound. First, all bleeding is stopped, and the wound is swabbed
clean and dry. The ligatures on either side are tied in two bunches and
the ends cut off just within the vagina (Fig. 72). The anterior and
posterior flaps of peritoneum are united with a few catgut sutures
passed by means of Schauta’s needle-holder (Fig. 73); the walls of the
vaginal vault are treated in a similar fashion, leaving a circular
orifice in the median line into which gauze can be inserted for the
purpose of drainage.

Some operators prefer to control the vessels in the broad ligaments by
means of hæmostatic forceps instead of ligatures. Each broad ligament is
clamped in three or more portions and the tissue between them and the
uterus cut through. They must be allowed to remain in position for at
least forty-eight hours, as recurrent hæmorrhage is possible if they are
removed earlier. The only advantages of the forceps appear to be the
rapidity with which the operation can be carried out, and the good
drainage. The disadvantages are, that it is a somewhat unsurgical
proceeding; there is often much pain from the nipping of the broad
ligaments, and inconvenience from the presence of the handles between
the labia; the intestines may be damaged; sloughing and risk of sepsis
must be reckoned with.

=After-treatment.= The catheter should be used at first four times
daily; the author recommends that the gauze should be removed at the end
of twenty-four hours, but some operators retain it longer. The ligatures
should be pulled upon a little daily after the seventh day, and they
gradually cut their way through the tissues in their grasp. No vaginal
douching should be administered until after the expiration of a week.

=Vaginal hysterectomy for fibroids.= This is not often called for. The
operation is necessarily limited to fibroid uteri not exceeding in size
a fœtal head. Uterine fibroids of such a size can usually be treated in
other ways, either temporarily by curetting, or, if submucous,
permanently by enucleation through the vagina. The operation is most
suitable for uteri containing many small fibroids causing severe
hæmorrhage which cannot be controlled by more palliative measures.

The vagina must be large enough to admit of delivery of the uterus
through its lumen. Therefore, in virgins and nulliparæ, the abdominal
operation is always to be preferred. In any case, if the vagina be too
narrow, additional room may be gained by lateral vaginal section (see p.
148) or episiotomy.

The operation does not differ in technique from the removal of the
uterus for carcinoma, already described. In some cases it may be
preferable to bisect the uterus in the sagittal plane before removing
it, after the cervico-vaginal attachments have been separated and the
peritoneal pouches opened.




                        SECTION II

                  OPHTHALMIC OPERATIONS

                            BY

               M. S. MAYOU, F.R.C.S. (Eng.)

  Assistant Surgeon, Central London Ophthalmic Hospital;
    Surgeon, The Children’s Hospital, Paddington Green




CHAPTER I

GENERAL CONSIDERATIONS APPLICABLE TO OPERATIONS UPON THE EYE


Operations upon the eye differ so widely from general surgical
operations that it is necessary to say something of the preparations for
them before passing on to their actual performance. Although not
formidable in themselves, they require great accuracy and presence of
mind; slight mistakes, such as too small an incision, may cost the
patient his sight, which sometimes may be almost more important than
life itself.

Most intra-ocular operations are performed without general anæsthesia;
it is therefore important that the patient should be given confidence by
talking to him during the operation, so that he may follow the
instructions of the surgeon during its performance; loss of self-control
on the part of the patient, movement of the head, screwing up of the
eyes, &c., may lead to disastrous results, however well performed the
operation itself may be.


GENERAL PRELIMINARIES TO AN OPERATION

_The urine_ should always be examined, especially in cases of cataract,
as not infrequently this disease is associated with diabetes, and it is
often advisable to treat the general condition before operation.

_The bowels_ should be opened by an aperient the night before the
operation, as it is desirable to keep them confined for the first two
days afterwards, so as to avoid straining. During the first week after a
major operation, when the patient is confined to bed, they should be
evacuated in the supine position.

_The best time_ for operating, if possible, is the morning, as the
patient has had a night’s rest and is less likely to lose self-control.
Usually there is some pain after the cocaine has gone off, and the
patient is better able to stand it during the daytime.

_Anæsthetics._ _General_ anæsthesia should be induced in all patients
with congested eyes, in small children, patients who are deaf, and those
who show a want of self-control. Chloroform should be used for all
intra-ocular operations, and should be given to the full surgical
degree. It should be given on a towel or an inverted mask specially made
for the purpose, a Junker’s inhaler being used during the time the
actual operation is being performed. As the surgeon usually stands at
the head of the patient, the anæsthetist should stand on the side away
from the eye being operated on. The local use of cocaine in addition to
general anæsthesia is indicated when operating on patients to whom it is
advisable to give as little anæsthetic as possible.

[Illustration: FIG. 74. WINDOW OF THE OPERATING THEATRE, KING’S COLLEGE
HOSPITAL. The windows are fitted with outside blinds so that either can
be used separately, or the surgeon may stand in the angle and operate
with his back to the light. A recess beneath the window allows the
patient’s face to be brought close to the light on dark days.]

_Local_ anæsthesia is obtained by the use of a 4% solution of cocaine
instilled four or five times before the operation at intervals of three
minutes; a drop of the solution should also be instilled into the eye
which is not being operated on, to prevent an accidental reflex
stimulation of the conjunctiva and screwing up of the eyes. Adrenalin
(1-1,000) may be used in conjunction with the cocaine; it is especially
useful in squint operations, as it lessens the hæmorrhage. Eucaine and
stovaine have been used, but are not nearly so satisfactory. Under
ordinary circumstances the only pain felt during an intra-ocular
operation is during removal of the iris; this is obviated to a great
extent by instilling the cocaine at least 15 minutes before the
operation is performed, so as to allow time for its diffusion into the
anterior chamber. The patient should be warned when to expect the pain,
so that he may not move; his self-control may be tested beforehand by
pricking the nose with a pin.

_The theatre._ The theatre should possess, as far as possible, all the
modern improvements found in an up-to-date general surgical
operating-room. The light should proceed from a single large window,
which, if possible, should face the north. _The window_ should consist
of a single pane of glass or of two panes forming the angle of the
theatre; it should begin about 5 feet from the floor and should extend
to the ceiling (Fig. 74). The advantage of an angular window is that it
allows the operator to stand with his back to the light in the angle,
and so enables onlookers to see. No top light should be allowed, as it
produces a corneal reflection which may prevent the operator from seeing
the position of his knife in the anterior chamber. Beneath the window
there should be a recess for the end of the operating table, so that the
patient’s face can be brought close to the window if necessary (Fig.
74). This recess is formed by building the main wall of the theatre
further out than the window, which has to be supported by a transverse
girder.

[Illustration: FIG. 75. BULL’S-EYE ELECTRIC HAND-LAMP. For use when
artificial illumination is required.]

The window should be fitted with outside blinds so that the theatre can
be easily darkened for the operations, such as capsulotomy, which
require the use of artificial light. The best artificial light is a
small enclosed electric hand-lamp fitted with a bull’s-eye, by means of
which the operation field can be brilliantly illuminated while the
surrounding area is left in comparative darkness (Fig. 75). Failing
this, a single powerful lamp with a ground-glass globe, placed in front
of the patient, will serve, the rays of light being brought to a focus
on the eye by means of a large convex lens of about + 10 D.

For _squint operations_ it is desirable to have a light fixed to the
ceiling, directly over the head of the operating table, for testing the
position of the eyes either by the reflection of the light from the
surface of the cornea or by the Maddox rod test.

_The operating table_ should be provided with a means of adjusting its
height and the position of the head-piece, so that the patient’s head
can be brought to about the level of the operator’s elbows when the
latter is standing upright with his arms at his side.

_After operation_ the patient should be warned to lie still and not to
strain in any way; he should be carried to bed and should lie on his
back if possible. If a patient cannot sleep on his back it is better
that he should lie on the sound side than be without rest. A length of
bandage should be fastened round the wrist of the hand on the same side
as the eye which has been operated upon, and should be attached to the
bed so as to prevent the hand being put up to the eye during sleep.
After major operations, such as those for cataract and glaucoma, the
patient is confined to bed for ten days, during the first four of which
the head should not be raised from the pillow, the bowels being
evacuated while the patient is in the supine position; but old patients
with a tendency to bronchitis or hypostatic pneumonia must be propped up
in bed and allowed to get up earlier: in these patients it is better to
perform the operation in the summer if possible. In old people and
patients with a tendency to melancholia the mental condition must be
carefully watched, as frequently they cannot stand the confinement to
bed and darkness.


LOCAL PREPARATION OF THE PATIENT

When operating upon the eye, a surgeon has to face the great difficulty
that he is operating in an area which is not always aseptic, since it is
practically impossible to render the conjunctival sac sterile. At the
same time, the conjunctiva has been shown to be sterile in health in 25%
of cases, pyogenic organisms (principally the staphylococcus albus)
being found only in 15%; but, although these are usually not of a very
virulent character, they are by far the most frequent cause of sepsis;
ten cases of suppuration after operation which the author has examined
were all due to this organism. After the methods of purification given
below, this percentage is considerably reduced, so that, if due
precautions are taken, the risk of sepsis is comparatively small. On
the other hand, if conjunctivitis or lachrymal obstruction be present,
the risks are enormously increased, especially in the latter condition
owing to the frequent presence of the pneumococcus in the discharge,
unless special precautions are taken. It is, therefore, of the utmost
importance that every case should be examined for lachrymal obstruction
before operation. Care should be taken also to see that there is no
purulent discharge from the nose or any septic sores about the face.

Sepsis after intra-ocular operations manifests itself in one of two
forms: either by suppuration, which usually ends in a rapid and complete
destruction of the eye (panophthalmitis), or more rarely in less
virulent cases by recurrent attacks of hypopyon associated with acute
irido-cyclitis; or by a plastic irido-cyclitis, which may lead to slow
disorganization of the eye, with always the possibility of destruction
of the other eye by sympathetic cyclitis (sympathetic ophthalmia).
Although these conditions are comparatively rare, owing to the
improvement in modern aseptic and antiseptic methods, every surgeon of
experience will meet with these disastrous complications; indeed it has
been suggested that immunization with staphylococcus vaccine should be
carried out before major intra-ocular operations, since infection is
generally due to this organism.

[Illustration: FIG. 76. LANG’S EYE SPECULUM. Designed to hold the lashes
away from the field of operation.]

_The methods of purifying the eye before operation._ On the second night
previous to the operation the eye should be bandaged and examined the
following morning for conjunctival discharge. If any be present, an
examination for organisms should be made, and the operation postponed
until the conjunctival condition has improved. In the event of the case
being extremely urgent, the conjunctiva should be swabbed over with
nitrate of silver (10 gr. to the oz.) immediately before the operation;
some surgeons prefer 1-2,000 perchloride of mercury. If lachrymal
obstruction be present, the sac should be thoroughly washed out with
boric lotion and protargol (10%) injected. The canaliculi may be
temporarily occluded subsequently (see p. 294). If the lashes be very
long they should be cut short. Epilation is performed by some
Continental surgeons, but is not practised in this country. Various
forms of specula are made to keep the lashes out of the field of
operation; of these, a modification of Lang’s is perhaps the best (Fig.
76).

On the morning of the operation the lids should be thoroughly cleansed
with soap and water, followed by 1-2,000 solution of perchloride of
mercury, special attention being paid to the lid margins and lashes. The
conjunctival sac should be washed out with boric lotion and a pad of
cyanide gauze applied over the closed lid.


GENERAL CONSIDERATIONS AS TO MAKING AND HEALING OF WOUNDS IN THE GLOBE

It has already been pointed out that the great danger in intra-ocular
operations is sepsis. It is the aim and object of every ophthalmic
surgeon to make such wounds into the globe as will become rapidly shut
off from the conjunctival sac. Delay in the healing tends to the
formation of a fistulous opening into the globe. This aperture in the
continuity of the globe may lead either directly on to the surface or
beneath the conjunctiva, subsequent inflammation in which may spread to
the interior of the eye.

[Illustration: FIG. 77. UNDINE FOR WASHING OUT THE CONJUNCTIVAL SAC.]

_Cocaine_ and other solutions used at the time and subsequently to
operation should be sterilized. To ensure this the solutions should
either be boiled immediately before use, or put up in drop bottles made
in one piece with a long tapering neck, which is sealed off, and can be
broken immediately before use. These bottles can be kept in an aseptic
solution so as not to soil the hands of the surgeon.

_The hands_ of the surgeon are purified. After the dressings have been
removed, the patient’s head and the area surrounding the operation are
covered with sterilized towels. In operations such as advancement, where
sutures are used, it is desirable that the face should be covered with
sterile muslin, with a hole cut in it for the eye, so as to prevent the
sutures being contaminated from the skin of the face. The eyelids are
again washed in 1-2,000 perchloride of mercury lotion, and the
conjunctival sac is washed out with a strong stream of boric lotion or
normal saline by means of a sterilized irrigator or an undine (Fig. 77)
which has been kept in a bowl of lotion.

_Instruments._ Non-cutting instruments are boiled for 15 minutes in
distilled water and placed in a tray of 1-80 carbolic lotion. Some
surgeons prefer to place the instruments in the tray without lotion on
sterile wet lint, as this excludes infection from the surgeon’s hands
due to the lotion running off them on to the instrument. Failing
distilled water, a small quantity of soda may be added to the water used
for boiling, but this has the disadvantage that a deposit is liable to
form on the instruments. This may be obviated to a certain extent by not
placing them in the solution until it is boiling. Cutting instruments
should be sterilized by dipping them in liquefied carbolic acid
(crystals dissolved by heating with 10% of water) for half a minute
immediately prior to use and then into absolute alcohol to remove the
acid; they are then placed in the tray. The greatest care should be
taken to see that cutting instruments and needles do not touch the side
of the dish. The edges and points should always be carefully tested
immediately before sterilization on a drum covered with fine kid
specially made for the purpose. The points should pass through the drum
by the weight of the instrument held flat on the open palm; the cutting
edge should also be tested. Scissors are best tested by cutting wet
cigarette paper, special care being taken to see that the edges are good
near the points. Immediately after operation the instruments should be
boiled, and dried whilst hot in order to prevent rust.

[Illustration: FIG. 78. CATARACT EXTRACTION. The drawing shows the line
of incision. Note the conjunctival flap.]

_The direction of an incision_ into the globe should be as oblique as is
consistent with the object of the operation, so as to allow larger
healing surfaces to come into apposition. With this object in view it is
desirable that a conjunctival flap should be formed to all wounds
wherever possible (Fig. 78). Further, owing to the extreme vascularity
of the conjunctiva, as has been shown elsewhere,[3] wounds in it become
firmly united after 48 hours. As a rule sutures are best avoided and are
seldom required.

[3] Mayou, _Hunterian Lectures_, 1905.

_Position of the incisions._ Corneal incisions are to be avoided, if
possible, for the following reasons: firstly, the cornea being free from
blood-vessels heals comparatively slowly; secondly, the wound is liable
to become fistulous owing to the rapidity with which the epithelium
grows down the side of the wound. On the other hand, incisions situated
from 3 to 6 millimetres behind the limbus are liable to injure the
ciliary body, and, in addition to irido-cyclitis being set up by the
trauma, the iris or ciliary body will prolapse into the wound and
prevent the union of its edges, with the result that sepsis may spread
into the globe along the prolapsed portion of the uveal tract and set up
an irido-cyclitis which may not only ruin the eye affected but may also
cause a sympathetic irido-cyclitis in the other eye (Fig. 79).

[Illustration: FIG. 79. SYMPATHETIC OPHTHALMIA. The exciting eye of a
case following cataract extraction. The section shows the incarceration
of the iris in the wound.]

[Illustration: FIG. 80. CYSTOID SCAR AFTER GLAUCOMA IRIDECT]

_The site of election of an incision_ into the anterior part of the
globe is therefore about 1 millimetre behind the limbus; that is to say,
as near the cornea as is consistent with obtaining a good conjunctival
flap to cover the wound in the globe (Fig. 78). When possible it is
advisable to make all incisions in an upward direction for the following
reasons: They are more easily performed; any deformities, such as an
iridectomy, are hidden by the upper lid; more perfect rest is obtained,
as the wound is not exposed in the palpebral aperture, the eye being
turned upwards when the lids are closed.

[Illustration: FIG. 81. AN EYE BANDAGE. The first turn, A, encircles the
head and is fixed with a pin. This portion of the bandage can be put on
before the operation and obviates movement of the head. The turn B is
then brought up below the ear and fixed with pins.]

[Illustration: FIG. 82. A PRESSURE BANDAGE. The first turn of a
1-1/2-inch bandage encircles the head. It is then carried beneath the
ear and over the head in a figure-of-eight. The final turn goes round
the head and is fixed by a pin at the point of crossing of the previous
turns.]

The immediate danger of the passage of a knife into the anterior chamber
of the eye is the wounding of the lens. To avoid this the point of the
knife should be always kept superficial to the iris if a clear lens be
present in the eye. After operation the chief danger is prolapse of the
iris into the wound. This is best avoided at the time of operation by
carefully replacing the iris with the spatula at the end of the
operation, but unfortunately prolapse not infrequently occurs during the
first few days owing to the reaccumulation of the aqueous in the
anterior chamber and its sudden escape through the imperfectly healed
wound as the result of straining or of some movement on the part of the
patient; the iris may be carried into the wound with the escaping
aqueous, and a fistulous opening or a scar may form subsequently (Fig.
80).

The less manipulation used consistent with the object of the operation
the less likelihood is there of cyclitis following it. All instruments
should be held lightly in the fingers, which should be as far as
possible responsible for the fine manipulation required. The part of the
hand not actually holding the instrument should be steadied on the face
before the instrument is brought in contact with the eye.

When more than one operation has to be performed on the same eye it is
desirable that all ciliary injection after the first operation should
have disappeared before the second is undertaken.

_Dressings._ A pad of sterilized wool, with a few layers of cyanide
gauze moistened with 1-6,000 perchloride of mercury lotion next the
closed eyelid, held in position by a bandage, is all that is necessary.

_Bandaging._ The bandage is started on the forehead over the affected
eye and is carried in a direction away from the eye to be covered. A
complete turn is made to encircle the head and is fixed with a pin. The
bandage is then brought up beneath the ear and over the eye and fixed
with pins on the forehead (Fig. 81). When absolute rest is desired, it
is necessary to bandage both eyes. After intra-ocular operations this is
desirable for the first three days. When pressure is desired, a
figure-of-eight bandage should be used (Fig. 82). A useful bandage
(Moorfield’s bandage) for occlusion of both eyes is made from
stockinette, which fits closely over the eyes and nose and is fastened
with tapes.

The dressings should not be disturbed for at least 24 hours. The lids
are then cleansed with 1-6,000 perchloride of mercury lotion, and the
lower one is pulled down so as to allow the escape of tears and to see
if any discharge be present. The upper lid should not be touched. If no
discharge be present the eye is re-dressed. If discharge be present the
conjunctival sac should be washed out carefully with boric lotion. Most
wounds with conjunctival flaps are shut off in 48 hours, after which
time it is advisable to wash out the conjunctival sac twice a day with
boric lotion. Great care should be taken to see that no undue pressure
is made on the globe. The patient should be warned not to screw up the
eyes or strain whilst the dressing is being performed.




CHAPTER II

OPERATIONS UPON THE LENS


=Surgical anatomy.= The lens consists of fibres which are developed from
cells originating in an inclusion of the fœtal epiblast. A normal lens
is surrounded by a capsule, the anterior half of which is lined with a
single layer of epithelial cells on its inner surface. In fœtal life the
cells which line the posterior half of the capsule go to form the lens
fibres, so that after birth the lens capsule is lined by cells only on
its anterior surface. The lens capsule, which is deposited from the
epithelial cells lining it, consists of a highly elastic membrane; small
wounds in its continuity, therefore, gape widely. Throughout life the
cells lining the capsule continue to become new lens fibres, but at the
same time the bulk of the lens does not increase markedly. This is due
to the fact that the lens fibres become more closely packed together and
lose some of their watery constituents (sclerosis). The older central
part of the lens is the first to undergo this process, with the result
that a definite hard nucleus is found in the lenses of people about the
age of thirty to thirty-five and upwards.

[Illustration: FIG. 83. A LENS THREE WEEKS AFTER NEEDLING. The section
shows the swelling and breaking up of the lens in the anterior chamber.
The iris has become adherent to the needle puncture.]

Chemically the lens fibres are composed of crystallin, which is closely
allied to a serum globulin and is therefore soluble in salt solution.
When the lens capsule has been opened, by operation or accident, the
saline aqueous is admitted to the lens, which becomes opaque, swells up,
and is gradually absorbed (Fig. 83). In those under the age of thirty,
therefore, a simple incision into the capsule is all that is required to
cause it to be absorbed. But, as has already been pointed out, the lens
develops a hard nucleus after that age and will not then be absorbed
satisfactorily by simply opening its capsule; to remove it, as is done
in senile cataract, the hard nucleus must be extracted from the eye.

[Illustration: FIG. 84. ANATOMY OF THE ANTERIOR SEGMENT OF THE EYE.

  Cil. P. Ciliary process.
  S. Ch. Canal of Schlemm.
  L. P. Lig. pectinatum, between the fibres of which are the spaces
      of Fontana.
  Sup. C. Ly. S. Suprachoroidal lymph-space which extends
      backwards between the choroid and sclerotic.
  M. Longitudinal portion} of the ciliary muscle.
  C. M. Circular portion }
  O. Circulus arteriosus.
  S. Lig. Suspensory ligament of the lens.
  E. Epithelium covering the ciliary process.
  Pars Cil. Pars ciliariis retinæ. Pars plana of the ciliary body.
  R. The retina. } The junction of these with the pars plana is known as
  C. The choroid.}   the ora serrata.
  J. Iris.
  S.M. Sphincter muscle.
  Cry. Crypt.
  M. M. Pigment epithelium.
  S. Cornea. Substantia propria.
  B. M. Bowman’s membrane.
  D. M. Descemet’s membrane.
  A. Cap. Anterior capsule of the lens.
  C. P. Canal of Petit.
]

The lens is held in position by the suspensory ligament, which consists
of interlacing fibres attached on the one hand to the ciliary process
and on the other to the capsule at the lenticular margins (Fig. 84).
Prolapse of the vitreous after cataract extraction is prevented by the
integrity of this ligament and the posterior capsule of the lens,
together with the hyaloid membrane of the vitreous. The tension on the
fibres of the suspensory ligament, in addition to keeping the lens in
its place, also exercises traction on the lens capsule. In dislocated
lenses there is a gap in the suspensory ligament either as the result of
injury or of congenital malformation; when such cases require operation
there is some difficulty in producing a sufficient gap in the capsule to
promote their absorption, owing to the mobility of the lens and the want
of traction on the incision in the capsule.


DISCISSION OR NEEDLING

Discission of the lens has for its object the tearing open of the
anterior capsule, so that the lens substance may be broken up and
absorbed.

=Indications.= This operation will be required:

(i) =For cataract in patients under the age of about thirty.= The forms
of cataract for which these operations are usually performed are: (i)
_complete congenital cataract_, in which the whole lens is opaque and
consists of little more than a shrunken capsule which may have to be
extracted if discission is unsuccessful; (ii) _lamellar cataract_, of
sufficient density to interfere seriously with vision; (iii) _posterior
polar cataract_ in rare instances; (iv) _traumatic cataract_, to
complete the absorption of the lens by breaking up its fibres.

Before operating on any form of cataract the following facts must be
ascertained as far as possible:--

(_a_) _Vision._ It must be remembered that in children a defective eye
retaining the power of accommodation is often more useful than an eye
which sees better but has to wear different glasses for different
distances. Vision must be reduced to less than 6/18 in both eyes after
correction with glasses before the operation should be undertaken. In
rare cases, in children, and in traumatic cataract where the cataract is
very dense and confined to one eye, it may be removed partly to improve
the personal appearance and partly to enable the patient to see large
objects.

An eye without a lens (aphakia) will not work with an eye with a lens
even if the former be corrected with glasses.

If the patient be unable to see letters, he should have a ready and
quick perception of light, no cataract, however dense, being sufficient
to prevent this.

(_b_) A patient should have a good _projection of light_; that is to
say, he should be able to locate the light when thrown into the eye with
a mirror whatever direction it comes from. Children generally turn the
head towards the light, provided that they can see it and that the eye
is not defective from other causes.

(_c_) Note whether _the pupils_ are equal and active. In children most
useful information can often be obtained as to the condition of the
fundus by means of the pupil, which often will not react when the
patient is unable to appreciate light.

(_d_) _The condition of the fundus of the other eye_, if observable,
should be taken into account, as many diseases of the fundus, such as
choroiditis and myopia, are bilateral, and would influence the prognosis
considerably.

(_e_) _The lachrymal sac_ and conjunctiva should be free from all signs
of inflammation (see p. 181).

[Illustration: FIG. 85. EYE SPECULUM.]

[Illustration: FIG. 86. FIXATION FORCEPS.]

(ii) =For the removal of a lens for high myopia.= In selected cases
operation gives very satisfactory results with great improvement of
vision; indeed full normal distance vision has been obtained without
glasses. The operation, however, is only justifiable under certain
circumstances, the chief of which are:--

  (_a_) The amount of myopia should exceed 18 D.
  (_b_) Distance vision should be defective--less than 6/18
        with glasses.
  (_c_) Ophthalmoscopically the macular region should be sound.
  (_d_) Binocular vision should be absent.
  (_e_) The patients should be children or young adults.
  (_f_) If there is some serious reason why the patient is
        unable to wear glasses.

In emmetropia, if the lens be removed, a glass of + 11 D. has to be
placed before the eye for distance vision and + 14 D. for near vision.
It is impossible to predict the exact amount of correction of myopia
which will be produced by the removal of the lens, owing to the
surgeon’s inability to estimate the refractive power of the lens
associated with the distortion of the posterior pole of the globe.
Usually a patient with about 22 D. of myopia is rendered emmetropic by
the operation.

There are two main objections which have been raised to the operation:
first, that there is a slight risk of septic infection, sympathetic
ophthalmia even having been known to occur; secondly, that retinal
detachment seems rather more common after operation than in ordinary
myopia of the same degree. As a rule it is only advisable to perform the
operation on one eye, the patient using the other for reading purposes,
but under certain circumstances, as when the operation has been
successful for a considerable period of time, it would be justifiable to
perform it on the other eye. The operation should never be performed on
patients having only one eye.

=Instruments.= Speculum (Fig. 85), fixation forceps (Fig. 86),
discission needle.

=Operation.= _First step._ The operation is best performed by artificial
light. The pupil having been dilated with atropine and the eye
anæsthetized with cocaine (a general anæsthetic being necessary,
however, for young children), the speculum is inserted by first drawing
up the upper lid, making the patient look down, and inserting the top
blade, and then drawing down the lower lid, making the patient look up,
and inserting the lower blade. The speculum is opened to its full width
without undue strain on the canthus and is kept in position by
tightening the screw. The eye is steadied by fixation forceps held in
the left hand, which grasp the conjunctiva as close to the cornea as
possible directly opposite to the spot at which the puncture is to be
made; the puncture is made directly behind the limbus and the needle is
passed into the anterior chamber.

_Second step._ Using the shaft of the needle lying in the cornea as a
fulcrum on which to rotate the needle, an incision is made in the
anterior capsule of the lens, and the lens fibres are broken up by a
stirring movement. The needle is then rapidly withdrawn in the same
plane in which it was inserted so as to avoid making a crucial incision
in the cornea with the spear-like end and thereby losing the aqueous.
The best way to make sure of this is to mark one side of the handle so
that it may be inserted and withdrawn in the same position. A pad and
bandage are then applied.

=After-treatment.= The pupil should be kept dilated subsequently by the
use of atropine twice a day until the lens has become absorbed. The
bandage may be removed about the fourth day and dark glasses worn.

The effect of the operation on the lens varies considerably. It may
swell up so rapidly that the tension of the eye becomes increased, in
which case an evacuation may have to be performed; in other cases,
especially in the cases of a patient with high myopia, several needlings
may be required before absorption is complete.


CAPSULOTOMY

Capsulotomy is the division of the opaque capsular membrane left after a
cataract has been removed.

=Indications.= After a cataract has been removed, either by discission
or extraction, an opaque membrane is usually left. This is due to the
proliferation of the cells in the anterior capsule of the lens while
attempting to lay down new lens fibres. Although the posterior capsule
is clear and free from cells, those from the anterior capsule may spread
to it and so render it opaque. A fibrinous exudate may also organize and
help to thicken the membrane (Fig. 87). For these reasons and also
because the soft matter may not have absorbed entirely, it is not
advisable to operate too soon after a cataract has been removed. There
should be at least six weeks’ interval after an extraction has been
performed. A few surgeons operate earlier than this, the idea being that
the membrane is then softer and more easily divided.

[Illustration: FIG. 87. SECONDARY CATARACT. Opaque capsule after
cataract extraction.]

Although the operation of discission for after-cataract (capsulotomy) is
simple it is not to be undertaken lightly. The patient’s vision should
be less than 6/18. In former days the operation was looked upon as
attended with as much risk as the extraction, owing to the frequency
with which it was followed by inflammation. The reasons for this seem to
have been want of proper antiseptic precautions, the passage of the
needle through the non-vascular corneal tissue instead of through the
conjunctiva, and also the use of a badly made needle, often resulting in
prolapse of the vitreous into the wound. A proper discission needle
should have sufficient width in its spear-like point to cut a hole large
enough to admit the shaft freely; hence needles which have been
sharpened several times should be discarded. It need hardly be said
that there should be no signs of cyclitis (keratitis punctata) present
when the operation is undertaken.

=Instruments.= These are the same as for discission, with the addition
of a needle with a long cutting edge.

[Illustration: FIG. 88. CAPSULOTOMY. _The method of incising the
capsule._ The fulcrum of movement of the needle is where the shaft lies
in the sclerotic.]

[Illustration: FIG. 89. CAPSULOTOMY. _The method of dividing a dense
band._ This is done with two needles.]

=Operation.= Capsulotomy is best performed by artificial light under
cocaine. The cutting needle is inserted into the anterior chamber as in
the previous operation. The point is then thrust through the membrane
below (but it should not penetrate deeply, otherwise the vitreous will
be torn) and an incision is made in an upward direction. This incision
usually gapes sufficiently to give a clear pupil (Fig. 88). Those
surgeons who operate early try to cut out a triangular portion of the
membrane. When a dense band is present which gives before the needle
and cannot be divided, a second or ordinary discission needle should be
passed into the anterior chamber from the limbus opposite to the cutting
needle. The discission needle is made to pass behind the band whilst the
cutting needle lies in front of it. By a rotary movement of the
discission needle around the cutting needle the band is carried against
the edge of the latter and so divided. The needles are then withdrawn
(Fig. 89).

=Results.= These are good as a rule, but the operation may have to be
performed again owing to an insufficient or non-central opening being
obtained in the membrane, or to a fresh membrane forming; this is liable
to take place if any irido-cyclitis follow the operation.

=After-treatment.= This should be carried out as described for needling.


EVACUATION

=Indications.= (i) In cases of increased tension associated with soft
lens substance in the anterior chamber.

(ii) To accelerate the absorption of soft lens matter from the anterior
chamber. As a rule it is only undertaken for the former condition.

=Instruments.= Speculum, fixation forceps, bent broad needle, curette.

=Operation.= Under cocaine.

_First step._ An incision is made behind the limbus, usually in an upper
segment of the cornea, by means of a bent broad needle. The point of the
instrument is passed into the anterior chamber immediately behind the
limbus with the handle at right angles to the cornea; directly the
anterior chamber has been entered the handle is depressed so that the
point of the instrument shall turn forwards and avoid injuring the iris.
The blade is passed on into the anterior chamber until the point reaches
about the centre of the pupil. It is then either withdrawn directly, or,
if a larger incision be desired, lateral pressure is made so that in
withdrawing the blade the wound is enlarged.

_Second step. Evacuation._ With the rush of aqueous which follows the
incision some soft matter is usually evacuated; then a curette may be
introduced, if necessary, and the lens fragments removed by gentle
manipulation. Occasionally the iris may prolapse into the wound; if this
happens it should be replaced, but if it occur more than once the
prolapsed portion should be removed. Suction apparatus has been used for
removing the soft lens matter, but it is not to be recommended in most
cases, owing to the difficulty of sterilization and the trauma which it
may cause. After-treatment as for needling should be carried out.


EVULSION OF THE CAPSULE

=Indications.= (i) In congenital cataract when the lens consists of
little more than a dense capsular mass.

(ii) In dense capsular membranes following removal of a lens by
discission in which a cutting needle cannot make a hole.

=Instruments.= Speculum, fixation forceps, keratome, capsule forceps,
discission needle.

=Operation.= A general anæsthetic is usually desirable.

_First step._ The pupil is previously dilated with atropine. In the case
of congenital cataract a discission needle is first passed into the mass
to estimate its consistency. If it consist of little more than capsule
an incision is made at the limbus with the keratome as described for
evacuation.

_Second step._ The blades of the capsule forceps are then inserted
closed, opened, and the opaque capsule grasped and withdrawn from the
eye. The speculum is then removed and a pad and bandage applied. The
pupil should be kept dilated with atropine subsequently, as a certain
amount of irido-cyclitis following the operation is not infrequent.
Occasionally the iris may become entangled in the wound, and it should
then be removed.


EXTRACTION OF THE LENS

=Indications.= (i) For all forms of cataract in patients over thirty
years of age.

(ii) For cases of high myopia over the same age.

(iii) For lenses containing foreign bodies.

(iv) For displacement of the lens causing irritation.

Probably no operation in surgery has so many modifications, many of
which possess advantages and disadvantages which counterbalance each
other so nearly that the individual surgeon must decide for himself
which is the most satisfactory to carry out. The opinion of many
surgeons, including the author, is that the ideal operation is one which
can obtain sight for the patient at one sitting. The operation described
below is carried out with this object in view, the various modifications
and the indications for their use being subsequently discussed.

_Instruments._ Speculum, two pairs of fixation forceps, a Graefe’s
knife, iris forceps (Fig. 90), iris scissors (Fig. 91), capsule forceps,
cystotome, curette or spoon, iris spatula, vectis (Fig. 92), or lens
spoon (Fig. 93).

=Operation.= The operation is performed under cocaine and is divided
into five steps:--

  1. Incision.
  2. Iridectomy.
  3. Opening the lens capsule.
  4. Delivery of the lens.
  5. Toilet of the wound.

[Illustration: FIG. 90. IRIS FORCEPS. Care should be taken to see that
the teeth dovetail properly.]

[Illustration: FIG. 91. IRIS SCISSORS. Their cutting power should be
tested on wet cigarette paper before use.]

[Illustration: FIG. 92. A VECTIS. It should be made of stiff steel.]

[Illustration: FIG. 93. PAGENSTECHER’S SPOON. It is an advantage to bend
the shaft near the spoon to a right angle.]

=First step.= _The incision._ The surgeon, standing behind the patient’s
head and holding the knife with the edge directed upwards, in the right
hand for the right eye and in the left hand for the left, fixes the eye
with a pair of forceps held in the other hand, by grasping the
conjunctiva below and to the inner side as close to the limbus as
possible (Fig. 94). Most continental surgeons stand in front of the
patient and cut upwards. The point of the knife is then passed on the
flat into the anterior chamber from the outer side, 1.5 millimetres
behind the corneo-sclerotic junction.

[Illustration: FIG. 94. LENS EXTRACTION. Showing the position of the
hands when making a section upwards with a Graefe’s knife.]

It is first directed downwards and inwards until the chamber is
penetrated (Fig. 95). The knife-point is then directed horizontally and
passed across the anterior chamber in a line parallel with an imaginary
tangential line across the top of the cornea. The counter-puncture is
then made, the knife emerging 1 millimetre behind the corneo-sclerotic
junction (Fig. 96). In making the counter-puncture the beginner is apt
to go too far back in the sclerotic owing to the angle of the chamber
being placed behind the limbus; he should therefore aim for a point
about 1 millimetre inwards from the limbus. The knife is next made to
cut upwards by a sawing movement so that a flap is formed of corneal
tissue about 3 millimetres in breadth (a breadth and a half of a new
Graefe’s knife), the upper margin being at the corneo-sclerotic
junction. When the corneal flap has been made, the knife should lie
beneath the conjunctiva, from which a flap about 3 or 4 millimetres in
length should be formed. The knife-edge is then turned forward and made
to cut its way out. In making the section, care must be taken not to
prick the patient’s nose or eyelid with the point of the knife, as it
may cause him to move his head with disastrous results. This is more
likely to happen with patients who have sunken eyes.

[Illustration: FIG. 95. THE KNIFE ENTERING THE ANTERIOR CHAMBER IN
CATARACT EXTRACTION. The point of the knife is directed downwards and
inwards.]

[Illustration: FIG. 96. MAKING THE COUNTER-PUNCTURE IN CATARACT
EXTRACTION. The counter-puncture is shown completed.]

=Second step.= _Iridectomy._ The patient is made to look downwards. A
pair of iris forceps are inserted, closed, into the anterior chamber,
opened, and the iris grasped near its root, and withdrawn. The piece of
iris is then removed with the iris scissors, dividing it parallel with
the incision as close to the eye as possible (Fig. 97). If the
conjunctival flap hinders the insertion of the iris forceps into the
anterior chamber, it may be turned forward over the cornea with the
point of the closed forceps.

=Third step.= _The capsule of the lens is opened._ This is done in order
to allow the lens nucleus and soft matter to escape. Since the anterior
capsule becomes opaque after the removal of the lens, owing to the
multiplication of the cells in their attempt to lay down new lens
fibres, it is desirable to remove a portion of the anterior capsule from
the pupillary area. This may be performed (_a_) by means of capsule
forceps which are inserted closed, and when in position over the lens
are opened as widely as possible without entangling the iris, then
pressed down on to the anterior capsule of the lens and closed; in this
manner the portion of the capsule thus included is removed by a slight
lateral movement (Fig. 98); (_b_) by means of a cystotome, the lens
capsule being opened by a triangular or T-shaped incision over the
pupillary area; (_c_) by the point of the knife as it passes across the
anterior chamber; (_d_) by a discission needle before the section is
made. When the capsule of the lens has been opened properly the lens
nucleus is usually seen to come forward. The advantage of the capsule
forceps over the other methods is that they remove a larger portion of
the capsule and leave no tags which may become incarcerated in the
wound. On the other hand they are somewhat more difficult to use; more
pressure on the lens is required, and therefore dislocation of the lens
in its capsule may result. It is, therefore, not advisable to use them
in cases in which a fluid vitreous is suspected. If the teeth of the
forceps are not well made they will not grasp the capsule; it is
therefore always advisable to have the cystotome in readiness. The
cystotome also should be used when the anterior chamber becomes filled
with blood so that the margin of the iris cannot be seen and there is a
risk of the iris being grasped by the forceps.

[Illustration: FIG. 97. INCISION AND IRIDECTOMY IN CATARACT EXTRACTION.]

The method of opening the capsule with the point of the knife or needle
is useful in cases of extraction without iridectomy; the pupil should be
dilated before the operation.

=Fourth step.= _Delivery of the lens_ is performed by a gentle pressure,
combined with massage, on the extreme lower margin of the cornea with a
curette or spoon, until the upper margin of the lens presents in the
wound, when the pressure is gradually made upwards over the cornea until
the lens is delivered. Delivery of the lens may be prevented by--

(_a_) Imperfect opening of the capsule, which is usually the result of
using a blunt cystotome; if capsule forceps are used this difficulty
hardly ever arises.

(_b_) Too small an incision. The margin of the nucleus may present and
not be able to pass the wound. The wound must then be enlarged with the
iris scissors and the lens delivered in the ordinary way. Only by
experience can the amount of pressure required for the delivery of the
lens be gauged.

[Illustration: FIG. 98. OPENING THE CAPSULE WITH FORCEPS IN CATARACT
EXTRACTION. The forceps are inserted closed, brought in contact with the
lens, opened, and the capsule grasped between the blades and withdrawn
by a gentle side-to-side movement.]

(_c_) A sticky consistency of the cortex is not infrequently found in
cases of immature cataract. When the lens presents and cannot be
delivered readily it may be helped out by means of the cystotome plunged
into its substance, pressure being used on the cornea at the same time.

If from these or any other causes the suspensory ligament rupture and
the vitreous present in the wound, the lens should be removed with the
vectis. The vectis, which should be made of stiff steel, is passed
vertically into the incision and behind the lens nucleus by depressing
the handle; with a steady gentle pressure forwards it is then withdrawn
together with the nucleus. The forward pressure should be such as to
prevent the instrument slipping on the nucleus, for if it does so the
accident is nearly always followed by a rush of vitreous. A
Pagenstecher’s spoon may be used instead of the vectis, and is to be
preferred in cases where a small nucleus is suspected, since the latter
may slip through the loop of the vectis and fail to be delivered.

=Fifth step.= _Toilet of the wound._ After the nucleus has been
extracted, all the soft matter should be removed as far as possible by
gentle expression with the spoon. The angles of the coloboma in the iris
should be replaced by stroking it inwards on its anterior surface with
the iris spatula, paying particular attention to the angles of the wound
(Fig. 99). The spatula should also be passed throughout the extent of
the wound so as to free it from any capsule which may have prolapsed
into it. The conjunctival flap is then placed in position by stroking it
upwards with the iris spatula.

[Illustration: FIG. 99. CATARACT EXTRACTION. Replacing the iris, and any
tags of capsule which may be in the wound, with an iris spatula.]

=After-treatment.= Atropine is instilled either at the time of operation
or at the first dressing, and continued until all signs of redness of
the eye have disappeared. The patient should remain in bed for at least
ten days, both eyes being bandaged during the first four days. The eye
that has been operated on should be covered for at least two weeks;
subsequently a shade or dark glasses should be worn.

=Modifications.= The operation may be modified in various ways.

=The incision.= _The position_ of the incision has undergone many
modifications. The one described above is now in general use.

_The size_ of the incision should be increased when (_a_) a large
nucleus is expected, as in old people; (_b_) an immature cataract is to
be extracted; or (_c_) a fluid vitreous is suspected, so that the lens
may be delivered with as little pressure as possible.

=The iridectomy= may be omitted. _Extraction without iridectomy_ is
undoubtedly the ideal operation; it leaves the pupil unbroken and the
eye looking normal to external appearance. Further, the pupil reacts
more strongly to light than if an iridectomy has been performed. The
presence of the iris further prevents the prolapse of any capsule into
the wound. At the same time it is attended with considerable risk of
prolapse, which, as has been pointed out, is a very great danger to the
eye. With proper care this probably only occurs in about 5% of the
patients operated upon, but is so serious that the opinion of most
surgeons is in favour of the combined method (iridectomy and
extraction); but at the same time it is the practice of many surgeons to
omit the iridectomy under the following circumstances: first, if the
patient be young and the deformity will interfere with his getting
employment; secondly, if extraction of the lens in its capsule be
performed the unbroken circle of the iris will help to prevent the
prolapse of the vitreous which is otherwise so liable to take place.

[Illustration: FIG. 100. MCKEOWN’S IRRIGATION APPARATUS FOR WASHING OUT
THE ANTERIOR CHAMBER. The second and third terminals are the most
useful.]

Eserine (gr. ii ad ℥i) should be used to prevent prolapse of the iris
after the extraction has been performed, and should be continued once a
day until a good anterior chamber is present, which is usually in about
twelve to twenty-four hours, when atropine should be substituted. If the
iris betray any liability to prolapse after the operation, as shown by
the drawing upwards of the pupil, an iridectomy should be performed
before the patient leaves the table. In any case the eye should be
examined on the evening of the operation, and, if prolapse has occurred,
that portion of the iris should be removed. If a prolapse of the iris
occurs and is not discovered until the wound has healed, the conjunctiva
should be dissected off the surface in the form of a flap and the iris
tissue drawn out of the wound and removed, the angles caught in the scar
being freed if possible. The opening in the globe is subsequently closed
by replacing the conjunctival flap in position, or, if it has not been
possible to preserve the conjunctiva over the cicatrix, by raising a
flap from the ocular conjunctiva in the neighbourhood and stitching it
down over the opening in the globe. Not infrequently this operation is
followed by an attack of acute iritis, which usually subsides under
treatment.

_Preliminary iridectomy._ The iridectomy may be performed at a previous
operation. It has the advantages that the surgeon learns how the patient
will behave under operation, and how the eye will react to such an
operation. There is an absence of bleeding at the second operation,
which makes it easier, and there is less liability for the iris to
become adherent to the capsule. The disadvantages, which seem to
outweigh the advantages, are that there is a double chance of sepsis,
and that the patient has to submit to two operations when one is
sufficient. It is only performed by the author in cases in which there
is a tendency to increased tension in the eye due to swelling of the
lens in the early stages of the cataract. When a preliminary iridectomy
is performed a keratome may be substituted for the Graefe’s knife in
making the incision for the iridectomy, a much smaller one being
necessary.

=Delivery of the lens by irrigation.= McKeown removes the soft lens
matter by a process of irrigation into the anterior chamber, a practice
not yet much adopted, but of considerable service in removing the soft
matter after the extraction of the nucleus, especially in immature
cataract. It is also probable that the thorough removal of the soft lens
matter by this method reduces the number of cases of cyclitis following
the operation, since the soft matter forms a suitable medium for the
growth of organism. The apparatus used is shown in Fig. 100, nozzle No.
2 being the most useful; it is inserted into one angle of the wound and
a stream of sterilized normal saline solution at 39°C. (in the flask) is
allowed to flow into the anterior chamber; this stream is obtained by
raising the flask until sufficient pressure is obtained. An undine may
be substituted for the flask. Care should be taken that there is a free
return of fluid from the anterior chamber; irrigation should be
continued until as much as possible of the soft matter has been removed.

=Extraction of the lens in its capsule.= This operation is frequently
performed in India, where patients will often not return for needling of
secondary cataract (capsulotomy). Although the method undoubtedly yields
good results, the percentage of eyes damaged by loss of the vitreous
must be higher than when the posterior capsule of the lens is left
intact. The operation may be performed with or without an iridectomy,
the lens being removed by pressure on the cornea with a large strabismus
hook. If the vitreous should present, the lens should be removed with
the vectis.

Extraction of the lens in its capsule is also performed when the lens is
dislocated and causing irritation. If the lens be in the anterior
chamber immediate extraction is called for, as glaucoma is a usual
complication. Eserine is first instilled in order to contract the pupil
and prevent the lens passing back into the posterior chamber; an
incision is then made as for a cataract extraction and the lens removed
by means of the vectis. Complete dislocation of the lens into the
vitreous rarely requires operation, as the patient is able to see.
Partial dislocation (luxation) occasionally calls for extraction, the
vectis usually being employed for delivering the lens, but before
undertaking the operation an attempt should be made to get the lens into
the anterior chamber by dilating the pupil and making the patient lie
face downwards; if this is successful eserine should be instilled to
contract the pupil behind the lens and so retain it in the anterior
chamber, from whence it can more easily be extracted. Some surgeons
prefer to fix the lens with a needle passed through the sclerotic behind
the ciliary body before making the incision.

=Subconjunctival extraction.= In order to diminish the risks of sepsis,
more especially in cases in which the conjunctiva is affected with
trachoma, some continental surgeons deliver the lens into a pocket
beneath the conjunctiva, whence it is subsequently removed. The
operation has the additional advantage of a better blood-supply to the
corneal flap, which is also held in better position after the operation.

_Operation._ A section upwards is made with a Graefe’s knife as in the
ordinary method of extraction previously described, the lens capsule
being opened with the point of the knife as it is passed across the
anterior chamber. When the section through the sclerotic has been
completed and the knife lies entirely beneath the conjunctiva it is
withdrawn.

The wound in the conjunctiva on the outer side is then enlarged upwards
with scissors, and an iris spatula is passed beneath the conjunctiva
from the small wound on the inner side and the point made to appear in
the wound on the outer side; by this means the conjunctiva is raised on
the spatula, and by means of sharp-pointed scissors a pocket is made in
an upward direction by undermining the conjunctiva (Fig. 101). Delivery
of the lens is then performed into this pocket, from which it is
subsequently removed, the conjunctival wound on the outer side being
closed with a stitch. The advantage of this form of subconjunctival
extraction over other forms which have been devised is that if
difficulty is met with in delivering the lens, &c., the operation can be
readily converted into an ordinary extraction by completing the division
of the conjunctival flap.

[Illustration: FIG. 101. SUBCONJUNCTIVAL EXTRACTION. The section in the
sclerotic being completed with a Graefe’s knife, the figure shows the
method of undermining the conjunctiva to form a pocket into which the
lens is delivered and from which it is subsequently removed.]

=Complications.= These may be immediate or remote.

=Immediate.= 1. If the knife-point become entangled in the iris as it is
passed across the anterior chamber it should be slightly withdrawn, if
this can be done without loss of aqueous, the iris being thereby
disengaged.[4]

[4] For the other complications which may arise in passing a Graefe’s
knife across the anterior chamber, see Glaucoma Iridectomy, p. 222.

2. _Loss of the aqueous before the section is complete_ may result in
the entanglement of the iris as before described, or the iris, owing to
the presence of the aqueous in the posterior chamber, may bulge forward
in front of the knife-blade. The latter complication is more likely to
occur if the section be made too rapidly. The iris may sometimes be
disengaged by depressing the handle of the knife towards the patient’s
chin and raising the blade towards the cornea so as to allow the aqueous
in the posterior chamber to escape. If this cannot be accomplished, the
section should be completed and the iris, which may be divided by the
knife, removed subsequently when doing the iridectomy.

3. _Avulsion of the iris_ due to movement of the patient’s head. This is
more liable to take place if the eye has not been properly cocainized
some time before the operation. The grasping of the iris by the forceps
is always felt by the patient to a certain extent, and he should be
warned not to move. Avulsion is usually not complete and only results in
a larger iridectomy than was intended.

4. _Dislocation of the lens._ (_a_) When opening the capsule, either
from too great pressure of the capsule forceps, or from the patient
moving his head. The lens must then be delivered by the vectis. (_b_)
If, in delivering the nucleus, the upper edge is not made to present by
pressure on the lower part of the cornea, the nucleus, especially if it
be small, is liable to be dislocated upwards beyond the incision. It
must then be removed with the vectis. In cases where a small nucleus is
suspected, pressure should be made on the sclerotic above the incision
with a curette, as well as on the lower part of the cornea, so as to
make the nucleus present in the wound.

The lens may be dislocated backwards into the vitreous; if this should
happen and the lens cannot be delivered, the flap must be replaced in
position and the eye bandaged. Unfortunately this complication is
usually followed by irido-cyclitis and loss of the eye.

5. _Loss of the vitreous._ There are two chief phenomena which may
indicate that loss of vitreous is about to take place after the
extraction of the lens.

(_a_) The wound gapes unnaturally after the expulsion of the lens, and
the clear vitreous may be seen presenting in the wound in the still
unruptured hyaloid membrane.

(_b_) There may be an apparent deepening of the anterior chamber owing
to the fluid vitreous making its way forward through the ruptured
hyaloid into that cavity.

If the vitreous presents in the wound before the lens has been removed,
the latter should be delivered as rapidly as possible by the vectis, as
has previously been described.

If the vitreous be lost or one of the phenomena previously mentioned
occurs after the delivery of the lens, the speculum should be removed
from the eye and the conjunctival flap replaced in position as quickly
as possible. The eyelid is then carefully raised from the surface of
the eyeball by means of the lashes held in the finger and thumb and
carried downwards over the globe until it is in the closed position, and
a bandage is then applied.

As little manipulation as possible should be carried out when once the
vitreous has shown itself about to present, and unless the iris be
obviously in the wound no attempt should be made to replace it.

Loss of vitreous may be the result of subchoroidal hæmorrhage, which may
only make itself manifest after the patient has been put back to bed.

Loss of vitreous is frequently accompanied by hæmorrhage into the
vitreous, as is seen subsequently by the floating opacities therein. As
a rule these clear, and useful vision is obtained.

Detachment of the retina may follow loss of vitreous even months after
operation. This complication seems more liable to occur if the vitreous
which is lost in the first instance be normal and not of the fluid type.

6. _Intra-ocular hæmorrhage_ (see Glaucoma Iridectomy, p. 224).

=Remote.= 1. _Panophthalmitis_ is a result of infection of the wound. It
usually makes its appearance about the third day and must be treated by
evisceration. Occasionally the purulent material is limited to the line
of the incision or even to the anterior chamber; in the latter instance
the wound should be opened up and the anterior chamber washed out with
peroxide of hydrogen solution (10 vols. %). Microscopic examination of
the pus should be made and a vaccine prepared and administered; in two
cases so treated by the author a good recovery resulted.

2. _Escape of the aqueous beneath the conjunctiva_ usually occurs about
the third day, owing to the conjunctival wound having healed without the
opening into the globe being properly shut off. This is accompanied by
considerable pain, with chemosis and some œdema of the upper lid. It is
usually distinguishable from acute iritis by the pupil being evenly
dilated and discoloration of the iris being absent. The condition
usually subsides in three or four days, when the wound in the globe has
become shut off.

3. _Acute iritis_ not infrequently occurs after extraction. It usually
comes on about the third day and may be accompanied by hypopyon. It may
settle down under atropine, leeching, and dry heat, but may also pass on
into the more chronic form; adhesion of the iris to the capsule,
however, frequently results. More rarely the disease may not make its
appearance till two or three weeks after the operation (latent sepsis),
the patient suffering from recurring attacks of hypopyon. In these cases
in which the hypopyon persists, washing out the anterior chamber with
peroxide of hydrogen (10 vols. %) and the administration of a vaccine is
of service.

4. _Chronic irido-cyclitis_ is usually primary, but may occasionally
follow an acute attack of iritis. Of all the disastrous complications,
this is by far the worst. It may not only destroy the sight of the eye
on which the operation has been performed, but may set up sympathetic
ophthalmia in the other eye. The eye does not settle down well after the
operation, there being usually some prolapse of the iris or capsule into
the wound. It remains injected or flushes up on exposure to light. After
a time (usually about the end of the third week) keratitis punctata
makes its appearance, and the tension of the eye may become decreased or
occasionally increased. The disease may resolve or go on to shrinking of
the globe. Energetic treatment with atropine and hot fomentations
locally, with the internal administration of iron, is indicated. The
administration of staphylococcus vaccine causes only temporary
improvement in most instances. In six cases so treated by the author the
improvement was only temporary, in spite of the fact that there was a
definite local reaction to the vaccine and in two cases the
staphylococcus albus was isolated from the fluid in the anterior
chamber. If at the end of two months the eye be red and well-marked
keratitis punctata be present, and if the pupil be beginning to be drawn
up and the eye shows no tendency to improve, enucleation should be
seriously considered; this is especially advisable if the projection of
light has become defective, showing that the retina is probably
detached. If any signs of sympathetic irritation, such as mistiness of
vision, ciliary flush, or photophobia, appear in the eye which has not
been operated on, the exciting eye should be enucleated. On the other
hand, if well-marked inflammation has developed in the sympathizing eye,
which may also be cataractous, and the other eye has a fair amount of
vision, it becomes extremely questionable whether it is advisable to
enucleate the exciting eye. Every case must be judged on its own merits
according to the extent and severity of the disease. In a few cases in
which the incarceration of the capsule in the wound leads to a very
chronic cyclitis, its division with a cutting needle will sometimes lead
to subsidence of the inflammation. It is most important that every eye
that has been operated on should be examined for the presence of
keratitis punctata, especially before allowing the patient to use the
eye or before another operation is performed on it.

5. _Glaucoma_ following extraction occurs as a result of (_a_) soft lens
matter blocking the angle of the anterior chamber. As a rule the tension
will usually subside under eserine, but evacuation of the anterior
chamber (see p. 233) may have to be performed; on the whole the results
are satisfactory. (_b_) The incarceration of the capsule in the wound,
pulling forward the iris and blocking the angle of the anterior
chamber. Division of the lens capsule is usually sufficient to make the
tension subside. Failing this, sclerotomy should be performed; the
prognosis is not nearly so good when the increased tension is due to
this cause.

6. _Striate keratitis_ usually makes its appearance on the second or
third day after operation. The cornea near the line of incision presents
a grey striped appearance with the striæ arranged at right angles to the
wound. Pathologically the condition is due to an infiltration of the
deeper layers of the cornea, the striped appearance being caused by
wrinkling of Descemet’s membrane; the condition probably arises from
septic infection. As a rule the affection subsides without giving rise
to further trouble, but occasionally local suppuration and even
panophthalmitis may follow.

A grey horizontal line about the centre of the cornea is sometimes seen
after an eye has been too tightly bandaged; this always disappears when
the bandage is removed.

7. _Erythropsia_ (red vision) occasionally follows the extraction of the
lens, and is probably due to bleaching of the visual purple following
the admission to the eye of an unusual amount of light; it usually
disappears in a few weeks.

8. _Defective vision._ Glasses have to be worn after removal of the
lens. Usually patients who were previously emmetropic require about + 11
to see clearly for distance and + 15 for near vision.

The section produces some flattening of the corneal curvature at right
angles to the line of the incision; this usually amounts to about two
diopters.


COUCHING

Couching is the removal of the lens from the pupillary area by
depressing it backwards into the vitreous. It is rather a relic of the
past than a present-day operation, although it is extensively practised
by quacks in India. Under certain circumstances the operation still
seems justifiable; it is very simple, and is followed by immediate
restoration of vision, but the subsequent risks of irido-cyclitis,
retinal detachment, and glaucoma are so great, that, according to some
authorities, couching should only be undertaken in preference to
extraction when the latter operation has only a chance of one in three
of giving satisfactory vision.

=Indications.= The chief indications for its performance are:--

(i) The presence of a fluid vitreous, the patient having had the lens of
the other eye extracted with bad results.

(ii) In the insane, where it would be impossible to carry out the
after-treatment of extraction satisfactorily.

=Operation.= The operation is usually done under cocaine; in the case
of the insane a general anæsthetic is usually necessary. It has been
performed by simple depression of the lens backwards into the vitreous
with a needle passed through the cornea (anterior route). This operation
yields unsatisfactory results owing to the lens being liable to return
into the pupil; this can be partly overcome by sweeping the needle round
the periphery of the lens so as to divide the suspensory ligament, but
the operation is not so satisfactory as when the needle is passed in
from behind the ciliary body and the lens pressed down from behind
(posterior route), to which the following description applies. The
capsule of the lens should be torn freely, so that some absorption may
subsequently take place and diminish the risk of complications.

=Instruments.= Speculum, fixation forceps, needle.

_First step._ The pupil should be dilated with atropine. The patient’s
head should be well raised on the table. The needle is passed through
the sclerotic about 5 millimetres behind the limbus to the outer side.
The posterior capsule of the lens is then freely divided by a sweeping
movement.

_Second step._ The needle is next made to appear in the lower part of
the pupil by carrying it round the lower and outer border of the lens.
The anterior capsule is then freely divided.

_Third step._ The shaft of the needle is laid flat on the surface of the
lens towards its upper part, and by raising the handle of the needle the
lens is displaced backwards into the vitreous. The tearing of the
suspensory ligament on the inner side may be assisted by the cutting
edge of the needle during depression.

=Complications.= _Immediate._ Difficulty may be experienced in making
the lens lie at the bottom of the vitreous, and it is only by frequent
depression of the lens backwards and downwards, with a sweeping movement
of the needle to divide the suspensory ligament, that the desired effect
can be obtained.

_Remote._ The lens nucleus may prolapse through the pupil into the
anterior chamber. If this should happen, the patient should be placed on
his back and the pupil dilated with atropine; if the nucleus does not go
back into the vitreous chamber it should be depressed by means of a
needle passed through the cornea.

Glaucoma may result from the dislocation of the nucleus into the
anterior chamber and should be treated as described above. It may also
be present with a lens which is dislocated backwards. This condition is
very liable to end in loss of sight. Probably the only hope of relieving
the tension is by the use of eserine or the performance of a
cyclo-dialysis.

Cyclitis and retinal detachment may also follow, and usually end in
blindness.




CHAPTER III

OPERATIONS UPON THE IRIS


IRIDOTOMY

=Indications.= Iridotomy is an operation which is performed when the
iris has become drawn up after a cataract extraction, so that there is
no pupil, or the pupillary area is covered by the upper lid. A long
interval should elapse between the extraction and the iridotomy, since
these cases have usually suffered from cyclitis following the operation.
Iridotomy should not be performed for at least six months after all
signs of cyclitis have disappeared, for the frequent failure of the
operation is due to the fact that the opening made in the iris and
underlying capsule becomes filled with fibrous exudation as the result
of cyclitis, which is frequently set up again by the operation if
undertaken before a sufficient time has elapsed for the eye to settle
down after the inflammation. The ideal operation, therefore, is to make
an artificial pupil with the least amount of trauma to the ciliary body.

=Instruments.= Speculum; fixation forceps; a long, narrow, bent ‘broad
needle’; Tyrrell’s hook, iris scissors, iris forceps, and spatula.

=Operation.= Many operations have been devised for this most troublesome
condition, but the following is the one that the author has found to be
successful.

The operation is usually performed under a general anæsthetic, but this
is not essential.

_First step._ The surgeon stands facing the patient on the same side as
the eye to be operated on. The long, bent, broad cutting needle is
passed into the anterior chamber from the limbus downwards and inwards,
and is driven directly through the iris and underlying capsule. The
needle is then made to pass in an upward and outward direction behind
the iris into the pupillary area above, or if no pupil be present, again
through the iris (Fig. 102). The bent broad needle is made to cut
laterally by slightly deflecting the handle so as to produce a band of
iris and capsule; the cutting needle is then withdrawn.

_Second step._ A Tyrrell’s hook, bent to the correct angle, is passed
beneath the band (Fig. 103), which is drawn into the wound and removed
with iris scissors. A large opening is thus obtained with a minimum
amount of trauma. If the hook should slip, the band may be seized with
iris forceps, withdrawn from the wound, and removed.

=Alternative methods.= The following methods have been practised:--

=Simple incision= across the fibres of the iris by means of Graefe’s or
Knapp’s knife.

=Division with scissors= through a wound of the limbus.

By these two methods the opening produced is small, and is very liable
to be closed by the subsequent cyclitis. The following operation yields
more satisfactory results.

[Illustration: FIG. 102. IRIDOTOMY. Showing the incision with a long,
bent broad needle.]

[Illustration: FIG. 103. IRIDOTOMY. Showing the method of withdrawing
the band of iris and capsule with a Tyrrell’s hook.]

=Kuhnt’s operation.=

=Instruments.= Speculum, fixation forceps, Graefe’s knife, iris forceps
and scissors.

_First step._ The surgeon, standing facing the patient, enters the
anterior chamber about 2 millimetres inwards from the limbus at the
junction of the middle and lower third of the cornea with a Graefe’s
knife, the cutting edge directed downwards. The knife is then made to
penetrate the iris and underlying capsule, and to travel beneath this to
a similar point on the other side, where it is made to come back again
into the anterior chamber by again penetrating the iris, and finally out
again through the cornea. The knife is then made to cut out in a
downward direction.

_Second step._ Iris forceps are inserted and the flap of iris and
capsule is withdrawn and as much of it removed as possible. A more or
less triangular opening usually results.

=Ziegler’s operation.=

=Instruments.= Ziegler’s knife needle, speculum, fixation forceps.

The object of the operation is to cut a V-shaped flap in the iris and
underlying capsule, folding the flap backwards on its base so as to form
a triangular opening in the iris membrane to serve as a pupil.

_First step._ The knife needle is entered at the corneo-sclerotic
junction with the blade turned on the flat and is passed completely
across the anterior chamber to within 3 mm. of the apparent iris
periphery. The knife is then turned edge downwards, and carried 3 mm. to
the left of the vertical plane (Fig. 104).

[Illustration: FIG. 104. IRIDOTOMY BY ZIEGLER’S METHOD. Showing the
shape of the knife and the position of the first puncture in the iris;
the cutting is performed by a sawing movement.]

_Second step._ The point is now allowed to rest on the iris membrane,
and with a dart-like thrust the membrane is pierced. Then the knife is
drawn gently up and down with a saw-like motion, without making much
pressure on the tissue to be cut, until the incision has been carried
through the iris tissue from the puncture in the membrane to just
beneath the corneal puncture. This movement is made wholly in a line
with the long axis of the knife, the shank passing to and fro through
the corneal puncture, loss of the aqueous being avoided in the
manipulation (Fig. 105).

_Third step._ The pressure of the vitreous will now cause the edges of
the incision to bulge open immediately into a long oval. The knife-blade
is raised until it is above the iris membrane, and is then swung across
the anterior chamber to a corresponding point on the right of the
vertical plane. Owing to the disturbance in the relation of the parts
made by the first cut, this point is somewhat displaced and the second
puncture must be made 1 mm. further over.

_Fourth step._ With the knife-point again resting on the membrane, a
second puncture is made and the incision is carried rapidly forward by
the sawing movement to meet the extremity of the first incision at the
apex of the triangle, thus making a V-shaped cut. Care must be taken
that the pressure of the knife-edge on the tissue shall be most gentle,
and that the second incision shall terminate a trifle inside the
extremity of the first, in order that the last fibres may be severed and
thus allow the apex of the flap to fall down behind the lower part of
the iris membrane (Fig. 106). When the operation has been completed the
knife is turned on the flat and withdrawn.


IRIDECTOMY

The operation of iridectomy differs widely in its performance, according
to the different conditions for which it is used. Hence it is better to
prefix the condition for which it is employed, thus: preliminary
iridectomy, optical iridectomy, glaucoma iridectomy.

[Illustration: FIG. 105. IRIDOTOMY BY ZIEGLER’S METHOD. Showing the
first incision and the position of the second.]

[Illustration: FIG. 106. IRIDOTOMY BY ZIEGLER’S METHOD. Final step; the
triangular flap of iris attached at its base is turned downwards.]

Apart from being one of the stages of removal of a cataract, already
described, it is performed as an independent operation in the following
conditions:--

1. For optical purposes (optical iridectomy).

2. For the relief of glaucoma, primary and secondary (glaucoma
iridectomy).

3. For small growths at the free margin of the iris.

4. For prolapse of the iris through a wound.


OPTICAL IRIDECTOMY

=Indications.= Iridectomy for optical purposes is performed for a
centrally situated nebula of the cornea and in some very rare cases of
small central opacities in the lens. In the latter condition it is
rarely of much value, as nearly all the rays which enter the eye pass
through the central portion of the lens. Further, in this condition the
lens may be removed and better sight obtained with glasses. Optical
iridectomy should always be performed opposite a clear portion of the
cornea, the lower segment of the eye being chosen, otherwise the
coloboma may be subsequently covered by the upper lid. The site of
election for the operation is downwards and inwards, but in all cases
the patient should be carefully examined in the following ways: (1) the
vision is tested, any refraction being corrected without a mydriatic;
(2) the pupil is then dilated, and the best situation for the iridectomy
determined by means of a stenopaic slit. The vision must be definitely
improved by the use of these before operation can be advised. The
disadvantage of an iridectomy is that it allows more light to enter the
eye, and, if the periphery of the lens be uncovered, spherical
aberration may result. For both these reasons, therefore, it is
advisable to make the iridectomy as small as possible. Tattooing of the
central scar in the cornea will often diminish the amount of light
entering the eye, but before undertaking the latter operation, the eye
should be cocainized and the area covered with a piece of black paper to
see if the vision is improved thereby.

[Illustration: FIG. 107. OPTICAL IRIDECTOMY. The incision being made
with a keratome.]

=Instruments.= Speculum, fixation forceps, bent broad needle or small
keratome, Tyrrell’s hook, iris forceps, scissors, and spatula.

=Operation.= The operation is usually performed under cocaine.

_First step._ The eye is fixed by grasping the conjunctiva directly
opposite the spot at which the incision is to be made. The incision is
then made by means of a keratome or bent broad needle directly behind
the limbus, and enlarged laterally if desired (Fig. 107).

_Second step._ A Tyrrell’s hook, bent at the correct angle, is passed on
the flat into the anterior chamber. When the margin of the iris is
reached the handle is rotated and the hook is made to engage the free
border of the iris, which is then withdrawn from the wound; a small
portion is removed with scissors, which should be held at right angles
to the wound when dividing the iris (Fig. 108).

[Illustration: FIG. 108. OPTICAL IRIDECTOMY. Method of removing the iris
to produce a small coloboma.]

_Third step._ The iris should be carefully replaced and the pupil kept
under the influence of eserine until the anterior chamber has re-formed,
when atropine should be substituted.

Care must be taken to see that the Tyrrell’s hook presents no sharp
angle, and great care is required in its manipulation, otherwise the
lens capsule may be damaged, and traumatic cataract will result. If the
iris slips from the grasp of the Tyrrell’s hook, iris forceps should be
used, the iris being grasped near its free margin and as small a portion
as possible withdrawn.

=Brudenell Carter’s method.= The ordinary optical iridectomy divides the
sphincter iridis and so inhibits the activity of the pupil. With the
idea of obviating this, Brudenell Carter removed a small portion of the
iris (button-hole), leaving the pupillary margin intact. On the whole
the results of the latter operation are no more satisfactory, and the
operation is more dangerous to perform owing to the likelihood of
wounding the lens, and to the fact that monocular diplopia occasionally
results.

The pupil should be under the influence of eserine. The incision is made
as in the previous operation. De Wecker’s iris scissors are inserted
open into the anterior chamber, closed, and the piece of iris which
bulges up between the blades cut off; this can usually be withdrawn with
the scissors; or if not, it should be removed subsequently by forceps.

[Illustration: FIG. 109. OPTICAL IRIDECTOMY. Showing the coloboma.]


GLAUCOMA IRIDECTOMY

=Surgical and pathological anatomy.= The fluid in the anterior and
posterior chambers of the eye is secreted from the ciliary body by a
process of modified filtration. The fluid passes partly direct into the
posterior chamber and partly behind the suspensory ligament of the lens,
making its way forward into the posterior chamber through the fibres of
the suspensory ligament. From the posterior chamber it passes into the
anterior through the pupil; from the anterior it filters at the angle of
the anterior chamber through the ligamentum pectinatum into the canal of
Schlemm; thence it is carried into the blood-stream by the venous
anastomosis in that region (Fig. 110).

The essential change found in all cases of primary glaucoma is the
blocking of the angle of the anterior chamber owing to the root of the
iris being applied to the back of the cornea, and thus preventing the
filtration of the fluid into the canal of Schlemm, as a result of which
the tension of the eye is raised, either acutely (acute glaucoma) or
slowly from time to time (chronic glaucoma) (Fig. 111). The aim of every
operation for the permanent relief of glaucoma is the opening up of
Schlemm’s canal at the angle of the anterior chamber or the creation of
a new lymph channel between the anterior chamber and the
subconjunctival tissue (filtrating cicatrix). Although this latter
condition is not unattended by the risk of the spread of inflammation
from the conjunctiva to the interior of the globe, it is not an
inadvisable condition to obtain in some cases of chronic glaucoma if the
scar be small and free from iris tissue; in this disease the opening up
of the canal of Schlemm by iridectomy is often impossible. (See
Sclerectomy, p. 231.)

=Indications.= Since the days of von Graefe, who first performed
iridectomy empirically for the relief of glaucoma, the operation has
held the first place in its treatment.

(i) =In primary glaucoma.= Iridectomy should be undertaken as early as
possible in the disease. _In acute cases_, unless the tension is
relieved, the disease ends in rapid destruction of the sight. Operation
should always be undertaken as quickly as possible, provided the patient
has not lost his perception of light for longer than about ten days.

[Illustration: FIG. 110. THE NORMAL ANGLE OF THE ANTERIOR CHAMBER.

  A. Cornea.
  B. Ciliary processes.
  C. Iris.
  D. Ciliary muscle.
  E. Pectinate ligament, to the right
     of which is the angle of the chamber.
  F. Canal of Schlemm.
  G. Lens.
  H. Posterior chamber.
  I. Anterior chamber.
]

Whilst waiting for the operation, the pupil should be put under the
influence of eserine (2 to 4 grains to the oz.) with the idea of
reducing the tension by contraction of the pupil. Some surgeons, in
addition to using eserine, perform a posterior scleral puncture with the
idea of temporarily reducing the tension and allowing the acute symptoms
to subside, and do the iridectomy some twenty-four to forty-eight hours
later. This method is extremely useful (_a_) in cases where a general
anæsthetic is inadvisable, since the reduction of tension allows cocaine
to diffuse into the eye; (_b_) in cases liable to subsequent
intra-ocular hæmorrhage, a more gradual reduction of tension being
obtained, rupture of a choroidal vessel is less likely to occur; (_c_) a
deeper anterior chamber is often obtained, and hence there is less risk
of wounding the lens during the operation; (_d_) in cases where the
operation has been performed in one eye and the lens has been
subsequently extruded on the dressings.

_In chronic cases_ early iridectomy is desirable, since the root of the
iris applied to the posterior surface of the cornea becomes atrophic,
so that when an iridectomy is performed the iris tears off at the
anterior part of the atrophic portion, leaving the angle of the chamber
still occluded by its root (Figs. 112 and 113). It is especially in
these cases that a filtrating cicatrix, which sometimes follows
iridectomy or sclerotomy, is desirable, and indeed some surgeons
(Herbert and Lagrange, see p. 231), have recently performed operations
with this idea in view, and it is probable that this operation or
cyclo-dialysis will prove to be of use in these cases.

Operation is only contra-indicated in a few very rare cases in which the
tension is controlled by the use of eserine.

(ii) =In congenital glaucoma (bup[h]thalmos).= In this affection the
results of iridectomy vary. Without doubt, the tension has been relieved
by iridectomy in some cases, and either this operation, sclerectomy, or
cyclo-dialysis should be tried if the disease be not too far advanced.

(iii) =In secondary glaucoma.= For obvious reasons the predisposing
causes should always be taken into consideration. Thus it would be of no
use to perform an iridectomy in the case of a growth in the choroid. On
the other hand, an iridectomy would be unjustifiable for soft lens
matter in the anterior chamber, which merely requires evacuation. An
early iridectomy in cyclitis is not likely to influence the course of
the disease favourably; at the most a paracentesis is required. As the
early stages of cyclitis may give rise to tension, it is essential that
every case of glaucoma should be examined for keratitis punctata before
operation.

[Illustration: FIG. 111. THE ANGLE OF THE ANTERIOR CHAMBER FROM A CASE
OF RECENT GLAUCOMA. Showing its occlusion by the base of the iris, A,
being adherent to the posterior surface of the cornea, so preventing
filtration of the aqueous into the canal of Schlemm, B.]

In iris bombé and total posterior synechiæ an iridectomy is indicated
more to re-establish the communication between the anterior and
posterior chambers than to clear the angle, and therefore it need not be
so extensive. In cases of iris bombé where iritis is still present, and
in cases of cysts of the iris, transfixion is all that is necessary.

It is very doubtful if iridectomy in glaucoma following thrombosis of
the central vein is justifiable, for as a rule the tension is not
permanently relieved thereby. In secondary glaucoma following cataract
extraction or anterior synechiæ, division of the capsule or the anterior
synechiæ will often relieve the tension.

=Instruments.= Speculum, fixation forceps, Graefe’s knife (with a short,
stiff, narrow blade), iris forceps, scissors, and spatula.

=Operation.= With the idea of opening up the angle of the anterior
chamber by removing the iris as near its root as possible, the incision
should be made somewhat further back behind the corneo-sclerotic
junction than in cataract extraction. At the same time, if the incision
be placed too far back the ciliary body is liable to prolapse into the
wound. The old idea of opening up the canal of Schlemm by dividing it
has been abandoned, as to do so would certainly result in prolapse of
the ciliary body; and even if this did not happen, no good would result,
since the canal would become closed subsequently by cicatricial tissue.

[Illustration: FIG. 112. THE ANGLE OF THE CHAMBER IN A CASE OF CHRONIC
GLAUCOMA. The iris, A, has become atrophic at its root. An iridectomy in
this case would not free the angle of the chamber, as the iris would
separate at the point A.]

Although von Graefe used a keratome for making the incision, most
British surgeons of the present day use a Graefe’s knife, as it gives an
incision that is less shelving and more irregular, thus predisposing to
the formation of a filtrating scar; a good conjunctival flap is obtained
with it and there is less risk of wounding the lens.

When performing the iridectomy it is practically impossible to cut the
iris with scissors at its attachment to the ciliary body, and it is
better to rely on tearing it off from the ciliary body, as it is in this
situation that the iris is thinnest and most likely to give way,
provided it has not become atrophic by prolonged contact with the
cornea.

In acute cases and in cases of secondary glaucoma where there are many
adhesions a general anæsthetic is desirable.

_First step. The incision._ The position of the surgeon is as for
cataract extraction. The eye is fixed by grasping the conjunctiva close
to the limbus downwards and inwards. If the patient be under an
anæsthetic, two pairs of fixation forceps should be used, one being held
by an assistant. Occasionally in glaucoma the conjunctiva tears very
easily, and in these cases scleral forceps are of use, or, if the knife
be already in the eye, grasping the insertion of the superior or
inferior rectus. The Graefe’s knife should be directed downwards and
inwards towards the point of fixation, the point being passed through
the sclerotic 1.5 mm. behind the limbus to the outer side. Directly the
anterior chamber is entered, the handle is depressed towards the
patient’s chin. The knife-point is kept superficial to the iris and is
passed very slowly across the anterior chamber, close to its periphery
until the position of the counter-puncture is reached. The
counter-puncture should be situated about 1 mm. behind the limbus in a
direct line with the original puncture. Care must be taken in making the
counter-puncture that the knife-point does not slip back on the
sclerotic and so emerge further back in the eye than is desired. The
knife is then made to cut out upwards and a good conjunctival flap is
obtained. The incision should be carried out slowly, so that the aqueous
escapes gradually, as sudden reduction in the intra-ocular tension is
liable to lead to intra-ocular hæmorrhage.

[Illustration: FIG. 113. IRIDECTOMY FOR GLAUCOMA. Failure to relieve the
tension owing to the iris not tearing off at its junction with the
ciliary body, due to atrophy from prolonged contact with the cornea.]

_Second step. The iridectomy._ The iris forceps are inserted closed into
the anterior chamber, opened, and made to grasp the iris near the
periphery (Fig. 114) towards the side of the wound on which the iris is
first to be divided; then with a slight side-to-side movement of the
forceps the iris is withdrawn from the wound until its peripheral
attachment to the ciliary body, near where it is held by the forceps,
is felt or seen to give way (irido-dialysis) (Fig. 115). The iris is
then drawn a little further out from the wound, and one side of the
dialysis is divided with the scissors as near the scleral wound as
possible. The iris held in the forceps is then pulled over to the other
angle of the wound, and as much of it as possible is pulled out and
divided close to the scleral incision (Fig. 116). The angles of the
incision are freed from iris by means of the spatula and the
conjunctival flap is replaced in position. Both eyes are then bandaged.

=After-treatment.= The patient should be kept in bed for a week, and
during the first four days should not be allowed to raise the head from
the pillow. After that time the eye not operated upon may be uncovered;
eserine should have been instilled into it before the operation and at
subsequent dressings to prevent the possible onset of glaucoma owing to
the dilatation of the pupil which follows the application of the bandage
to the eye. It is not necessary to use any mydriatic or myotic for the
eye which has been operated upon.

[Illustration: FIG. 114. IRIDECTOMY FOR GLAUCOMA. Showing the position
in which the iris should be grasped with forceps.]

[Illustration: FIG. 115. IRIDECTOMY FOR GLAUCOMA. Showing the
irido-dialysis produced before division.]

=Complications.= These may be immediate or remote.

=Immediate.= 1. In passing a Graefe’s knife into the anterior chamber to
make the section, care must be taken that the cutting edge is directed
upwards. If by accident it should be inserted with the cutting edge
directed downwards the knife should be withdrawn and the operation
postponed for a day or two until the anterior chamber has re-formed.

Care must be taken that the cutting edge is kept on the same plane as
the upper edge of the back of the knife, otherwise the incision is
liable to pass further back than is intended.

2. _Splitting the cornea._ The anterior chamber often being little more
than a potential space, the knife may be passed between the lamellæ of
the cornea and may not enter the anterior chamber at all. The indication
that the knife-point is not in the anterior chamber is that there is no
diminished resistance, such as is usually felt when the knife enters the
chamber; if its point be slightly depressed, the cornea will be seen to
dimple in over the position of it, showing that the point is not free in
the anterior chamber.

3. _Locking of the knife._ This is due to the fact that the puncture and
counter-puncture are not made in the same plane, the knife being
twisted. It is much more liable to occur if a knife be chosen with a
blade which is not sufficiently stiff. As a rule the blade can be made
to cut out, but failing this, the knife should be withdrawn sufficiently
to allow a fresh counter-puncture to be made, or else withdrawn
altogether and the operation postponed.

[Illustration: FIG. 116. IRIDECTOMY FOR GLAUCOMA. Division of the iris
to form the inner angle of the coloboma. The iris is pulled out as far
as possible before removal.]

4. _Wound of the lens._ The great safeguard against wounding the lens is
to keep the point of the knife always superficial to the iris and in the
periphery of the anterior chamber. If the lens be definitely wounded at
the time of the operation it should be extracted immediately after the
iridectomy. If the wound be only subsequently discovered (usually about
the third or fourth day), provided the lens be not presenting in the
wound, the eye should be allowed to settle down and the traumatic
cataract extracted some time after the tenth day.

5. _Presentation of the lens in its capsule._ The lens may present in
its capsule at the time of the operation or be found subsequently on the
dressings. In the latter instance it is very liable to carry iris into
the wound, and a cystoid cicatrix results. This accident is usually due
to increased tension in the vitreous chamber; a large incision,
especially if placed rather far back in the sclerotic, will also favour
its occurrence. If the accident should happen to one eye, and acute
glaucoma be present in the other, it is advisable to do a posterior
scleral puncture before the iridectomy is performed. Partial dislocation
of the lens forward may occur after the wound has healed, leaving the
tension of the eye not reduced. This is a condition extremely difficult
to recognize, and it is usually only discovered pathologically; if
recognized clinically, extraction of the lens should be performed (Fig.
117).

6. _Intra-ocular hæmorrhage. Hæmorrhage into the anterior chamber_
occurs at the time of the operation and is readily absorbed;
occasionally it may persist for a considerable time in cases of glaucoma
of long standing.

After the operation hæmorrhage may also occur from the cut margin of the
iris, which never heals, viz. never becomes covered with endothelium.
The hæmorrhage may occur as late as two weeks after the operation and
may recur from time to time; it is especially liable to occur in old
people with arterio-sclerosis. It is usually absorbed without giving
rise to any trouble beyond delay in the convalescence.

_Retinal hæmorrhages_ are frequent and usually small, but a considerable
hæmorrhage may take place into the vitreous. As a rule these clear up
satisfactorily unless the macular region be involved.

[Illustration: FIG. 117. GLAUCOMA IRIDECTOMY. Failure to relieve the
tension owing to displacement of the lens.]

_Subchoroidal hæmorrhage._ Of all the immediate complications which
follow an intra-ocular operation this is by far the worst. The
hæmorrhage is due to the giving way of a large choroidal vessel
following the sudden reduction of tension, with the result that the
choroid and retina are stripped up from the sclerotic, and, with the
lens, may be partially extruded from the wound in the globe, from which
the hæmorrhage then proceeds. It may occur whilst the patient is still
on the operating table, or it may be discovered only after he has been
put back to bed, the blood being seen coming through the dressings.
Patients who have this condition complain of pain in the ‘corner of the
eye’ at the time of the operation. The treatment consists in
evisceration or enucleation. It is probable that limited extravasation
of blood may also occur, which need not end in disintegration of the
eye, but may cause vitreous opacity and defective vision for some weeks
after the operation.

=Remote.= 1. _The tension is not reduced by the iridectomy._ In acute
cases the prognosis with regard to the reduction of the tension and the
improvement of vision is very satisfactory. The same cannot be said of
chronic cases, especially those which have been operated on rather late
in the disease. If iridectomy, which may be repeated downwards or
extended from the previous coloboma, fail to reduce the tension, one or
more of the following measures should be adopted:--

(_a_) The use of eserine.

(_b_) Sclerotomy.

(_c_) Cyclo-dialysis.

(_d_) Sclerectomy.

(_e_) Post-scleral puncture.

It is probably in this order that they should be tried.

2. _Prolapse of the iris and irido-cyclitis_ should be treated as
already indicated under cataract extraction (see p. 208).

3. _The onset of glaucoma in the other eye_ may be induced by the
dilatation of the pupil caused by bandaging, and is best avoided by the
use of eserine. If it should occur, an iridectomy should be performed.

4. _Astigmatism_ produced by the incision is corrected with glasses.
This astigmatism is very marked, often amounting to six or eight
diopters or more.


IRIDECTOMY FOR SMALL GROWTHS OF THE IRIS

=Indications.= This is performed--

   (i) As a diagnostic measure.
  (ii) As a curative measure.

In the latter instance it is obvious that the growth must be very small
and situated at the free margin of the iris to yield a satisfactory
result, especially if it be of a malignant character.

=Operation.= The operation is performed under cocaine, eserine having
been previously instilled in order to contract the pupil.

_First step._ An incision should be made with a narrow Graefe’s knife in
the limbus in a position most suitable for removing the growth. The
incision should be as large as possible so as to avoid wiping off any
portions of the growth into the anterior chamber.

_Second step._ The iris should be seized well in the periphery so as to
avoid breaking up the growth; it is then withdrawn with the growth, and
the latter removed.


IRIDECTOMY FOR PROLAPSE OF THE IRIS

This operation is usually performed for prolapse of the iris following a
wound of the cornea or limbus, and may be attempted up to about the
third day after the original injury.

=Operation.= A general anæsthetic is usually desirable. The prolapsed
iris should be seized with the forceps and withdrawn from the wound. A
second pair of forceps is used to take a fresh hold on the iris, which
can usually be drawn out further (Fig. 118). It is then divided as close
to the corneal wound as possible. The iris usually flies back into the
anterior chamber clear of the corneal wound by its own elasticity, but
if it does not do so it should be freed with a spatula. The pupil should
be kept subsequently under atropine.


TRANSFIXION OF THE IRIS

=Indications.= This operation is undertaken in cases of iris bombé when
iritis is still present and when an iridectomy would subsequently lead
to a drawn-up pupil. It is also of service to evacuate the contents of
cysts of the iris (local iris bombé).

[Illustration: FIG. 118. PROLAPSE OF THE IRIS THROUGH A PUNCTURED WOUND
OF THE CORNEA. Method of withdrawing the iris by two pairs of iris
forceps before removal.]

=Instruments.= Speculum, fixation forceps, Graefe’s knife (narrow).

=Operation.= The knife is entered at the limbus from the outer side
directly opposite the occluded pupil. The apex of the iris bombé is
transfixed and the point of the knife made to appear above the pupillary
area; the iris bombé on the other side of the pupil is then transfixed
and the knife is withdrawn.


THE DIVISION OF ANTERIOR SYNECHIÆ

=Indications.= Anterior synechiæ rarely require division unless they are
likely to cause tension or the adherent iris is considered a source of
danger to the eye on account of its liability to septic infection. If
the synechiæ are causing tension, the method of division described under
sclerotomy is probably the most satisfactory; otherwise the following
method devised by Lang can be used.

=Instruments.= Speculum, fixation forceps, Lang’s knives--one with a
sharp point, and one blunt.

=Operation.= Under cocaine. The incision is made at the limbus in a
favourable situation for the division of the synechia. The sharp-pointed
knife is introduced into the anterior chamber and then rapidly withdrawn
so as not to lose the aqueous. The blunt knife is then inserted through
the incision and, partly by cutting and partly by tearing, the synechia
is divided in a direction from the periphery towards the pupil.

The operation is not at all easy to perform, since the iris gives before
the knife. Great care should be taken to avoid evacuating the aqueous,
as the operation is thereby rendered much more difficult or even
impossible.




CHAPTER IV

OPERATIONS UPON THE SCLEROTIC


ANTERIOR SCLEROTOMY

=Indications.= Sclerotomy is an operation undertaken for the relief of
increased intra-ocular tension. It is performed--

(i) Usually as a secondary operation when iridectomy has failed.

(ii) As a primary operation for the division of anterior synechiæ
causing tension.

A few surgeons prefer the operation to iridectomy, especially in cases
of bup[h]thalmos. When practised after an iridectomy which has been done
upwards, the sclerotomy is sometimes performed in a downward direction;
otherwise the section is usually made upwards. The intra-ocular tension
is probably relieved by the formation of a filtration cicatrix, and it
is therefore probable that it may be largely superseded by the
operations of cyclo-dialysis and sclerectomy.

When performed for the division of anterior synechiæ the position of the
incision should be planned according to the situation of the synechia to
be divided.

=Instruments.= Speculum, fixation forceps, Graefe’s knife with a narrow
blade.

=Operation.= The operation is done under cocaine. Eserine should have
been previously instilled in order to contract the pupil and prevent
prolapse of the iris.

Graefe’s knife should be passed across the anterior chamber in the same
manner and position as for a glaucoma iridectomy (see p. 221). In the
_complete_ method the knife is made to cut out through the sclerotic,
leaving a band of conjunctiva to hold the flap in position. In the
_incomplete_ method a band of sclerotic is left in the periphery. If the
operation is done in a downward direction, it is better for the surgeon
to stand on the opposite side of the patient to the eye on which the
operation is to be performed, operating across the patient.

=Complications.= Any of the complications which follow an iridectomy for
glaucoma may occur (see p. 222). Prolapse of the iris is probably the
most frequent.


CYCLO-DIALYSIS

=Indications.= This operation has only recently come into general use in
this country, so that statistical results have at present by no means
been worked out, but most satisfactory results have been obtained from
it in individual cases; according to German authorities about 30 per
cent. are permanently cured. Although at present its performance is
largely limited to blind eyes and to eyes that have undergone previous
operations for glaucoma, it is probable that it may come into further
use as a primary operation in the treatment of chronic glaucoma and
bup[h]thalmos. It is also of service in cases of dislocation of the lens
backwards, associated with increased tension, where iridectomy would
certainly be followed by loss of the vitreous.

[Illustration: FIG. 119. CYCLO-DIALYSIS OPERATION. Showing the method of
commencing the incision in the sclerotic; it is subsequently deepened
with the point of the knife. The dotted lines mark the incision for
turning forward the conjunctival flap.]

The operation has for its object the separation of the ligamentum
pectinatum from its attachment to the sclerotic, with the probable
result that the ciliary body and iris root become retracted by the
ciliary muscle, so that the canal of Schlemm is opened up and again
communicates with the anterior chamber. It also opens up a free
communication between the anterior chamber and the suprachoroidal
lymph-spaces. The reduction of tension is often not fully manifest for
about ten days after the operation.

=Instruments.= Speculum, fixation forceps, Graefe’s knife, fine pair of
straight iris forceps, fine pair of sharp-pointed straight scissors,
iris spatula.

=Operation.= The operation is best performed under a general anæsthetic,
as it is attended with considerable pain, although cocaine and adrenalin
are frequently used and are always advisable, since the hæmorrhage from
the scleral vessels renders it difficult to gauge the depth of the wound
in the sclerotic.

[Illustration: FIG. 120. CYCLO-DIALYSIS OPERATION. Showing the spatula
separating the ciliary body and ligamentum pectinatum from the
sclerotic.]

_First step._ By means of the straight iris forceps and sharp-pointed
scissors a semilunar conjunctival flap is first raised over the site for
the scleral incision. The incision in the sclerotic should be situated
about 5 mm. behind the corneo-sclerotic junction over the ciliary
region, the outer and upper quadrant of the eye being the easiest
position for subsequent manipulation (Fig. 119).

_Second step._ With a Graefe’s knife the fibres of the sclerotic are
carefully divided in an oblique direction forward until the
suprachoroidal lymph-space is opened for about 3 mm. The first part of
the incision is performed with the blade and completed with the point
of the knife, the anterior flap of sclerotic being held forward by
straight iris forceps. Heine uses a keratome, dividing the fibres of the
sclerotic with the point by stroking it along the line of the incision.
The depth of the incision should be carefully gauged from time to time
with the iris spatula; the pigment of the ciliary body is usually seen
in the bottom of the wound when the sclerotic has been penetrated.

_Third step._ The iris spatula is directed forwards and inserted between
the sclerotic and the ciliary body, keeping close to the former. With a
gentle side-to-side movement the spatula is made to separate the ciliary
body from the sclerotic for about one-eighth of its whole circumference;
then the ligamentum pectinatum is detached from the sclerotic for about
the same distance by gently passing the spatula forwards and making the
latter appear in the anterior chamber (Fig. 120). If it be desired to
evacuate the anterior chamber, the spatula is slightly rotated so as to
allow the escape of the aqueous. As a rule this is not necessary or even
advisable. The spatula is then withdrawn and the conjunctival flap is
replaced in position. Eserine should be instilled.

=Complications.= (1) Unless the incision be carried carefully through
the sclerotic, or the manipulations with the iris spatula be very
gentle, loss of vitreous is liable to take place. As a rule, this, if
not great, is of little consequence. (2) In passing the iris spatula
forward to separate the ligamentum pectinatum the point may pass between
the layers of the cornea; this is recognized in the resistance offered
to the side-to-side movement of the spatula, which should be withdrawn
slightly and the point depressed so as to engage the ligamentum
pectinatum. (3) Subchoroidal hæmorrhage has been known to occur after
the operation.


SCLERECTOMY

The object of the operation is the production of a filtration cicatrix
free from iris tissue for the relief of intra-ocular tension in chronic
glaucoma.

=Instruments.= As for glaucoma iridectomy, with the addition of a small
curved pair of scissors.

=Operation.= Under cocaine.

_First step._ The incision is performed as for glaucoma iridectomy (see
p. 221), except that the incision should be rather smaller and should be
carried more obliquely through the sclerotic, so that a long scleral
flap is obtained. A large conjunctival flap is very essential to cover
the wound.

_Second step._ An iridectomy is usually performed as for glaucoma; this
may be omitted.

_Third step._ After all the bleeding has ceased, the conjunctival flap
is turned forwards on to the cornea so as to expose the scleral flap;
with small curved scissors made for the purpose, an elliptical portion
is removed from the sclerotic by a single snip (Figs. 121 and 122), and
the conjunctival flap is replaced in position. As a result, a hole is
made into the anterior chamber, which thus communicates with the
subconjunctival tissue, which is bulged forwards in the form of a clear
vesicle by the escaping aqueous when the wound has healed.

[Illustration: FIG. 121. LAGRANGE OPERATION FOR THE PRODUCTION OF A
CYSTOID SCAR IN CHRONIC GLAUCOMA. Showing the method of removing a piece
of the sclerotic.]

[Illustration: FIG. 122. LAGRANGE OPERATION FOR CHRONIC GLAUCOMA.
Showing the piece of sclerotic removed by the scissors (black lines).]

The immediate results of this operation are satisfactory provided that
enough sclerotic be removed to produce a filtration cicatrix. As yet
sufficient time has not elapsed for any statistical results to be
obtained, but the cases in which the operation has been performed are
reported as satisfactory.


POSTERIOR SCLEROTOMY

=Indications.= Posterior scleral puncture is performed--

(i) For the relief of tension, the indications for which have already
been described under the indications for iridectomy in glaucoma (see p.
218).

(ii) For the evacuation of fluid behind a detached retina.

The operation in the latter instance, although not yielding very
satisfactory results with regard to the reattachment of the retina, may
be carried out with some hope of success in certain cases. Before
performing the operation the pathological cause of the detachment
should be carefully investigated, for it is obvious that it would be
useless to perform the operation in a case of detachment due to a
choroidal tumour or if definite bands of fibrous tissue could be seen in
the vitreous pulling off the retina. Undoubtedly it should be undertaken
as soon as possible after the detachment has occurred and the puncture
should enter the space filled with subretinal fluid. Whether the
puncture should penetrate the overlying retina is still a disputed
point.

After the operation a pressure bandage should be applied and the patient
should be kept on his back and not allowed to raise his head from the
pillow for at least three weeks. This latter part of the treatment is
most essential; indeed as good results may be obtained with complete
rest as by performing scleral puncture. Unfortunately, recurrence is
very liable to take place whichever method be used, even if reattachment
of the retina be obtained.

=Instruments.= Speculum, fixation forceps, Graefe’s knife.

=Operation.= Under cocaine. If no special position be indicated the
puncture is best made upwards and inwards. The patient is made to look
outwards and downwards. The conjunctiva over the sclerotic, well behind
the ciliary body, is drawn down so that when released it shall form a
valvular opening to the scleral wound. The Graefe’s knife is driven
through the conjunctiva and sclerotic, the incision being made
antero-posteriorly in the direction of the fibres of the sclerotic to
avoid wounding the choroidal vessels. It is probably better to enlarge
the wound when withdrawing the knife than to turn the latter at right
angles before it is withdrawn, as has been recommended by some surgeons.
A bead of vitreous usually escapes under the conjunctiva. If the tension
be not lowered, gentle massage of the globe through the lid should be
employed.


PARACENTESIS OF THE ANTERIOR CHAMBER

=Indications.= Evacuation of the contents of the anterior chamber is
performed for several conditions:--

(i) To reduce the tension of the eye when due to an altered consistency
of the aqueous, as for instance in cyclitis.

(ii) To evacuate pus from the anterior chamber following metastatic
infection.

(iii) To evacuate the anterior chamber in bad corneal ulceration,
especially when associated with hypopyon and tension.

(iv) To examine the aqueous for organisms in cases of cyclitis following
operation or of metastatic origin.

(v) To evacuate soft lens matter (see p. 194).

The operation is usually performed through an incision directly behind
the limbus. In the case of corneal ulceration it is sometimes performed
by dividing the base of the ulcer with a Graefe’s knife (Sämisch’s
section). When collecting the aqueous for bacteriological examination, a
sterile hollow needle with a point similar to a discission needle,
attached to a hypodermic syringe, should be passed into the anterior
chamber at the limbus and the fluid withdrawn into the syringe by an
assistant (Fig. 123). The spot through which the needle is passed is
first touched with the electro-cautery to ensure asepsis.

=Instruments.= Speculum, fixation forceps, bent broad needle, iris
spatula.

=Operation.= Under cocaine. The puncture is usually made upwards and
outwards unless there be some other special indication for its position,
such as a mass of pus in the lower angle of the anterior chamber. The
eye is fixed opposite the spot at which the puncture is to be made, and
the bent broad needle is passed into the anterior chamber through an
incision directly behind the limbus. The needle is then withdrawn and is
usually followed by a rush of aqueous. The remainder of the aqueous is
then evacuated by pressing the lower margin of the wound with an iris
spatula. In some cases where a very tenacious hypopyon is present it may
be withdrawn with the iris forceps. The only complication liable to
occur is prolapse of the iris into the wound, which should be replaced
with the spatula, or failing that, removed.

[Illustration: FIG. 123. HOLLOW NEEDLE USED FOR PARACENTESIS OF THE
ANTERIOR CHAMBER. This is used when it is desired to examine the aqueous
bacteriologically. Care should be taken to see that the cutting blade is
sufficiently wide to take the shaft of the needle.]


OPERATIONS FOR PENETRATING WOUNDS OF THE GLOBE

=Indications.= Of all the conditions which a surgeon is called upon to
see, penetrating wounds of the globe may present the most difficult
problems as to treatment. The most important factors in their treatment
and prognosis are--

1. _The time at which the patient presents himself for treatment_ and
the condition of the wound are all-important in the prognosis. Thus in
the case of a wound which is obviously septic and going to terminate in
panophthalmitis the eye should be eviscerated.

2. _The position and extent of the wound._ Formerly it was taught that
if the ciliary body were wounded the eye should be excised. The reason
for this was that these injuries were so frequently followed by
sympathetic ophthalmia owing to prolapse of the iris and ciliary body.
It is now generally recognized that sympathetic ophthalmia only follows
if the wound becomes septic, irido-cyclitis with keratitis punctata
being present, and it is only after the latter symptom manifests itself
that the eye should be excised, provided that the wound be not so
extensive as to preclude all chance of recovery from the outset.

_In wounds of the sclerotic_ all portions of the uveal tract and
vitreous which prolapse should be removed, and the wound closed with
sutures passed through the superficial episcleral tissue. Unless the
wound be small the prognosis is not good, as it is liable to be followed
by irido-cyclitis, or, if this does not occur, detachment of the retina
may ensue, following on organization of the exudates in the vitreous.

_Wounds of the cornea_ usually result in prolapse of the iris, which
should be removed in the manner described under iridectomy (see p. 208).

3. _If the lens be injured._ Unless the wound amounts to little more
than a punctured wound of the globe involving the lens, the prognosis is
bad. The wound in the lens capsule and the breaking up of the lens mean
the presence of soft matter in the anterior chamber--a condition which
favours sepsis and is liable to produce increased tension from blocking
the angle of the chamber. In patients under thirty the pupil should be
dilated with atropine and the lens allowed to absorb--assisted at a
later date by needling, when the eye has entirely settled down after the
original injury. If the patient be over thirty it is often extremely
difficult to decide whether extraction of the lens should be undertaken
at the time of the injury or at a later date. The results of both
procedures are very unsatisfactory, and the surgeon should be guided
partly by the position and extent of the wound. Given these in a fairly
favourable position, it is probable that immediate extraction will give
the best result.

4. _If the eye contain a foreign body._ Usually these are pieces of
metal or glass. The following points should be investigated to determine
whether the foreign body be in the eye:--

(i) The history of these accidents is usually the same. The patient is
chipping with a hammer and chisel, and a piece flies off and strikes the
globe. In the case of glass it is usually a mineral-water bottle which
bursts.

(ii) The position and nature of the wound in the cornea and sclerotic.

(iii) The condition of the anterior chamber--whether evacuated or not.

(iv) The tension of the eye, which may be lowered.

(v) The presence of a hole in the iris.

(vi) The presence of traumatic cataract.

(vii) Whether the foreign body is visible with the ophthalmoscope or by
focal illumination.

(viii) The localization of the foreign body by the X-rays. The latter is
the most important factor of all, since the foreign body may pass right
through the globe and be embedded in the orbit.

[Illustration: FIG. 124. AUTHOR’S CHAIR FOR THE LOCALIZATION OF FOREIGN
BODIES IN THE EYE BY THE X-RAYS. A is a rifle sight for centring the
anode, C, on the cross wire, B, behind which the photographic plate is
subsequently placed. P is the screw clamping the head-piece on to the
patient’s head. Q is the screw for regulating the height of the tube and
the distance from the patient. R is the screw for regulating the height
of the head-piece. The inset shows the arm carrying the tube more highly
magnified. E is the sliding arm carrying the tube for lateral
displacement marked for stereoscopic photographs. F is the pointer for
marking the position of the anode. D is the screw for clamping when in
position.]

=Operative treatment.= If the injury be a recent one and the foreign
body a metal of magnetizable properties, it is best removed by an
electro-magnet after localization by the X-rays (Fig. 124). Sideroscopes
have been used, but are not so satisfactory. If the foreign body be
non-magnetizable, such as a piece of copper cap or manganese steel, an
attempt may be made to remove it with forceps after localization. If
the foreign body be embedded in the lens it is often advisable to
extract the lens together with it. If the foreign body be of glass, and
it be only small, it is usually best left alone, unless capable of easy
removal, _e.g._ if it be situated in the anterior chamber; the eye will
often tolerate the presence of glass provided it be aseptic.

_The eye should be removed_--

(i) If the wound be obviously septic.

(ii) If the wound be very large, more especially if the lens be injured.

(iii) If the foreign body be a large piece of metal and cannot be
extracted.

(iv) If the eye does not settle down after one of the operations
described below, especially if irido-cyclitis with keratitis punctata
should have supervened.

=If the injury be of long standing.= It is of little use as a rule
attempting to extract a foreign body from the eye after three days,
unless it be loose in the vitreous or embedded in the lens, as it
becomes surrounded by lymph. Under these circumstances it is better to
leave it alone, or, if it be causing signs of irritation, to enucleate
the eye.


ELECTRO-MAGNET OPERATIONS

Magnets for the removal of magnetizable foreign bodies from the eye are
of two types--(1) a small magnet, which is inserted into the globe, (2)
a giant magnet, which is used to attract the foreign body in the eye
from the outside.

Surgeons differ as to which is the best method to employ. The
statistical results of both are about the same. Many surgeons in this
country, and with them the author, prefer the small magnet, especially
of the recent more powerful type (Hirschberg), which runs off the main
electric current, for the following reasons: it is more accurate (after
localization by the X-rays), there is less trauma to the globe involved,
it is more portable, and, when the foreign body is in the anterior or
the posterior chamber, it is much easier to extract it with a small
magnet than with a large one.

=With the small magnet. Instruments.= Beer’s knife, fixation forceps,
magnet (Fig. 125), and suture. The points of the magnet, which are
detachable, are sterilized by boiling.

=Operation.= The foreign body is first localized accurately by means of
the X-rays. If it lies near the wound of entrance the magnet point is
inserted, the electric circuit completed, and the foreign body
withdrawn, the wound of entrance being enlarged if necessary. If the
foreign body lies at some distance from the wound, as for instance in
the vitreous, an antero-posterior incision is made in the sclerotic, as
near to it as possible, by plunging the knife through the conjunctiva
and the sclerotic, the former having previously been drawn to one side
so as to form a valvular opening. The size of the incision should be
such that it will admit the point of the magnet and allow the foreign
body to come out, the size of the foreign body being judged by the X-ray
photograph. After the knife has been withdrawn, the point of the
electro-magnet is inserted and the circuit closed, the magnet being
withdrawn with the foreign body attached to it. The conjunctival wound
is closed by a suture if necessary. If the foreign body be situated in
the anterior or posterior chamber or the lens, an incision should be
made into the anterior chamber with a keratome, the point of the magnet
inserted, and the foreign body withdrawn. In cases in which the foreign
body is deeply embedded in the lens, more especially in patients over
thirty years of age, extraction of the lens together with the foreign
body should be performed.

[Illustration: FIG. 125. SMALL ELECTRO-MAGNET FOR EXTRACTING PIECES OF
STEEL FROM THE EYE. It is made to work direct off the electric main.]

=Complications.= _Immediate._ Failure to extract the foreign body may
arise from--

1. The foreign body being embedded in lymph. It is therefore of the
utmost importance that the operation should be performed as soon as
possible after the injury.

2. The foreign body being deeply embedded in the sclerotic so that the
magnet will not exert sufficient traction to withdraw it.

3. The foreign body being non-magnetic (all steel is not magnetic).

4. Too small a wound being made for its extraction, the metal being
wiped off on the edges of the wound as the magnet is withdrawn.

5. Insufficient power in the magnet.

_Remote._ 1. Panophthalmitis, which must be treated by evisceration.

2. Irido-cyclitis; if this be prolonged, and keratitis punctata appear,
enucleation should be performed.

3. Traumatic cataract; this may subsequently require needling.

4. Detached retina as the result of organization in the vitreous; this
may occur months after the original injury.

=With the giant magnet.= The foreign body should have been previously
localized by the X-rays, and its position and size determined, so that
it may be removed by the shortest possible route and with the least
amount of injury to the eye.

=Instruments.= Giant magnet (Fig. 126), steel spatula. (Watches and
magnetizable metal should be removed from both the patient and the
surgeon.)

=Operation.= Under atropine and cocaine. The patient is at first seated
in a chair some three feet in front of the magnet, the eyelids being
held apart by the surgeon; the electric circuit is closed. The patient’s
head is next gradually advanced towards the magnet. If a foreign body be
present in the eye and be magnetizable, the patient will usually
withdraw his head or cry out with pain, and the foreign body may be seen
bulging forward the iris from the posterior chamber. From this position
it may be removed by manipulating the head and eye in relation to the
magnet so as to withdraw it into the anterior chamber, from whence it is
removed through the entrance wound or an incision at the limbus either
by the giant magnet directly applied to the wound or by magnetizing a
steel spatula which is inserted into the anterior chamber and connected
with the magnet by a flexible steel cable. The small magnet previously
described may be used, or the foreign body removed by means of iris
forceps.

[Illustration: FIG. 126. LARGE ELECTRO-MAGNET. The current is turned on
by means of the foot pedal.]

A piece of steel in the vitreous always travels round the posterior
surface of the lens and through the suspensory ligament, and does not
injure the lens capsule.

=Complications.= These are similar to those described under the small
magnet operation.




CHAPTER V

OPERATIONS UPON THE CORNEA AND CONJUNCTIVA


OPERATIONS UPON THE CORNEA

REMOVAL OF A FOREIGN BODY FROM THE CORNEA

Removal of a foreign body from the cornea requires a good light (focal
illumination). The use of a binocular lens is also of service. Foreign
bodies lodged on the surface of the cornea can be removed easily under
cocaine with a spud. If the foreign body be deeply embedded in the
cornea a fine sterile discission needle should be used. When a foreign
body, such as a chip of iron, is deeply embedded, the needle should be
inserted slightly to one side of the entrance wound and passed beneath
the foreign body so as to lift it from its bed. When the foreign body
has partially penetrated the anterior chamber but still lies in the
cornea, an incision should be made with a keratome at the limbus and the
foreign body pushed back through the entrance wound with the aid of an
iris spatula. If the foreign body be iron, the electro-magnet may be of
use, and in this case should be tried before resorting to an incision in
the anterior chamber. A stain is left frequently after the removal of
foreign bodies; this should be removed as far as possible. Subsequently
the eye should be bandaged for a few days and bathed with boric lotion.
Atropine should be instilled if there be any signs of infiltration
around the wound.


CAUTERIZATION OF THE CORNEA

Either a chemical or the actual cautery may be used.

=Indications.= _Corneal ulceration._ The cornea being extremely dense,
organisms do not penetrate very deeply into its substance, so that
destruction of the bacteria is effected by cauterization of the
spreading portion of an ulcer; the albumin is also coagulated and so a
barrier is presented to their advance.

=Operation.= The eye is thoroughly cocainized, and the spreading portion
of the ulcer is first defined by staining with fluorescine, washing away
the excess of stain with boric lotion.

_By a chemical caustic._ Liquefied carbolic (carbolic acid crystals
liquefied in 10 per cent. of water) is applied upon a sharpened match.
Any excess should be removed so as to prevent its running on to the
cornea. A speculum is inserted and the cornea is dried by blotting with
cigarette paper; the stained area is lightly touched with the point of
the stick, particular attention being paid to the spreading margin. A
dense white plaque is the result; this usually clears up in a few days.
Atropine ointment is applied daily to the conjunctival sac.

[Illustration: FIG. 127. ELECTRO-CAUTERY.]

_By the actual cautery._ The electro-cautery (Fig. 127) point should be
extremely fine and only raised to a dull red heat. The stained area
should be touched lightly with the point.

The actual cautery is best for serpiginous corneal ulcers, carbolic acid
being more satisfactory for those of the vesicular type.


OPERATIONS FOR CONICAL CORNEA

=Indications.= Since the operation for conical cornea is not without
serious risks, it should only be undertaken when the vision cannot be
improved with glasses to 6/18; high + or - cylinders will often yield
satisfactory results. The object of all forms of operation is the
flattening of the cone.

=Operation.= This may be carried out either by excision of the apex of
the cone or by cauterization.

=Excision of the apex of the cone= is probably the more satisfactory
method, although it is somewhat more difficult to perform. The object of
the operation is to remove an elliptical portion of the whole thickness
of the cornea from the apex of the cone, the long axis of the ellipse
being placed horizontally. It leaves the eye with only a minute scar as
compared with the nebula produced by the cautery, which is often so
great as to require an optical iridectomy to restore vision.

=Instruments.= Speculum, fixation forceps, a narrow Graefe’s knife,
straight iris forceps, and scissors.

The operation is done under cocaine, atropine having been previously
instilled.

_First step._ The apex of the cone is transfixed by the Graefe’s knife
with the blade directed slightly upwards and forwards, the knife being
made to cut out. The cornea in this situation is extremely thin, being
often not more than 1 mm. in thickness. The length of the incision
should not exceed 2 mm.

_Second step._ The flap of corneal tissue thus made is seized with the
straight iris forceps and removed with iris scissors, producing a small
elliptical opening. The chief difficulty of the operation is the seizing
of the corneal flap, which is most difficult to hold; care must be taken
not to injure the lens capsule with the iris forceps or scissors when
the cornea has collapsed as the result of the evacuation of the anterior
chamber. The eye should be firmly bandaged subsequently, and the patient
kept in bed until the anterior chamber has re-formed.

=Complications.= _Slow re-formation of the anterior chamber._ The
anterior chamber will often take two or three weeks to re-form, owing to
the hole in the cornea not closing. During this time the eye is open to
septic infection and therefore the greatest care should be taken to keep
it aseptic when dressing it. For this reason and also because the
following complications are due to the same cause, it is desirable to
remove as little corneal tissue as possible in performing the operation.
It is probable that conjunctivoplasty (see p. 245) would considerably
facilitate the rapid closure of the wound.

_Anterior polar cataract_ may result from prolonged contact of the lens
with the wound in the cornea. As a rule this seldom interferes much with
vision.

_Anterior synechiæ_ from incarceration of the iris in the wound
occasionally result and may require subsequent division.

_Acute glaucoma_ is by no means an infrequent complication--indeed the
author has seen four successive cases of conical cornea, operated on
both by excision and by the cautery, followed by this complication. It
is probably due to adhesion of the root of the iris to the back of the
cornea during the time the anterior chamber is empty. It can usually be
relieved by an iridectomy.

=The electro-cautery operation.= The operation generally adopted is
known as the target operation. It consists in surrounding the apex of
the cone with two rings of cautery marks, the outer made at a dull red
heat, the inner with the point slightly brighter, whilst the apex is
cauterized at a red heat, so that rings of different depth are obtained.
Cauterization of the apex should stop just short of perforation, the
inner ring being deeper than the outer. With this method secondary
glaucoma and anterior synechiæ are not so liable to occur. On the other
hand, an optical iridectomy has to be performed more frequently. A few
surgeons still cauterize the apex of the cone until a perforation is
produced. This latter operation seems to have the disadvantages of both
methods and the advantages of neither.


REMOVAL OF TUMOURS INVOLVING THE CORNEA

Tumours which involve the cornea are usually secondary to tumours
occurring at the limbus. The chief of these are: _simple_--dermoid
patches, moles of the limbus; _malignant_--sarcoma, endothelioma,
epithelioma. Dermoid patches should be shaved off as close to the cornea
as possible; the white area left after their removal can be improved by
tattooing.

Malignant tumours in very early stages may be removed locally with
scissors and forceps, the cautery being applied to their base, since
they do not tend to invade the sclerotic deeply.


TATTOOING THE CORNEA

=Indications.= (i) To do away with the blinding effects of light through
a scar after iridectomy has been performed (see p. 215).

(ii) To simulate a pupil on a white scarred cornea.

[Illustration: FIG. 128. TATTOOING NEEDLES.]

The operation is not without risks, as it may light up old inflammation
in a previously quiet eye. Panophthalmitis and sympathetic ophthalmia
have both been known to follow it. The pricking of the needle may carry
in epithelium and implantation dermoids may arise.

=Instruments.= A fine single needle is generally used, occasionally a
bundle of needles (Fig. 128).

=Operation.= Under cocaine. Chinese ink, sterilized and prepared by
rubbing up with 1-6,000 perchloride of mercury, is smeared over the area
to be tattooed. Multiple punctures in an oblique direction are then made
into the cornea over the area desired. More paste is then rubbed in over
this area. The cornea should be intensely black after the operation, as
a certain amount of the ink is carried away by phagocytosis and shedding
of the epithelium. Subsequent reaction may be reduced by means of an
iced compress. Atropine should be instilled.


SCRAPING CALCAREOUS FILMS

Calcareous films, when not associated with active irido-cyclitis, may be
removed with advantage to the vision. Care should be taken to see that
no keratitis punctata is present before the operation is undertaken.

=Instruments.= Speculum, fixation forceps, a spoon which should have
rather a blunt edge.

=Operation.= Under cocaine. The area is very lightly scraped with the
spoon. The calcareous changes are in the deeper layers of the epithelium
and Bowman’s membrane and hence are easily removed. The scraping should
be carried well beyond the apparent margin of the film. The epithelium
often takes some time to regenerate. As a rule the results are
satisfactory, although the film is apt to recur in the course of years,
but it may be removed again if necessary.


OPERATIONS UPON THE CONJUNCTIVA

THE REMOVAL OF FOREIGN BODIES

Foreign bodies lodged in the conjunctival sac, unless embedded in the
conjunctiva, are usually found by the surgeon under the upper lid, the
sulcus subtarsalis being a favourite situation. They are easily removed
with a spud or needle, after the instillation of a drop of 4% cocaine
solution. Subsequently the eye should be bandaged for a few hours until
the effect of the cocaine has passed off, as in wiping the eye the
patient may wipe off the epithelium of the cornea whilst it is
insensitive from the cocaine.

_In order to evert the upper lid_ the patient is made to look strongly
down, the eyelashes are seized between the thumb and forefinger of the
left hand, the skin of the upper lid is pushed down above the tarsal
cartilage with the thumb of the right hand, and the lid is everted by
pulling it upwards against the point of the thumb.


OPERATION FOR PTERYGIUM

=Indications.= Pterygium should be removed when advancing across the
cornea, especially when the pupillary area is becoming involved. The
operation of ablation is the one now generally in use.

=Instruments.= Speculum, straight iris forceps, small sharp-pointed
scissors.

=Operation.= Under adrenalin and cocaine the neck of the pterygium is
seized with the forceps and the body and neck are carefully dissected
from the conjunctiva. The body and neck should be very carefully
separated right up to the corneal margin by means of forceps and
scissors. The head is then stripped off the cornea with a sharp pull.
The wound in the conjunctiva should be subsequently closed with fine
sutures, otherwise the disease will certainly recur. In stripping the
head from the cornea some of the epithelium may be torn off with it.
This usually regenerates without impairing the vision.


EXPRESSION

This is an operation for the removal of follicular formations in the
conjunctiva, and is used more especially in trachoma.

=Instruments.= Graddy’s forceps (Fig. 129), fixation forceps.

=Operation.= The operation may be performed under cocaine and adrenalin,
a little solid cocaine being rubbed into the area to be expressed. In
severe cases in which both eyes are affected, and in small children, a
general anæsthetic may be necessary.

Although a number of instruments are in use, perhaps the best, and
certainly the least painful, is Graddy’s forceps. In the case of the
upper lid it is everted, one blade of the forceps being passed into the
fornix, the other being placed over the upper surface of the everted
lid. A gentle steady pressure is applied, and the lid is drawn out
between the blades. In this way as much of the conjunctiva is gone over
as is necessary. The lower fornix is best expressed by picking up the
loose fold of the fornix with ordinary forceps and then expressing with
Graddy’s.

[Illustration: FIG. 129. GRADDY’S FORCEPS.]

If only one or two follicles be present they can be picked up with the
ordinary fine dissecting forceps and expressed, but when situated on the
tarsus the follicles are best enucleated with a spud; a solution of 1 in
50 perchloride of mercury in glycerine is then rubbed into the
conjunctiva. The operation may have to be repeated several times as new
follicles form.


CONJUNCTIVOPLASTY

Conjunctivoplasty is an operation for the transplantation of a flap of
conjunctiva to cover some loss of substance or defect in the continuity
of the globe.

=Indications.= The operation may be necessary--

(i) To close large recent wounds of the cornea.

(ii) To close the wound made by the excision of a cystoid scar.

(iii) To facilitate the healing of a clean ulcer such as Mooren’s ulcer,
or to cover the aperture made by an ulcer that has perforated.

(iv) In the treatment of conical cornea by excision of the apex of the
cone, it might facilitate the rapid closure of the wound and assist in
flattening of the cornea.

=Operation.= _First method._ Under cocaine. A flap of conjunctiva is
raised from around the limbus, having its base as near the area to be
covered as possible; its breadth should be one and a half times the
width of the area to be covered. This flap is drawn across the defect in
the cornea and stitched to the conjunctiva on the other side; the wound
made in raising the flap should be allowed to heal by granulation.

The stitches holding the flap in position cut through in two or three
days, but by that time their purpose will have been served. If the flap
be still adherent to the wound its base may be divided and any
superfluous tissue removed; the remainder will disappear rapidly.

_Second method._ The conjunctiva is dissected up all round the cornea as
close to the limbus as possible, and backwards as far as the insertion
of the recti. A purse-string suture is then inserted around its margins
and drawn tight so that the whole cornea is covered by conjunctiva. The
operation is suitable for cases in which large areas have to be covered.


REMOVAL OF TARSAL CYSTS

The Meibomian glands being embedded in the tarsal plate, cysts in them
present both on the conjunctival surface and towards the skin, but the
contents are always evacuated from the former.

=Instruments.= Walton’s iris knife, sharp spoon.

=Operation.= Under adrenalin and cocaine. The eyelid is everted and a
drop of the solution is injected into the cyst with a hypodermic
syringe. A vertical stab is made into the cyst with the knife and the
contents are then evacuated with a sharp spoon.

Difficulty may arise in fixing the cyst whilst making the incision; this
is best obviated by holding the everted lid between the finger and
thumb.

In some cases, when the cyst has persisted for a considerable time, the
sac-wall becomes so thickened that it has to be dissected out before the
mass in the lid will disappear.




CHAPTER VI

OPERATIONS UPON THE EXTRA-OCULAR MUSCLES


SQUINT OPERATIONS

=Indications.= Operations upon eyes with concomitant squint are
undertaken for two purposes:--

(i) For cosmetic reasons, to remedy a deformity due to a squinting eye
which is amblyopic.

(ii) To rectify the muscular equilibrium in alternating or latent
squints, so that binocular vision may be regained.

When the operation is performed for the latter reason the adjustment
will naturally have to be much more accurate than for the former, so as
to bring about the superimposition of the images falling on each macula.
The muscular balance is interfered with by the administration of a
general anæsthetic, and therefore the results cannot be gauged
accurately. Thus it is desirable that operations upon the ocular muscles
should be performed under local anæsthesia. This is usually possible,
except in the case of very small children.

During and after the operation muscular equilibrium is tested by means
of an electric light fixed to the ceiling immediately over the head of
the patient (see Fig. 74). The room is darkened and the patient is made
to look at the light. In a case with an amblyopic eye the reflection of
the light should appear in the middle of each cornea if the eye be
properly adjusted. In cases where good vision is present in both eyes
the Maddox rod test should be used, the rod being placed before the eye
not being operated on; the bar of light produced by the rod should pass
through or within a few inches of the light if the adjustment has been
performed accurately.

The tendons of the recti muscles are inserted into the globe at the
following distances from the corneo-sclerotic junction: internal, 5 mm.;
inferior, 6 mm.; external, 7 mm.; superior, 8 mm. Each muscle is held in
place by expansions on either side of the tendon as well as by the
tendinous insertions. Division of these expansions allows a greater
retraction of the muscle and is, therefore, to be undertaken when a
considerable degree of squint has to be overcome. On the other hand,
there will be a danger that the muscle may not regain a proper
attachment to the globe if division be too freely performed, and a
squint in the opposite direction may result; proptosis also may be
caused thereby. It is, therefore, better to combine tenotomy with
advancement in high degrees of squint over twenty degrees convergent and
in all cases of constant divergence. This is usually better than
performing a tenotomy in the other eye, as there still remains the
muscle of the other eye in reserve to tenotomize if necessary, if the
advancement be insufficient to correct the squint. Further, it is much
easier to rectify a muscular error by accurate tenotomy than by
advancement. Division of the tendon of the internal rectus only, without
its expansion, will usually rectify cases of latent convergent
strabismus with a deviation of about 12° prism (Maddox test). Cases of
latent divergent strabismus of about 8° prism (Maddox test) require
complete division of the tendon of the external rectus, and, in some
cases, of the expansion as well. Tenotomy of the superior rectus for
hyperphoria should only be undertaken in bad cases; that is to say, of
over 12° prism, any lateral deviation being first corrected, as
occasionally the correction of the lateral deviation, especially when
this is due to the faulty insertion of a muscle, will sometimes correct
the hyperphoria present.

Partial tenotomies are performed by some surgeons for the correction of
latent muscular errors, but the experience of most in this country is
that little benefit is gained unless the tendon be completely divided.
Tendon-lengthening by various methods has been performed, but has not
come into general use.

After all operations upon the ocular muscles both eyes should be
occluded to keep the eyes at rest whilst the muscle is gaining its fresh
attachment to the globe; this usually takes about seven days, after
which time both eyes should be uncovered, and if there is a tendency to
convergence atropine should be used. Glasses correcting any error of
refraction should be worn.


TENOTOMY

Tenotomy may be performed by (1) the open, or (2) the subconjunctival
method.

=Instruments.= Speculum, straight blunt-pointed scissors, strabismus
hook, needle and silk, needle-holder.

=Operation.= The operation is performed under adrenalin and cocaine.

1. _By the open method._ The surgeon stands on the right side facing the
patient when dividing the right external or the left internal rectus,
but at the head of the table when dividing the right internal or the
left external rectus.

_First step._ The speculum is inserted and the patient is made to look
away from the muscle to be divided. The conjunctiva is freely divided
vertically with scissors directly over the insertion of the tendon into
the globe (see Fig. 130) and dissected backwards.

[Illustration: FIG. 130. TENOTOMY. Showing the method of holding the
scissors and the position of the hands.]

_Second step._ The tendon of the muscle is then seized with fixation
forceps and button-holed about its centre as close to the globe as
possible (Fig. 131). The lower blade of the scissors is then passed
through the hole in the tendon, and the rest of the tendon and its
expansions are divided upwards and downwards to the extent required to
bring the eye straight as tested by its appearance or by the Maddox rod
test. The strabismus hook may be inserted, both upwards and downwards,
to see that the tendon is properly divided, but all pulling on the
muscle with a hook should be avoided, as it is painful and disturbs the
muscular equilibrium. The conjunctiva is then brought together with a
fine silk suture. If the squint be over-corrected by the tenotomy, a
deep hold should be taken with the stitch so as to draw the eye back
into position.

2. _By the subconjunctival method._ This is unsatisfactory in that
accurate adjustment by division of the expansion of Tenon’s capsule is
not possible. It is painful, and is sometimes followed by a troublesome
hæmorrhage into the capsule of Tenon. Occasionally it may be of use in
some cases of amblyopic eyes where a small wound is desirable. The
conjunctiva is button-holed below the tendon, and separated from the
surface of the muscle. The capsule of Tenon is then opened below the
tendon, a strabismus hook is passed through the opening with its
concavity against the globe, and is then rotated upwards beneath the
tendon, which is subsequently divided between the hook and the globe.

[Illustration: FIG. 131. TENOTOMY BY THE OPEN METHOD. The tendon is
first button-holed about its centre and the expansions are then divided
upwards and downwards to the required extent.]

=Complications.= These may be immediate or remote.

=Immediate.= 1. _Hæmorrhage into the capsule of Tenon_, leading to
intense proptosis, only occurs when the subconjunctival method is
adopted. As a rule the hæmorrhage ceases on the application of pressure,
but occasionally it may be necessary to open up the wound and turn out
the blood-clot.

2. _Perforation of the globe_ has been known to occur during the
division of a tendon in an obstreperous patient. It should be treated as
a wound of the sclerotic (see p. 235).

3. _Tenonitis_ very rarely occurs, but may lead to matting down of all
the extra-ocular muscles and defective movements of the globe.
Panophthalmitis has been known to follow this condition.

=Remote.= 1. _Failure to correct the muscular error._ If the error be
large it must be rectified by tenotomy of the corresponding muscle of
the other eye or by the advancement of the opposing muscle of the same
eye. This should not be undertaken until five or six weeks have elapsed
since the previous operation.

2. _Over-correction of the muscular error at the time of the operation_
may be remedied by stitching the tenotomized muscle forward to the
extent required to bring the eye straight. Advancement of the
tenotomized muscle should be performed if the over-correction be only
discovered after the operation. In cases with binocular vision lesser
degrees of deviation may be corrected with prisms if they are causing
symptoms, while small errors of over-correction, of about 3° prism,
often disappear after the first few weeks.

3. _Defective movement in the tenotomized muscle_ is usually present for
the first week or two after the operation, but recovery usually takes
place after the muscle has regained its attachment to the globe; it may
persist, however, to a slight extent; this is most liable to occur after
free division of the tendon and its expansion (more especially in the
case of the external rectus), or because the tendon has not been divided
close enough to the globe. In patients with previous binocular vision
diplopia is present after the operation on turning the eyes towards the
same side as the tenotomized muscle, but this usually disappears.

4. _A granulation_ may form at the site of the tenotomy wound. It may be
due to a tag hanging from the wound or to a portion of a stitch that has
been imperfectly removed. It should be snipped off with scissors and the
conjunctiva drawn together over its base.

5. _Proptosis_ may result from too free a division of a tendon.

6. _Retraction of the caruncle_ is best avoided by closing the
conjunctival wound with a stitch, and thus pulling the caruncle forward.


ADVANCEMENT

Advancement is an operation undertaken to rectify a squint by forming a
fresh attachment for one of the ocular muscles nearer the cornea, and at
the same time shortening it. There are three main types of operation
performed:--

1. The capsulo-muscular, in which the tendon, together with the
attachment of the capsule of Tenon to it, is advanced.

2. The tendon only is isolated, shortened, and advanced.

3. The tendon is shortened by folding it upon itself.

The first operation is by far the most satisfactory of these, owing to
the fact that a broader new insertion of the muscle is obtained, which
is less likely to yield subsequently; it is the operation usually
performed in this country.

The chief cause of unsatisfactory results after advancement operations
is the cutting through of the sutures holding the tendon in position.
The various operations, which are some fourteen in number and have
mostly their respective surgeon’s name attached, differ principally in
the method of insertion of these sutures. Whichever method of inserting
sutures be used, the main factors which aim at preventing the stitches
from cutting out are (1) that the stitches should take a good hold in
the scleral and episcleral tissues on the corneal side of the wound, for
the passing of which it is most essential that the needles should be
sharp; (2) that complete rest of the muscles should be ensured by
bandaging both eyes for the first seven days after the operation; (3)
that the opposing muscle should be tenotomized so as to prevent traction
on the sutures.

[Illustration: FIG. 132. PRINCE’S FORCEPS FOR ADVANCEMENT. Care should
be taken to see that the spring catch holds satisfactorily.]

Of the many operations that have been devised the capsulo-muscular
advancement or some modification of it is most frequently used.

=Instruments.= Speculum, straight scissors, fixation forceps, Prince’s
advancement forceps (Fig. 132), four sharp needles and strong silk,
needle-holder.

=Operation.= Under adrenalin and cocaine. _First step._ The patient is
made to look away from the side on which is the muscle to be advanced,
and the conjunctiva over the muscle is freely divided with scissors, by
a curved incision with the convexity towards the cornea, and dissected
back.

_Second step._ The capsule of Tenon is button-holed by a small incision
well above or below the tendon. A tenotomy hook is passed beneath the
tendon and its expansion and brought out through a small hole in Tenon’s
capsule on the opposite side of the tendon. The smooth blade of Prince’s
forceps is then inserted in place of the hook, and the tendon with its
expansion is grasped between the blades. The forceps are given to an
assistant, who should avoid all traction on the muscle. The eye is then
rotated in the direction of the muscle to be advanced, and tenotomy of
the opposing muscle is performed by the open method.

_Third step._ The muscle to be advanced and its expansion, which are
clamped between the blades of Prince’s forceps, are separated from the
globe with the scissors and given again to the assistant to hold. Three
strong silk sutures are passed in the following order, middle, upper,
and lower, first through the conjunctival and episcleral tissue on the
corneal side of the wound and then as far back as possible through the
muscle and out through the conjunctiva near the cut margin on the other
side of the wound (Fig. 133). Care should be taken that the middle
stitch is passed through the episcleral tissue exactly opposite the
horizontal plane of the cornea and the central portion of the tendon.
The portion of the tendon and capsule within the grasp of the forceps is
then removed with scissors by cutting close to the blades of the
Prince’s forceps, taking care not to cut the sutures.

[Illustration: FIG. 133. ADVANCEMENT BY THE THREE-STITCH METHOD. Showing
the sutures in position. A firm hold on the sclerotic to the corneal
side of the wound is essential to the success of the operation.]

_Fourth step._ The middle suture should be first tightened to the extent
required to bring the eye straight. The upper and lower sutures are then
tied.

If, on testing with the Maddox rod, the error be found to be slightly
over-corrected by the advancement, the eye can be drawn back by taking a
firm hold with the conjunctival stitch over the tenotomy wound. The
conjunctival stitch may be removed on the fourth day, but the stitches
holding the advanced muscle in position should not be removed till after
the tenth day. Atropine in both eyes is desirable, especially when
there is any tendency to convergence. Glasses should be worn on
uncovering the eyes.

=Complications.= 1. _The eyes may not be straight after the operation._
No further operation for rectification should be undertaken for at least
two or three months. If there be a tendency to convergence, glasses
should be worn and atropine used. Small latent errors may be corrected
by prisms. _If the muscular error be insufficiently corrected_ tenotomy
may be performed on the other eye. _If the muscular error be
over-corrected_ it may also require tenotomy on the other eye, the
adjustment by tenotomy being more accurate than that by advancement.

2. _Thickening over the site of the advanced muscle_ usually disappears
in a few months.

Other complications as described under tenotomy may occur (see p. 250).




CHAPTER VII

ENUCLEATION OF THE GLOBE AND ALLIED OPERATIONS


The principal substitutes for simple enucleation are evisceration,
Mules’s and Frost’s operations.


ENUCLEATION

Enucleation is the removal of the globe from Tenon’s capsule.

=Indications.= Enucleation should be performed in preference to Mules’s
operation in--

(i) Malignant tumours.

(ii) Injuries followed by cyclitis.

(iii) Painful blind eyes.

In _malignant tumours_ enucleation should only be performed when there
are no signs of extra-ocular extension. If extra-ocular extension be
present, evisceration of the orbit should be performed, provided there
be no evidence of general metastasis. In cases of glioma of the retina
it is especially desirable that the optic nerve should be cut as far
back as possible and the cross-section carefully examined for gliomatous
tissue, since the disease spreads to the brain along this structure.

_In injuries followed by non-suppurative cyclitis_ enucleation or
Frost’s operation is preferable to Mules’s operation, since cases have
been recorded of sympathetic ophthalmia following the latter operation,
and it is these cases of non-suppurative cyclitis which are especially
prone to give rise to that disease.

_Blind painful eyes_, especially when affected with glaucoma, are best
removed, as occasionally the underlying cause, when not known, may prove
to be an intra-ocular growth.

=Instruments.= Speculum, fixation forceps (two pairs), straight
scissors, strabismus hook, strong curved scissors.

=Operation.= Before the anæsthetic is administered the forehead should
be marked over the eye to be enucleated, so as to guard against the
accident of removing the wrong eye. It is usual, at any rate in the case
of hospital patients, to get their written consent for the operation.

_First step._ The speculum is inserted. In the case of the right eye the
conjunctiva is seized with the fixation forceps downwards and outwards,
or in the case of the left eye, downwards and inwards. The straight
scissors being held with the right thumb and ring finger, the
conjunctiva is divided freely all the way round, as close as possible to
the cornea, and dissected back.

_Second step._ The capsule of Tenon is opened below the external rectus
by grasping it with forceps and buttonholing it with the scissors. The
strabismus hook is passed through the opening made in Tenon’s capsule
with its concavity against the globe, turned upwards beneath the tendon,
and the latter is pulled well forward and freely divided from above
downwards between the hook and the globe. The superior and inferior
recti are treated in a similar manner. In dividing the internal rectus a
small portion should be left attached to the globe, so that subsequently
it can be grasped with forceps to rotate the globe outwards when
dividing the optic nerve.

_Third step._ The globe is dislocated between the lids by opening the
speculum widely and pressing it backwards. If the globe will not
dislocate, it is either because the tendons are imperfectly divided, or
the palpebral aperture is too small to allow of its delivery; the latter
is liable to be the case in small children or in those with a
staphylomatous globe. In such cases the palpebral fissure should be
enlarged by dividing the outer canthus.

[Illustration: FIG. 134. ENUCLEATION. Method of suturing the
conjunctiva; the suture requires no knot.]

The _fourth step_ is the division of the optic nerve. The globe is
rotated strongly outwards, either by pulling on the tendon of the
internal rectus or by pulling the globe outwards with the finger; the
optic nerve is felt for by passing the strong curved scissors behind the
globe. When the nerve is defined the blades are opened widely, pressed
backwards, and the nerve divided. The globe is then pulled forward with
the finger, and the oblique muscles and remaining attachments divided.
Hæmorrhage is easily controlled by pressure and the use of adrenalin.

_Fifth step._ When the bleeding has ceased, the conjunctival wound is
united in a horizontal direction by means of a thick silk suture running
over and over; no knot is required and the ends are left long, so that
it may subsequently be removed easily (Fig. 134). The usual dressings
are applied with a firm pressure bandage for the first six hours. The
suture should be removed at the end of the seventh day. No artificial
eye should be worn for at least six weeks after the operation, and then
only for a few hours at a time until the conjunctiva becomes accustomed
to it. It should always be taken out at night.

=Complications.= These may be immediate or remote.

=Immediate.= _Cutting into the globe._ This may occur during the
division of the optic nerve, and is usually due to imperfect dislocation
of the globe. Although of little consequence as a rule, it may be
extremely serious, as for instance in the case of an intra-ocular
growth, when it is conceivable that a portion of it might be left
behind. If this accident should happen, the portion of the sclerotic and
choroid left behind should be carefully sought for and removed.

_Adhesion of Tenon’s capsule._ Eyes that have been the subject of acute
inflammation are much more difficult to enucleate, owing to adhesion of
the surfaces of Tenon’s capsule. In these cases the globe has
practically to be dissected out of that structure.

=Remote.= _Hæmorrhage_ into the stump may occur, leading to proptosis of
the conjunctiva and extravasation into the eyelids and beneath the skin
of the face. The use of a firm pressure bandage and the omission of the
suture is usually sufficient to prevent this occurring, but the
blood-clot may have to be turned out and the bleeding point sought for
and ligatured.

_Granulations and polypi_ in the socket are usually the result of
leaving some tag of tissue between the margins of the wound, and are
therefore more likely to occur when no suture is used to close the
wound. They should be removed with forceps and scissors.

_Polypoid masses_ sometimes form in a socket as the result of an
imperfect artificial eye causing an œdematous condition of the
conjunctiva. They should not be removed, owing to the contraction caused
thereby, but the artificial eye should be left out, when they will often
disappear.

_Contracted socket_ is usually the result of an imperfectly performed
enucleation or loss of large portions of the conjunctiva; for the
operations for its relief, see p. 261.


EVISCERATION

Evisceration is the removal of the intra-ocular contents.

=Indications.= It is the ideal operation for a suppurating globe; in
these cases enucleation is contra-indicated because the lymph-space
round the optic nerve is opened up by the division of the latter and the
inflammation may spread directly to the meninges.

=Instruments.= Speculum, fixation forceps, Beer’s knife, scissors, scoop
and stitches.

=Operation.= A general anæsthetic is necessary.

_First step._ The eye is transfixed about 4 mm. behind the
corneo-sclerotic junction with a Beer’s knife, which is made to cut out
upwards (Fig. 135). The flap of corneal and scleral tissue is then
seized with forceps and the cornea removed entirely by completing the
incision in the sclerotic round it with scissors (Fig. 136).

_Second step._ The contents of the globe are then eviscerated by means
of a spoon, and the cavity flushed out with 1 in 4,000 perchloride of
mercury lotion. Great care should be taken to remove all portions of the
uveal tract; this is best ensured by visual inspection after the
hæmorrhage has ceased. The interior of the sclerotic should appear
perfectly white.

[Illustration: FIG. 135. MULES’S OPERATION. _First step._ Excision of
the cornea.]

[Illustration: FIG. 136. MULES’S OPERATION. The completion of the
excision of the cornea with scissors.]

_Third step._ Although not absolutely necessary, and inadvisable in the
case of a septic globe, a single suture may be passed through the centre
of the wound in the conjunctiva and sclerotic.

=Complications.= As the operation is not infrequently performed for
panophthalmitis, much swelling of the lids and discharge from the socket
may take place after the operation; these symptoms usually subside in
the course of a few weeks without further trouble. The interval which
must elapse before an artificial eye can be worn is considerably longer
than after enucleation.


MULES’S OPERATION

Mules’s operation is the insertion of a celluloid globe into the
sclerotic after evisceration, followed by closure of the scleral wound
over it. In both this and Frost’s operation a better stump is formed, so
that more movement may be obtained in the artificial eye which is
subsequently worn over the inserted globe.

=Indications.= (i) The operation is especially suitable for anterior
staphyloma following ophthalmia neonatorum. In young children the
presence of the ball in the orbit assists the development of that
structure.

(ii) It is also suitable for large, recently made, fairly aseptic wounds
in the globe.

=Operation.= The _first two steps_ are the same as for evisceration.

_Third step._ A glass or, better, a celluloid or gold-plated ball is
inserted into the sclerotic, which is closed over it by two rows of
interrupted sutures, one of catgut passing through the sclerotic, the
other of silk closing over the conjunctival wound. To facilitate the
closure of the conjunctival wound it is advisable to dissect the
conjunctiva back from the limbus before excising the cornea. The ball
inserted in the sclerotic should fit the cavity loosely.

=Complications.= In about 17% of the cases the ball is not retained;
this is not infrequently due to too large a size being used, or to the
wound being imperfectly closed by the sutures. If two rows be used, as
described above, extrusion of the ball is far less frequent than if one
only be inserted. If the globe be extruded the patient is in the same
position as if he had had evisceration performed.


FROST’S OPERATION

In this operation the eye is enucleated, a celluloid globe is inserted
into Tenon’s capsule, and the conjunctiva is closed over it by means of
sutures passing through Tenon’s capsule and the conjunctiva.

=Operation.= The first four steps in the operation are similar to those
described under enucleation.

_Fifth step._ A small, loosely-fitting glass globe is inserted into
Tenon’s capsule. A purse-string suture of strong catgut is then inserted
into the cut margin of Tenon’s capsule, taking care to include in the
sutures the cut ends of the tendons of the recti muscles. The suture is
drawn tight and tied so that Tenon’s capsule and the muscles are thereby
drawn over the globe. The conjunctival wound is closed over this by a
separate suture of silk.

The advantage of this operation over the other substitutes for simple
enucleation is that it can be used after any enucleation. The chief
disadvantages are that the globe is sometimes extruded unless the wound
be carefully closed by sutures, and occasionally it may become
dislocated from Tenon’s capsule beneath the conjunctiva, thus preventing
an artificial eye from being worn, and requiring removal. These
disadvantages are largely done away with if the method of suture
described above be used.


OPERATIONS UPON THE SOCKET AFTER THE REMOVAL OF THE EYE

PARAFFIN INJECTION

=Indications.= Occasionally after an eye has been removed the movements
in the socket are not communicated sufficiently to the artificial eye
which is placed over it, so that the glass eye has a fixed, staring
appearance. As a rule, this can be remedied by the use of a Snellen’s
improved eye, which has a rounded posterior surface and fits well on to
the stump. If this be not satisfactory, the injection of paraffin into
the stump will often improve the movements considerably. The injection
should be made by what is known as the ‘cold method’.

=The ‘cold method’= of paraffin injection is by far the most
satisfactory, for the following reasons:--

(_a_) The temperature need not be so high, and no damage is therefore
done to the tissues.

(_b_) It is more easily regulated (see Vol. I, p. 682).

(_c_) Embolism is less likely to occur.

=Instruments.= Fixation forceps, tenotomy knife, speculum, a large
paraffin syringe, and a short needle having a big bore.

=Operation.= This may be performed under adrenalin and cocaine.

_First step._ The stump is drawn forwards with forceps. A tenotomy
knife, inserted well to the outer side of the stump, is then swept
freely round and a pocket is formed in the centre of the orbit into
which the injection can be made. The tenotomy knife is then withdrawn.

_Second step._ The sterile melted paraffin (melting-point 115° F.)
should be poured into the syringe, which should have been previously
kept in a hot-water bath. The paraffin is then allowed to cool slowly
until it just becomes opalescent. The injection should be made through
the hole made by the tenotomy knife, sufficient paraffin being inserted
to obtain the desired result. The operation is usually followed by
considerable swelling of the tissues, which will subside in three or
four weeks.


OPERATIONS FOR THE RESTORATION OF A CONTRACTED SOCKET

As the result of wearing badly-formed artificial eyes or of subsequent
inflammation in the conjunctival sac, the socket not infrequently
becomes so contracted that the prosthesis cannot be retained.
Enlargement of the sac may be obtained by two methods:--

(_a_) Skin-grafting (Thiersch’s method).

(_b_) Transplantation of skin from the surrounding structures (Maxwell’s
operation).


SKIN-GRAFTING

=Indications.= This procedure is especially suitable for cases in which
the base of the socket opposite the palpebral aperture has to be
enlarged, and it is usually performed prior to Maxwell’s operation for
the restoration of the fornices in severe cases.

=Instruments.= Scalpel, speculum, skin-grafting razor, probes, and a
piece of thick style wire.

=Operation.= _First step._ The base of the socket is freely divided in a
horizontal direction opposite the palpebral aperture so as to produce a
gaping wound.

_Second step._ This gaping wound is put on the stretch in the following
way: A thick piece of style wire is bent round to fit into the fornices
of the socket, the ends being brought out over the lid at the inner
canthus. The circle of wire is opened out as far as possible so as to
put the wound at the bottom of the socket on the stretch to its fullest
extent.

_Third step._ Skin grafts are then cut from the inner surface of the arm
(see Vol. I, p. 670), applied by means of probes, and pressed down on to
the raw surface. No dressings should be applied directly to the grafts,
but a watch-glass may be placed over the palpebral aperture and
dressings applied over it. The style wire should be removed on the
fourth day.


INCLUSION OF FLAPS. MAXWELL’S OPERATION

=Indications.= It is especially useful for the enlargement of the socket
by the formation of new fornices. As a rule it is performed for the
reproduction of the lower fornix, as it is frequently due to the
obliteration of this cul-de-sac that the artificial eye cannot be
retained. The operation, however, may be modified and applied to the
formation of both the upper and outer culs-de-sac.

=Instruments.= Scalpel, forceps, scissors, and sutures.

=Operation.= A general anæsthetic is required.

_First step._ An incision is made in the lower fornix throughout its
whole length and carried downwards for a distance of about half an inch
(Fig. 137, A).

_Second step._ A crescentic piece of skin is marked out on the lower lid
by two incisions which have their concavity directed upwards. The upper
one is parallel with the margin of the lower lid and about 5 millimetres
below it. This crescentic flap is then dissected up from the deeper
tissues all round, except for a small pedicle at its centre (Fig. 137,
B).

_Third step._ The incision forming the upper margin of the crescentic
piece of skin is deepened until it meets the incision made in the
fornix, so that the lower lid is converted into a band of tissue
attached only at each end.

[Illustration: FIG. 137. MAXWELL’S OPERATION FOR CONTRACTED SOCKET.
_First step._ A is the incision through the conjunctiva. The flap of
skin from the outer surface of the lower lid is entirely raised from the
subcutaneous tissue, except for the pedicle B which holds the new fornix
in position.]

[Illustration: FIG. 138. MAXWELL’S OPERATION. _Final step._ Showing the
flap of skin from the outer surface of the lower lid turned in to form
the new lower fornix. The surface wound has been closed by sutures.]

_Fourth step._ The upper margin of the incision in the fornix is
stitched to the upper margin or concavity of the crescentic piece of
skin after the latter has been displaced upwards beneath the band of
tissue carrying the lashes, and the lower margin of the crescentic piece
of skin is stitched to the conjunctival edge of the band, so that the
crescentic piece of skin is folded on itself and forms the new lower
fornix, being held down in its position by the pedicle (Fig. 138). The
sutures should be of catgut, as their subsequent removal is somewhat
difficult.

_Fifth step._ The surface wound is closed by silkworm-gut sutures. The
socket should be packed with gauze, or else a piece of style wire should
be inserted, as in the previous operation, so as to maintain the groove
in the new lower fornix.




CHAPTER VIII

OPERATIONS UPON THE EYELIDS


SURGICAL ANATOMY

The eyelids consist of well-marked planes of tissue, which are, from
without inwards--

1. Skin with very little subcutaneous fat.

2. Orbicularis muscle.

3. Tarsal plates, which are attached to the orbital margins by the
palpebral ligaments and which thereby form a barrier to the passage of
infection backwards into the orbit.

4. Subconjunctival tissue and conjunctiva.

It is most important for successful results that flaps and incisions
should be made accurately down to and in the correct layer of the lid.

Along the lid margin, between the eyelashes and the posterior border of
the eyelid, is a white line (intermarginal line) formed by the edge of
the tarsal plate. In the many operations in which the lid is split the
incision is carried along this line.

The blood-supply to the eyelids is derived from arterial arches--two in
the top lid, and one in the lower--which run parallel to the margins. As
far as possible, therefore, flaps should be planned with their bases at
right angles to the course of the vessels. The extreme vascularity of
the lid, together with the small amount of subcutaneous fat, allows of
almost complete detachment of flaps of skin without fear of necrosis,
but at the same time every care should be taken to avoid injuring these
flaps when manipulating them. Hæmorrhage is controlled during the
operation by means of clamps or by direct pressure of the lid between
the finger and thumb. As a rule a general anæsthetic is required for
most of the operations.


SUTURE OF WOUNDS OF THE EYELIDS

_Wounds which involve the skin only_ are brought together in the
ordinary way with a few fine sutures. In wounds of the upper lid care
should be taken to suture the levator palpebræ, if divided, as otherwise
traumatic ptosis may result.

_Suture of wounds involving the lid margin._

(_a_) In _simple division_ the margins of the lids are brought together
by means of a fine suture; the conjunctival surface is first
approximated, and then the skin by a deep suture which includes the
tarsal cartilage. Accurate apposition of the lid border is very
essential. Unfortunately a certain amount of ectropion frequently
follows, which may require for its relief one of the operations given
below (see p. 284).

(_b_) _Occasionally the lid margin carrying the lashes may be torn off._
As a rule, the strip remains attached to the lid. It should then be
accurately sutured in position, taking care that the lashes take their
correct turn outwards. In cases where the strip is torn off entirely,
the skin and conjunctiva should be sutured together. When large portions
of the lid are lost, some form of plastic operation, such as is
performed for making a new lid, is required (see p. 287).

(_c_) _When the canaliculus has been divided_ the end attached to the
lachrymal sac should be sought for and divided for a short distance
inwards from the wound (see p. 291), the entrance being kept open daily
by a probe to prevent traumatic stricture.


OPERATIONS FOR ANKYLOBLEPHARON

Fusion of the eyelids together is either a congenital condition or the
result of injury, and may take the form of bands or firm fibrous union.
It is rarely complete and is often associated with symblepharon. The
union should be divided on a director, or by careful dissection, taking
care not to wound the underlying globe. The raw surfaces are kept apart
by daily dressing until they are covered by epithelium. No externa[l]
dressing should be applied.


OPERATIONS FOR SYMBLEPHARON

_Partial adhesion of the lid to the globe_ in which a few bands pass
from the lid to the globe are best treated by division followed by union
of the ocular conjunctiva over the raw surface; no external dressing
should be applied. Any tendency to fresh adhesion may be prevented by
daily inspection.

_In extensive adhesion of the lid to the globe_, where the lids are
entirely adherent to the globe and the cornea is destroyed, interference
is inadvisable. In less extensive adhesion, the lid is first separated
from the globe, reunion being prevented by covering the denuded area on
the globe with a flap of bulbar conjunctiva transplanted from an area
that does not come in contact with the raw surface on the eyelid
(Teale’s operation), or by Thiersch’s grafts from a situation where
there are no hairs; or by grafting mucous membrane from the mouth of the
patient or a frog. Teale’s operation, or some modification, is by far
the most satisfactory, but unfortunately it cannot always be carried out
when the loss of conjunctiva is large.


OPERATIONS UPON THE PALPEBRAL APERTURE

CANTHOPLASTY

=Indications.= In contraction of the palpebral aperture, either due to a
congenital condition, or the result of a wound, trachoma, or other
cicatricial contraction.

=Instruments.= Speculum, forceps, scissors, and three sutures.

=Operation.= The speculum is inserted and opened as widely as possible.
One blade of the scissors is passed into the cul-de-sac at the outer
angle of the lid and the palpebral aperture enlarged by dividing the
outer canthus horizontally. The external tarsal ligament which is split
longitudinally is then cut across with scissors passed into the upper
and lower wound. The conjunctiva is drawn up into the wound and stitched
to the skin at the margin to prevent reunion. The stitches should be
removed about the sixth day.


CANTHOTOMY

Canthotomy is simple division of the outer canthus without stitching the
conjunctiva into the wound. It is useful in some cases of blepharospasm
associated with fissure at the outer canthus.


CANTHORRHAPHY

Union of the eyelids, usually at the outer canthus.

=Indications.= (i) When the eyelids do not cover the globe as the result
of--

(_a_) Cicatricial contraction of wounds, burns, &c., about the lid.

(_b_) Long-standing facial paralysis.

(_c_) Exophthalmic goître.

(ii) To help maintain the lid in position after ectropion operations.

=Instruments.= Beer’s knife, fixation forceps, spatula, and sutures.

=Operation.= _First step._ The position for the new external canthus is
determined by holding the lids together at the outer canthus, and is
marked on the upper and lower lids. From these points incisions are
carried outwards to the external canthus along the intermarginal line in
the top and bottom lids. These incisions are deepened to about 5
millimetres.

_Second step._ From the inner end of the incision in the lower lid a
vertical one is made downwards for about 5 millimetres, and is then
carried out to the external canthus. The tissue thus marked out, bearing
the lashes, is then removed.

_Third step._ A corresponding, slightly larger, area is similarly
removed from the under or conjunctival surface of the upper lid (Fig.
139).

[Illustration: FIG. 139. CANTHORRHAPHY.]

_Fourth step._ These two areas are brought into apposition by means of a
strong suture passed through their centre. The suture should have a
needle at either end, and these should be passed from the conjunctival
surface and brought out through the middle of the raw area in the lower
lid, about 2 millimetres apart, and then through the middle of the raw
area in the upper lid and out through the skin. The suture is tied so
that the two raw areas are brought into accurate apposition. The margins
of the wound may then be brought together by sutures if necessary. The
main suture should be left in for at least ten days.


TARSORRHAPHY

=Indications.= (i) Complete union of the eyelids may be required when an
eye has been removed and for some reason an artificial one cannot be
worn.

(ii) Partial union is effected in cases of paralysis of the first
division of the fifth nerve when corneal ulceration threatens. A similar
union is also useful in keeping the lower lid in position during the
process of cicatrization in many of the operations for ectropion
described below. The adhesions produced can be subsequently divided when
contraction has ceased.

=Instruments.= Knife, forceps, scissors, spatula.

=Operation.= _Complete._ As narrow a strip of tissue as possible is
removed from the lid borders behind the eyelashes. This is best
performed by everting the upper lid and shaving off the posterior margin
with a sharp knife; the lower lid is then treated similarly. The raw
areas are brought into apposition with fine sutures.

_Partial._ When only a temporary adhesion is required, as after
ectropion operations, it is sufficient to make raw corresponding areas
of about 2 millimetres on the posterior margins of the top and bottom
lids on either side of the central position of the cornea and unite them
with sutures, which may be removed about the end of the first week.


PTOSIS OPERATIONS

The following operations are usually only undertaken for congenital
ptosis, but they are occasionally required for the paralytic and
traumatic varieties. All the operations are far from satisfactory, and
should only be undertaken when the lid covers the pupil completely or so
nearly that the head has to be thrown back to see objects directly in a
line with the eyes. The relative value of the various operations apart
from their indications is a matter of opinion amongst ophthalmic
surgeons; therefore the various types of operations which are performed
are given below.

There are four types of operation, which respectively aim at--

1. Shortening the eyelid by excision of a portion of the tarsal plate.

2. Attachment of the lid to the occipito-frontalis muscle.

3. Advancement of the levator palpebræ muscle.

4. Grafting of part of the superior rectus muscle into the lid to take
the place of the levator palpebræ superioris.


SHORTENING THE EYELID BY EXCISION OF A PORTION OF THE TARSAL PLATE

=Fergus’s operation (modified).= The object of this operation is to
shorten the eyelid by removing the upper portion of the tarsal plate,
the cut margin of which is subsequently sutured to the tendon of the
levator palpebræ and the palpebral ligament.

The results of the operation are satisfactory, especially in cases in
which there is some movement in the eyelid. The author, who has
performed most of the ptosis operations on several occasions, has had
most uniform results by this method, the modification of which was first
suggested to him by Mr. Treacher Collins.

It has the advantage that the amount of retraction required may be more
easily estimated, the corneal complications are of much rarer
occurrence, and the resulting scar forms a natural fold in the lid. It
is obviously not applicable to cases in which the eyelid is already
short, as in the cases of ‘Chinese eye’ in which little can be done
beyond enlarging the palpebral aperture.

=Instruments.= Spatula, scalpel, artery and dissecting forceps,
scissors, and sutures.

=Operation.= _First step._ The spatula is inserted into the superior
fornix. A curved incision is made directly below the orbital margin
throughout its whole length. The skin and orbicularis muscle are divided
and dissected downwards so as to expose the upper surface of the tarsal
plate. A suture is then passed through this flap so that it may be drawn
down by an assistant.

_Second step._ A narrow strip about 3 millimetres broad is excised from
the whole length of the tarsal plate; in doing this care must be taken
not to button-hole the conjunctiva or flap of skin.

_Third step._ The cut margin of the tarsal plate is sutured to the
levator palpebræ and palpebral ligament by two sutures passed in the
following manner: A thick catgut suture armed with a curved needle is
passed through the upper cut margin of the orbicularis palpebrarum,
palpebral ligament, and levator palpebræ (if the latter be present) at
about the junction of the middle and inner thirds of the wound, a firm
hold being taken on these structures. The needle is then passed through
the tarsal cartilage parallel to the lid border for a distance of about
3 millimetres and out again on to its anterior surface. The needle is
then again carried through the levator palpebræ, palpebral ligament, and
orbicularis in the upper part of the wound. A similar suture is passed
about the junction of the middle and outer thirds of the wound. When
both sutures are in position they are tied sufficiently tightly to
produce the retraction of the lid desired, slight over-correction being
necessary. The skin wound is then closed with sutures.


ATTACHMENT OF THE LID TO THE OCCIPITO-FRONTALIS MUSCLE

There are three chief methods of affecting this attachment:--

(_a_) By cicatricial bands (_e.g._ Hess’s operation).

(_b_) By a suture left permanently in position (_e.g._ Harman’s
operation).

(_c_) By the attachment of the skin of the lid to the muscle (_e.g._
Panas’ operation).

=Indications.= In the majority of the cases of congenital ptosis the
levator palpebræ is completely absent, as shown by the want of upward
movement in the lid, and it is for this condition that one of the
operations of this type is performed. In rare cases the
occipito-frontalis muscle is also absent or imperfectly developed, and
in these cases these operations should not be undertaken.

=Hess’s operation.= The object of this operation is to insert silk
stitches between the eyelid and the occipito-frontalis muscle, and to
leave them in long enough for a fibrous band of union to form along the
stitch tracks.

=Instruments.= Scalpel, dissecting forceps, needle and holder, spatula,
artery forceps.

=Operation.= _First step._ The eyebrow having been shaved, an incision 2
inches long is made about in the line of the brow, and the skin is
dissected down almost to the lid margin.

_Second step._ Three sutures are passed, one in the middle, and one at
each end of the lid; each suture carries two needles. The needles are
inserted in the intermarginal line of the lid about 3 millimetres apart
and brought out into the wound above, so that the lid margin is held by
the loops. These threads are then carried deeply beneath the upper edge
of the wound into the substance of the occipito-frontalis muscle,
brought out through the skin well above the eyebrow and tied over a
piece of drainage tube. The sutures should be drawn tight enough to
produce an undue amount of retraction of the lid, as this tends to drop
again after removal of the sutures. The skin wound is then closed and a
small dressing is applied to cover the drainage tube on the forehead.
The eye itself should be covered with a celluloid shield, as it is
usually impossible for the patient to close the palpebral aperture, and
the cornea is liable to be injured by exposure. The deep sutures should
be left in for at least three or four weeks, so that they may bring
about a fibrous band between the muscle and the eyelid by their
irritation. The immediate result of the operation is usually excellent,
but the lid is very apt to drop again in the course of six months or a
year after removal of the stitches.

=Harman’s operation.= The aim of this operation is to insert a fine
metal chain between the occipito-frontalis and the lid, the chain being
left permanently in position. The operation has not yet been performed
sufficiently often to allow any definite statement about the final
results to be made.

The results have not been very satisfactory in three cases in which the
author has performed this operation.

=Instruments.= A 4-inch straight surgical needle, to which is attached
the fine wire chain such as is used by spectacle makers to attach
glasses to the dress. It measures about O.75 millimetre in diameter. It
is attached to the needle by a soldered ring or by means of a piece of
silk doubly looped through the needle without a knot.

=Operation.= Under a general anæsthetic. ‘The method of implanting the
chain will be followed readily by reference to Fig. 140. The
chain-needle is inserted above the external angular process at A, is
passed inwards, and with a slightly upward inclination deeply beneath
the tissues of the forehead, to be withdrawn at B; as much of the chain
is drawn through as desired. The needle is reinserted at B, passed
beneath the brow close to the orbital margin and through the tissues of
the lid to C, where it is withdrawn and the chain after it. In like
manner it is passed from C to D through the substance of the tarsus and
withdrawn. It is now returned from D to E above the brow and withdrawn,
and a final length embedded above the brow from E to F, which is just
above the internal angular process. The chain should be buried
completely and stretched evenly between the points A, B, C, D, E and F;
and by traction the loop BCDE should be adjusted at B and E; when the
lid is at the desired height the slack at B and E is taken up by
traction on A and F.

‘The position of the points E and B is of importance; they must be
situated in the region of the most effective elevation of the brow by
contraction of the frontalis muscle, as determined by experiment before
the commencement of the operation (and they should be placed well above
the eyebrow).

[Illustration: FIG. 140. HARMAN’S OPERATION FOR PTOSIS.]

‘The lengths of chain lying buried above the brows from A to B and E to
F, and the angles A B C and D E F, are arranged so that there is
sufficient holding power to prevent the subsequent drop of the lid, but
will not prevent adjustment to forcible traction on the lid until the
links of the chain have become interwoven and surrounded by the growth
of connective tissue. This growth should be sufficiently vigorous by the
end of a week to securely fix the chain against all the force of
traction of the orbicularis muscle. (In one case in which the author
removed the chain after two weeks there was no connective tissue in the
links and it was easily withdrawn.) Until this time the free ends of the
chain should be turned towards each other over the skin of the brow and
cemented in position by a cotton-wool and collodion dressing, after
which time the free ends, A and F, are cut off and the free extremities
pushed beneath the skin.’

=Panas’ operation.= In this operation a direct adhesion of the skin of
the lid to the occipito-frontalis muscle is aimed at.

=Instruments.= Lid spatula, scalpel, dissecting forceps, scissors,
sutures.

=Operation.= Under a general anæsthetic.

_First step._ An incision, 2 inches long, is made in the line of the
brow, and an incision of a similar length is made into the skin of the
lid about half an inch below it. The tissue between these two incisions
is undermined so as to produce a band of skin and subcutaneous tissue.
From the ends of the lower wound vertical incisions are made into the
lid, running slightly outwards and inwards respectively towards the
outer and inner canthus (Fig. 141).

[Illustration: FIG. 141. PTOSIS OPERATION. PANAS’.]

_Second step._ The flap, C (Fig. 141), thus produced is raised, and
doubly armed sutures, D D, are passed through its upper margin and are
carried beneath the band of skin and subcutaneous tissue. The needles
are then carried deeply beneath the upper margin of the wound A into the
substance of the occipito-frontalis muscle and brought out on to the
forehead. Outer and inner sutures, E E, are passed deeply into the
substance of the tarsus both ends are then passed beneath the band and
brought through into the upper wound, whence they are passed beneath the
upper margin of the wound into the occipito-frontalis muscle and are
tied over a piece of drainage tube. They hold the lid in position during
the process of cicatrization. Considerable over-correction should be
employed as the lid tends to drop subsequently. No dressings should be
applied over the open palpebral aperture. The stitches are removed on
the tenth day. A small depression is usually seen where the skin of the
lid passes beneath the band.


ADVANCEMENT OF THE LEVATOR PALPEBRÆ MUSCLE

This is especially suitable for cases in which the levator palpebræ has
some power, that is to say, when there is some movement of the lid
present. It is also suitable for cases of traumatic and paralytic
origin. The movement of the lid by the levator palpebræ is best
estimated by eliminating the action of the occipito-frontalis by holding
down the brow and asking the patient to raise the lid.

[Illustration: FIG. 142. PTOSIS OPERATION. ADVANCEMENT OF THE LEVATOR
PALPEBRÆ. Showing the suture passed through the tendon; the difficulty
of the operation is to find it. (_Diagrammatic._)]

=Instruments.= Lid spatula, knife, forceps, scissors, sutures.

=Operation.= Under a general anæsthetic.

_First step._ A spatula is inserted into the upper conjunctival fornix.
An incision is made just below the eyebrow over the upper margin of the
tarsal plate throughout its length. The skin, especially of the lower
margin of the wound, is dissected up and the orbicularis muscle divided,
the tarsal plate, with the superior palpebral ligament attached to it,
and the orbital margin being exposed. The superior palpebral ligament is
then divided carefully high up near the orbital margin and directly
below, in a small quantity of fat, will be found the tendon of the
levator palpebræ superioris. The tendon can usually be distinguished
from the palpebral ligament by the fact that it is elastic when pulled
on.

_Second step._ The advancement of the muscle is then performed in one of
the three following ways: (_a_) by excising a portion of the tendon and
suturing the divided ends together; (_b_) detaching the tendon from the
tarsal plate and bringing it from behind forward through a hole made in
the upper margin of that structure and suturing it on its anterior
surface towards the lower margin; (_c_) by folding the tendon on itself.
The last method is the one most usually performed. Two sutures with a
needle at each end are passed through the substance of the muscle and
tied (Fig. 142). The ends of these sutures are then carried downwards
between the tarsal cartilage and the orbicularis palpebrarum and out in
the intermarginal line of the eyelid. The sutures are then tied tightly
so as to secure rather more than the amount of retraction required (Fig.
143). The palpebral ligament and orbicularis palpebrarum are then united
and the wound in the skin is closed.

[Illustration: FIG. 143. PTOSIS OPERATION. ADVANCEMENT OF THE LEVATOR
PALPEBRÆ. _Showing the sutures in position._ The tendon is shortened by
folding it on itself.]


GRAFTING A PORTION OF THE SUPERIOR RECTUS INTO THE LID

=Motais’ operation.= =Indications.= This operation is performed for
cases of ptosis in which there is partial or complete loss of upward
movement of the lid. In cases of congenital ptosis the superior rectus
is not infrequently absent or imperfectly developed, as is shown by the
defective upward movement of the eye. It need hardly be said that it is
most important to see that the superior rectus is well developed before
undertaking the operation. Vertical diplopia always follows the
operation, and therefore it is advisable only to undertake it when the
ptosis is bilateral, a similar operation being performed on both sides.
Another somewhat hypothetical objection is that during sleep the eyelids
are rolled upwards by the superior recti so that the lids are slightly
open, but this occurs in almost all successful ptosis operations.
Occasionally there is some defective upward movement of the eye after
the operation.

=Instruments.= Speculum, straight strabismus scissors, lid retractor,
needle holders and stitches.

=Operation.= A general anæsthetic is desirable in all cases.

_First step._ The superior rectus is exposed through a horizontal
incision in the conjunctiva, as in the first stage for advancement. The
tendon is defined in the wound and a strabismus hook passed beneath it;
its middle portion is isolated and two silk sutures, with a needle at
each end, are passed through it and tied.

_Second step._ The speculum is removed and the eyelid everted and pulled
upward by means of a retractor or two silk stitches passed through the
substance of the lid. Starting from the middle of the wound the
conjunctiva of the fornix is divided backwards and the under surface of
the tarsal plate is exposed.

_Third step._ An incision is carried through the tarsal plate parallel
to and near its upper border well into the substance of the orbicularis
muscle on the other side. The needles on each end of the doubly armed
sutures holding the isolated portion of the superior rectus muscle are
passed through the hole in the tarsal plate and are carried downwards
between the orbicularis muscle and the tarsal plate to near the lid
margin, where they are brought out through the skin and tied over a
piece of drainage tube. The conjunctival wound is closed by sutures.

=Complications.= _Ulceration of the cornea_ is more likely to occur
after those operations in which the lid is much over-retracted, such as
Hess’s, Panas’ operation, and the advancement of the levator palpebræ.
It usually affects the lower corneal margin and may be merely roughening
and opacity of the epithelium or deep septic ulceration. If the
ulceration be severe, the sutures holding the lid in position should be
taken out and the eye treated as for corneal ulceration; on the other
hand, slight abrasion of the epithelium will often heal without taking
out the sutures.

_Sepsis._ The difficulty of keeping the wound aseptic after these
operations is considerable, and not infrequently inflammation may take
place; provided it does not go on to suppuration, the final result is
improved thereby; should suppuration take place the sutures must be
removed.




CHAPTER IX

OPERATIONS FOR ENTROPION, REPAIR OF THE EYELIDS TRICHIASIS, AND
ECTROPION


The operations commonly performed for entropion and trichiasis are of
three types:--

1. Operations for the destruction of the individual hair follicles.

2. Rectification of a faulty curvature of the tarsus.

3. Transplantation of the lash-bearing area.


ELECTROLYSIS

=Indications.= In cases of trichiasis where a few eyelashes turn in on
the conjunctiva or cornea they may be removed by this method.

=Operation.= A platinum electrolysis needle (negative pole) is passed
alongside each lash into the follicle, and a constant current of about 5
milliampères allowed to pass for a half to one minute. There is usually
some bubbling seen around the hair, which will fall out when touched if
the operation has been properly performed. It is a comparatively
painless operation and free from scarring if the hair follicle be not
penetrated by the needle. This is best ensured by using a rather blunt
point and not turning on the current until the needle is in position.


SKIN AND MUSCLE OPERATION

=Indications.= This operation is especially suitable for the senile or
spastic forms of entropion of the lower lid, not infrequently seen after
much bandaging in old people, which has failed to yield to treatment by
pulling the lid outwards with strapping.

=Instruments.= Straight scissors, fixation and entropion forceps.

=Operation.= Adrenalin and cocaine solution is injected beneath the skin
of the lower lid. A horizontal strip of skin as near the lid margin as
possible is seized with the entropion forceps (Fig. 144) and removed by
one snip of the scissors. The underlying orbicularis muscle is then
removed over the same area and the wound closed with sutures. If a more
pronounced result is required, a vertical piece of skin is removed at
the outer end of the previous wound and allowed to granulate.


RECTIFICATION OF A FAULTY CURVATURE OF THE TARSUS

DIVISION OF THE TARSAL CARTILAGE FROM THE CONJUNCTIVAL SURFACE OF THE
LID

=Burow’s operation.= The object of this operation is to restore the
inverted tarsal edge of the lid by dividing the cartilage from the
conjunctival surface, and it is especially suitable for those cases in
which the whole of the upper lid border is buckled inwards to a slight
extent owing to cicatricial contraction such as is often seen in the
late stage of trachoma and occasionally as a congenital deformity in the
lower lid.

[Illustration: FIG. 144. TREACHER COLLINS’S ENTROPION FORCEPS.]

=Instruments.= Lid spatula and Beer’s knife.

=Operation.= The operation is performed under a general anæsthetic.

_First step._ The lid is everted over the lid spatula. An incision is
then made along the white line, the result of cicatricial contraction,
seen in the sulcus subtarsalis about 3 millimetres behind the upper lid
margin; the incision should extend throughout the whole length of the
lid and completely divide the tarsal plate. Care should be taken that
the cut is made at right angles to, and not obliquely through the tarsal
cartilage. When the eyelid is replaced the lid margin will be found to
lie in its proper position.

_Second step._ If the skin of the upper lid be very lax or a more marked
result be desired an elliptical piece of skin may be removed from the
upper lid above the site of the underlying incision and the wound
stitched together so as to exaggerate the outward curve of the lashes;
this is usually desirable in most cases, since there is a strong
tendency for the lid to become inverted again owing to the contraction
of the wound, which is allowed to heal by granulation.


DIVISION OF THE TARSAL CARTILAGE FROM THE ANTERIOR SURFACE OF THE LID

=Streatfield’s operation.= The object of this operation is the removal
of a wedge-shaped piece of the tarsal cartilage directly behind the
lashes throughout the length of the upper lid. The division is made from
the outside, and the wound is subsequently sutured so that the margin of
the lid is everted. It has the advantage over the previous operation
that no granulating area is left to cicatrize; it is especially suitable
for cases in which there is much buckling inwards of the upper tarsal
plate, and yields most satisfactory results even when the deformity is
great.

[Illustration: FIG. 145. LID CLAMP.]

[Illustration: FIG. 146. STREATFIELD’S ENTROPION OPERATION.]

=Instruments.= Beer’s knife, fixation forceps, lid clamp (Fig. 145),
spatula, and sutures with a glass bead threaded on each.

=Operation.= The operation is performed under a general anæsthetic.

_First step._ The lid is fixed in a clamp. The surgeon makes an incision
in the skin directly above the lash-bearing area throughout the whole
length of the lid and parallel to its margin. A second incision is made
about 3 millimetres above this, and its extremities are curved downwards
to join the first. The piece of skin and orbicularis muscle between them
is removed and the tarsal cartilage is exposed.

_Second step._ A wedge-shaped strip is removed from the tarsal cartilage
throughout the whole length of the lid, the apex of the wedge reaching
just through the cartilage, but not the conjunctiva on its under
surface.

_Third step._ Mattress sutures are then inserted. Each suture should
have a needle at either end. A bead may be threaded on the stitch to
prevent it cutting into the lid margin. The needles are passed from the
margin of the lid directly above the eyelashes, about 3 millimetres
apart, and brought out through the lower margin of the wound. They are
then passed from within outwards through the tarsal plate and the upper
margin of the wound, being brought out through the skin about half an
inch above it and tied (Fig. 146). A few points of suture in the skin
may be added if necessary.

[Illustration: FIG. 147. ARLT’S OPERATION FOR TRICHIASIS.]


THE TRANSPLANTATION OF THE LASH-BEARING AREA

=Arlt’s operation.= =Indications.= The operation is suitable for cases
of trichiasis in which part or the whole of the lashes of the upper lid
turn inwards and rub on the surface of the cornea.

=Instruments.= Beer’s knife, forceps, scissors, sutures, lid clamp.

=Operation.= _First step._ A lid clamp is applied to the upper lid. An
incision is made in the intermarginal line and the tarsal cartilage is
split behind the lash-bearing area for a depth of about 5 millimetres
throughout the whole extent of the lid (Fig. 147).

_Second step._ An incision through the outer surface of the lid above
the lashes is made to meet the other at right angles, so that the lashes
are carried on a band of tissue attached at each end.

_Third step._ A semilunar piece of skin is then removed by a curved
incision above the last, joining it at the outer and inner ends, and the
band carrying the lashes is stitched to the upper margin of this
incision; the line of the incision along the intermarginal zone behind
the lashes is allowed to heal by granulation. The subsequent contraction
caused thereby pulls down the band carrying the lashes to a certain
extent. It is, therefore, desirable to pull the band of lashes upwards
at the time of operation to a greater extent than is required for the
final result in order to overcome this tendency for the condition to
re-form as a result of cicatricial contraction of the granulating area.
In order to obviate the cicatricial contraction some surgeons cover the
area with a graft of mucous membrane.


ECTROPION OPERATIONS

Ectropion may affect the upper lid, but it occurs far more frequently in
the lower. Operations undertaken for its relief vary very considerably
for the following reasons:--

1. _The cause of the ectropion._ The active or cicatricial form requires
different and more extensive operations than the passive form, such as
occurs after facial paralysis, senile ectropion, or that occurring after
blepharitis.

2. _The degree of ectropion_, whether it is partial, affecting merely
the lid margin; or complete, affecting the whole lid.

Ectropion of the lower lid is always accompanied by epiphora, owing to
the want of application of the canaliculus to the lacus lachrymalis. The
canaliculus is also apt to become obliterated as the result of marginal
blepharitis. Before undertaking any of the operations described below
this condition must be remedied, either by dilating the canaliculus or
by slitting it inwards for a short distance (see p. 290), otherwise,
even if the operation be successful in restoring the deformity, the
overflow of tears causes the patient to pull down the lower lid
constantly in wiping them away, and this tends to reproduce the
condition.

After many of the operations a temporary tarsorrhaphy is required to
keep the lid in position during the process of cicatrization. The
temporary bands produced by this operation are so placed on either side
of the cornea as not to interfere with vision altogether. Canthorrhaphy
is also desirable in some cases, especially when the ectropion affects
the outer end of the lid.

The deformity to be overcome in ectropion is not only the turning
outwards of the lid; in cases which have existed for any length of time
the lid border becomes permanently elongated and requires to be
shortened before it will keep in position. The exposed conjunctiva,
especially in cases secondary to blepharitis, becomes thickened near
the lid margin, and, though it may regain a more or less normal
appearance after the lid has been replaced in position, the thickened
margin frequently prevents the proper apposition of the canaliculus, and
in these cases it is often desirable to remove this tissue (see Fergus’s
operation).


OPERATIONS FOR PASSIVE ECTROPION

=Snellen’s suture method.= The object of this operation is to pass
sutures through the lower lid from rather above the apex of the eversion
out on to the cheek, so that when tightened they draw the lid up into
position. The inflammation which occurs around the sutures leaves a
permanent band of cicatricial tissue which continues the action of the
sutures after they have been removed.

[Illustration: FIG. 148. SNELLEN’S SUTURES.

A B

A. A suture in position.

B. The suture tightened.
]

=Indications.= Snellen’s sutures are useful in moderate degrees of the
senile form of ectropion in which there is not much thickening of the
lid margins. Although the results are satisfactory in carefully selected
cases, the operation is attended with considerable pain and is very
liable to be followed by a marked inflammation along the stitch tracks;
indeed, the final results are not very satisfactory unless some
inflammation does occur.

=Instruments.= Two, and occasionally three, sutures of thick silk armed
at either end with 3-inch straight needles.

=Operation.= A general anæsthetic is desirable, although not absolutely
necessary. The needles belonging to each stitch are inserted about 3
millimetres apart, from the conjunctival surface above the apex of the
everted lid, and after passing deeply near the lower cul-de-sac on the
posterior surface of the tarsus, they are brought out on the cheek low
down and tied over a piece of drainage tube. The loops, when drawn
tight, draw the lid margin inwards (Fig. 148). Two of these sutures are
usually required at such a distance apart as to divide the lower lid
into thirds. They should be left in place some two or three weeks.

=Fergus’s operation.= This operation consists in excision of the apex of
the everted lid.

=Indications.= It is a most satisfactory operation for cases in which
the lid margin has undergone thickening from blepharitis and for cases
of slight senile ectropion.

=Instruments.= Beer’s knife, fixation forceps, and sharp-pointed
scissors.

=Operation.= Under adrenalin and cocaine, a little solid cocaine being
rubbed into the conjunctiva. A strip of thickened conjunctiva and
subconjunctival tissue corresponding to the apex of the eversion is
removed along the whole length of the lid (Fig. 149). The wound produced
is united with sutures. The pull of the conjunctiva, which is stitched
to the lid margin, is sufficient to draw that structure inwards into
position.

[Illustration: FIG. 149. FERGUS’S OPERATION FOR SLIGHT ECTROPION OF THE
LOWER LID. Showing the lines of the incision.]

=Kuhnt’s operation= (modified). The object of this operation is the
removal of a triangular piece of conjunctiva and tarsal cartilage from
the centre of the lower lid, the base of the triangle being placed
towards the free margin of the lid so as to produce sufficient
shortening of the elongated lid border to hold it in position. The skin
of the lid is also shortened by removal of a triangular portion at the
external canthus.

=Indications.= It is especially suitable for cases of paralytic
ectropion (lagophthalmos) and severe degrees of senile ectropion of the
lower lid.

=Instruments.= Lid spatula, Beer’s knife, scissors, forceps and sutures.

=Operation.= A general anæsthetic is required.

_First step._ The lower lid being held between the finger and thumb is
split in the intermarginal line along the outer two-thirds of its
length, and the incision deepened till the lower border of the tarsus is
reached. For this purpose some surgeons use a broad keratome instead of
a Beer’s knife.

_Second step._ A triangular piece of conjunctiva and the whole thickness
of the tarsus are removed from the centre of the lower lid, the base of
the triangle being towards the free margin of the lid and being of
sufficient length to produce the shortening desired to bring the lid up
into position (Fig. 150); this is best estimated by making the incision
forming the inner limb of the V and overlapping the outer flap until the
lid is pulled upwards into position.

_Third step._ A triangular piece of skin with its base upwards is
excised from the outer canthus in the following manner (Fig. 150). An
incision is made outwards and slightly upwards from the canthus. A
vertical incision, twice the length of the preceding one, is made
directly downwards from its outer end to the outer canthus, and the
lower end of this is then joined by an incision completing the triangle.
The skin marked out by this triangle is then dissected up and removed.
The undermining of the flap formed by the skin and subcutaneous tissue
of the outer part of the lid is continued inwards until the flap, when
pulled up into place, restores the lid to its proper position.

[Illustration: FIG. 150. MODIFIED KUHNT’S OPERATION FOR SEVERE
ECTROPION. _Second step._ The outer half of the lid is split and a
V-shaped portion of the tarsal plate removed. The triangular piece of
skin at the outer canthus is entirely removed.]

[Illustration: FIG. 151. MODIFIED KUHNT’S OPERATION. _Fourth step._
Showing the sutures in position. The outer part of the lid has been
undermined and dissected up. The V-shaped gap in the tissues is sutured
first.]

_Fourth step._ The lid is sutured into position. The V-shaped wound in
the conjunctiva and tarsus is sutured, the knots being placed on the
conjunctival surface with the exception of the suture at the lid border,
which is turned the other way, the ends being brought out through the
skin of the outside flap, after the latter has been sutured in position,
and the two ends tied over a bead. The outside flap of skin is brought
up into position by a suture at its upper angle. As the result of this a
few eyelashes project beyond the outer canthus; these should be excised.
Additional sutures to hold the flap in position are then inserted. Both
eyes should be bandaged after the operation, otherwise the knots in the
conjunctiva may rub on the cornea.

=Argyll Robertson’s operation.= The operation aims at shortening the
border of the lower lid and at the same time pulling it upwards into
position by means of a strap of skin and subcutaneous tissue cut from
the outer side, the attached end of the strap being formed by the outer
portion of the skin of the lower lid.

=Indications.= It is especially useful for paralytic cases, and as a
subsequent measure to the VY operation described below for cicatricial
ectropion. The operation is likely to be successful if a marked
reduction in the deformity is effected by pulling the skin at the side
of the outer canthus upwards.

=Instruments.= Scalpel, dissecting forceps, artery forceps, scissors,
sutures.

[Illustration: FIG. 152. ARGYLL ROBERTSON’S OPERATION FOR ECTROPION.
_Second step._ Showing the method of shortening the lid and the strap of
skin reflected. The upper convex line shows the piece of skin to be
removed so that the lid may be pulled upwards into position.]

[Illustration: FIG. 153. ARGYLL ROBERTSON’S OPERATION FOR ECTROPION.
_Final step._ The strap of skin has been sutured in position after
pulling it upwards sufficiently to reduce the deformity and enlarging
the raw area upwards to allow this to be done.]

=Operation.= _First step._ An incision, 2 millimetres below the lid
margin and opposite its outer third, is carried through the skin
parallel to the border of the lower lid outwards to the canthus; having
reached this point the direction of the incision is changed and it is
carried more upwards and outwards till the upper end is on a level with
the upper orbital margin. The incision is then carried outwards for
about 6 millimetres and again downwards, slightly diverging from the
former incision, until it is opposite the lower orbital margin. This
flap of skin and subcutaneous tissue is dissected up from above
downwards (Fig. 152).

_Second step._ A V-shaped portion is removed from the margin of the
lower lid near the outer canthus, the base of the V being of sufficient
length to produce the shortening of the lid required when the edges of
the incision are brought together.

_Third step._ The strap of skin is pulled upwards to the extent required
to replace the lid in position, and sutured there. The raw area must be
enlarged upwards so as to accommodate the upper end of the strap. It is
better to do this than to shorten the strap, since a firm hold is thus
obtained (Fig. 153).


OPERATIONS FOR THE ACTIVE OR CICATRICIAL FORM OF ECTROPION

The numerous operations which have been devised for this condition are
divided into two groups: (1) the transplantation of flaps in the
neighbourhood of the lesion, and (2) the grafting of skin flaps from
other parts of the body. The latter method is usually only undertaken
when the employment of flaps from the neighbourhood of the deformity is
impossible, as the cicatricial contraction which follows the grafting of
flaps from other parts of the body is usually attended by considerable
shrinkage and therefore does not yield such satisfactory results.

[Illustration: FIG. 154. VY OPERATION FOR ECTROPION OF THE LOWER LID DUE
TO A SCAR. _First step._ Showing incision.]

[Illustration: FIG. 155. VY OPERATION FOR ECTROPION. _Final step._
Showing the lid in position.]


BY THE TRANSPLANTATION OF FLAPS

=VY operation= (Wharton Jones). =Indications.= This operation is useful
for cases of ectropion affecting the middle parts of the lower lid,
generally due to a scar such as would result from a healed sinus after
tuberculous periostitis of the lower orbital margin.

=Instruments.= Dissecting forceps, scalpel, artery forceps, sutures.

=Operation.= The operation is performed under a general anæsthetic. A
V-shaped incision, with the apex downwards, is made to embrace the
whole margin of the lower lid. The upper ends of the V should skirt the
outer and inner canthus and roughly lie over the lower orbital margin,
enclosing the scar, the apex of the V falling rather below the orbit.
The incision should include the skin and subcutaneous tissue. The
V-shaped flap is dissected up and the lid liberated from the underlying
scar tissue. The incision is then sewn up in the form of a Y (Fig. 155).
Temporary tarsorrhaphy (see p. 266) is always desirable. Subsequent
shortening of the lid margin by the Argyll Robertson method is sometimes
necessary.

=Denonvillier’s operation.= This procedure is useful to remedy an
ectropion of the outer portion of the lower lid by the transposition of
flaps at the outer canthus.

[Illustration: FIG. 156. DENONVILLIER’S OPERATION FOR ECTROPION OF THE
LOWER LID. By reversed flaps at the outer angle. _First step._ The flap
B C D is brought down to form the outer part of lower lid.]

[Illustration: FIG. 157. DENONVILLIER’S OPERATION FOR ECTROPION. Showing
the operation completed after transposition of the flaps.]

=Instruments.= Scalpel, dissecting and artery forceps, scissors,
sutures.

=Operation.= The operation is performed under a general anæsthetic.

_First step._ An oblique incision (Fig. 156), starting from below the
inner end of the deformity, A, is carried outwards and slightly upwards
for 12 mm. to the point B. From the point B a curved incision B C is
carried upwards to and along the orbital margin. This marks out a
triangular flap. From C the incision is carried outwards and downwards
in a curved direction to D, which is situated about 2 cm. from the
external canthus, thus marking out another triangular flap B C D.

_Second step._ Both flaps are dissected up, and, when all bleeding has
ceased, the apices of the triangles are transposed and sutured in
position, the incision thus forming a _Z_-like figure (Fig. 157). A
canthorrhaphy is generally required.

=Fricke’s operation.= This has for its object the transplantation of
flaps from the side of the forehead or face into the lid to remedy a
loss of tissue resulting from operation or cicatricial contraction.

=Indications.= The operation is usually performed for cicatrices about
the upper lid, the flap being turned down from the side of the forehead.
A flap may be turned in from the inner side in addition if necessary.
The operation may also be applied to ectropion of the lower lid.

=Operation.= When planning the flaps the following points must be taken
into account:--

(i) The flap must be cut so that its base contains the main blood-supply
of the part made use of.

(ii) It should be at least one-third larger than the area to be covered.
This is estimated by cutting a piece of protective the size of the area
to be covered and laying it on the skin before the flap is cut.

[Illustration: FIG. 158. FRICKE’S OPERATION. To replace the loss of
portions of the skin of the upper lid.]

(iii) The base of the flap should consist of a considerable amount of
subcutaneous tissue as well as skin, but the apex may be little more
than the skin itself.

(iv) The direction of the subsequent contraction should be taken into
account so as to assist the final result.

_First step._ The lid is first freed by dividing all the cicatricial
bands, or, if only a small cicatrix be present, by excising that. The
lid is then pulled down into position and put fully on the stretch. This
is best performed by stitching the margin of the lid to the cheek.

_Second step._ The flap is marked out at least one-third larger than the
size required to cover the raw area. The base of the flap should be
placed a little below the raw area to be covered, so that the rotation
of the flap into position is easily performed without danger of
constriction to the base (Fig. 158).

_Third step._ The flap having been raised and all bleeding stopped, it
is rotated and sutured in its new position, the wound made by the
removal of the flap being brought together by sutures or, if it be too
large for this, covered by skin grafts (see Vol. I, p. 670).


BY THIERSCH’S SKIN-GRAFTING METHOD

=Indications.= As has already been pointed out, this method is not so
satisfactory as the method by flaps described above, but it is
frequently the only one available when the surrounding skin has been
destroyed, as after extensive lupus of the face.

=Instruments.= Scalpel, forceps, skin-grafting razor, probes.

=Operations.= _First step._ As for the previous operation.

_Second step._ Grafts are cut from a situation free from hairs, such as
the inner side of the upper arm (see Vol. I, p. 671).

_Third step._ After all bleeding has been stopped, the grafts are
applied, straightened with probes, and pressed firmly down on to the raw
surface. The edges of each graft should slightly overlap the one next to
it. Great care should be taken in applying the dressings not to disturb
the grafts (see Vol. I, p. 673).

If the whole thickness of the skin be used (Wolff’s method), care should
be taken to see that the under surface is free from fat.


THE REPAIR OF LARGE LOSSES OF SUBSTANCE FROM THE EYELIDS

Losses of portions of the lid margins usually result from operations for
malignant growths. When the loss is in the _upper lid_, some modified
form of Fricke’s operation is the best method of remedying the
deformity. When a large area is to be covered, transplantation of a flap
from the arm by the Tagliacotian method has to be performed (see Vol. I,
p. 679).

Fricke’s operation is also applicable to the outer portion of the lower
lid. When the inner end of the _lower lid_ is affected, De Vincentiis’
operation yields satisfactory results. When the whole lower lid has been
lost, a modified Dieffenbach’s method with the use of the ear cartilage
is indicated.

=De Vincentiis’ operation.= The operation aims at shifting the remains
of the lid bodily inwards to cover the gap left by the removal of the
growth.

=Instruments.= Scalpel, dissecting forceps, artery forceps, scissors,
sutures.

=Operation.= _First step._ The portion of the whole thickness of the lid
together with the growth is excised by a V-shaped incision (Fig. 159).

_Second step._ The outer canthus and orbito-tarsal ligament are divided
with the scissors. The incision is then carried outwards and upwards
with a scalpel, in a line with the lower margin of the lid, the incision
being long enough to free the lower lid sufficiently to slide it inwards
and to enable the edges of the V-shaped wound to be united (Fig. 160).

=Dieffenbach’s operation= (modified with the use of ear cartilage). This
operation consists in shifting inwards a flap of skin and subcutaneous
tissue derived from the outer side of the face to take the place of the
eyelid which has been removed, the conjunctiva and tarsal plate being
represented by a piece of skin and cartilage taken from the posterior
surface of the ear and stitched to the inner surface of the flap.

[Illustration: FIG. 159. DE VINCENTIIS’ OPERATION TO REPLACE THE LOSS OF
THE INNER PORTION OF THE LOWER LID. Showing the inner portion of the lid
removed by a V-shaped incision and the relief incision made outwards
from the external canthus.]

[Illustration: FIG. 160. DE VINCENTIIS’ OPERATION COMPLETED. The lower
lid has been pulled inwards and united to the opposite side of the gap
left by the V-shaped incision. The incision outwards from the outer
canthus, now much diminished in length, is also sutured.]

=Operation.= _First step._ The growth, together with the eyelid, is
first removed by a V-shaped incision, the base of the V being formed by
the margin of the lower lid.

_Second step._ An incision is carried directly outwards from the
external canthus. The length of this incision should be 1-1/4 times the
length of the lid margin. An incision is then carried downwards from its
outer end parallel to the outer limb of the V by which the lower lid has
been excised. This flap is then raised freely (Fig. 161).

_Third step._ The ear is turned forward and a semilunar portion of the
skin is marked out and deepened down to the cartilage. The base of this
semilunar portion should be equal in length to the upper margin of the
flap that is to form the new lid (Fig. 162). The skin is then dissected
up for about 3 millimetres from the crescentic part of the incision back
towards the straight one forming the base of the semilune. When this
part of the skin has been raised the cartilage is divided, first by a
curved incision, 3 millimetres behind that through the skin, and then
along the straight incision joining the ends of the curved one. It is
separated from the skin on the anterior surface of the ear, and the
semilunar piece of skin and cartilage is thus removed. The portion of
cartilage removed with the skin is smaller than the latter; the two
portions coincide in length along their straight margins, but the depth
of the crescent of cartilage is considerably less than that of the skin
(Fig. 162). The cartilage is usually too thick to form the new tarsus
and must be pared down until the right thickness is obtained. It is then
applied to the inner surface of the flap to form the new lid, the skin
surface being directed inwards to help to form the lower conjunctival
sac. It is fixed firmly by sutures at its margin, which are passed
through the whole substance of both flaps, and tied on the outer surface
of the new lid.

[Illustration: FIG. 161. MODIFIED DIEFFENBACH’S OPERATION TO REPLACE THE
LOSS OF THE WHOLE LOWER LID. _First step._ The whole lower lid, together
with the growth, is removed by the V-shaped incision and the flap to
form the new lid is dissected up from the outer canthus. The diagram
shows the incision marking out the flap.]

[Illustration: FIG. 162. MODIFIED DIEFFENBACH’S OPERATION. _Third step._
Showing the flap turned down, to the free border of which is attached
the flap of skin and ear cartilage. The inset shows the proportion of
skin and cartilage (light area) to be removed from the back of the ear.]

_Fourth step._ The flap forming the new lower lid is sutured in
position. The surface from which the flap is taken is closed as far as
possible with sutures after undermining the edges, any raw area being
covered by skin grafts taken from the arm.




CHAPTER X

OPERATIONS UPON THE LACHRYMAL APPARATUS


Operations upon the lachrymal apparatus are divided into--

   I. Operations upon the lachrymal canals.
  II. Operations upon the lachrymal gland.

The majority of operations are undertaken for the relief of obstruction
to some portion of the canal which leads from the conjunctival sac to
the nose, obstruction to which causes an overflow of tears (epiphora)--a
condition which must be distinguished from hypersecretion
(lachrymation).

The obstruction may occur in any part of the canal, that is to say, in
the puncta, canaliculi, lachrymal sac or duct; and it is most important
to determine the cause and position of the obstruction in every case
before undertaking an operation for its relief. Hence it need hardly be
said that the nose should be carefully examined in every case unless the
cause is obvious. The operations are divided into two classes:--

1. Those which are undertaken for the relief of the obstruction.

2. Those which are undertaken for the obliteration of the canals.

Except under exceptional circumstances, the latter operations are only
undertaken when a cure cannot be brought about by the former.

The presence of a septic focus, such as a distended lachrymal sac, apart
from the irritation and increased lachrymal secretion caused thereby, is
a source of grave danger to the eye if not relieved, as it is a frequent
cause of serpiginous corneal ulceration.


OPERATIONS FOR THE RELIEF OF LACHRYMAL OBSTRUCTION

DILATATION OF THE CANALICULUS

=Indications.= (i) Contraction of the puncta following marginal
blepharitis, especially when associated with ectropion.

(ii) Preparatory to syringing or probing.

(iii) To dilate a stricture of the canaliculus.

=Instruments.= Nettleship’s canaliculus dilator (Fig. 163).

=Operation.= The operation is performed under adrenalin and cocaine, a
little solid cocaine being rubbed in over the canaliculus.

The lid is slightly everted and put on the stretch by pulling it
downwards and outwards with the thumb. The depression caused by the
punctum is seen on the top of a small elevation. The point of the
dilator is entered vertically into the punctum and then turned parallel
with the lid margin and passed onwards with a steady pressure. At the
same time it should be rotated between the finger and thumb, until the
inner bony wall of the lachrymal sac is felt. The only difficulty which
may be experienced is in entering the dilator into the punctum, owing to
the small size of the latter. For this reason the fine point of
Nettleship’s dilator is more suitable than the form modified by Lang.
Even Nettleship’s dilator is too large in a few cases, and here a large
sharp-pointed pin is sometimes of use in defining the punctum before
using Nettleship’s dilator.

[Illustration: FIG. 163. CANALICULUS DILATOR]


SLITTING THE CANALICULUS

=Indications.= To enlarge the punctum and direct the entrance to the
canaliculus inwards. This is especially desirable before ectropion
operations and for the removal of concretions (leptothrix) from the
duct. In former days the canaliculus used to be slit with the idea of
passing very large probes down the lachrymal duct; this has now been
abandoned, since slitting the canaliculus throughout its whole length,
as is required for this treatment, does away with the capillary
attraction.

[Illustration: FIG. 164. CANALICULUS KNIFE.]

=Instruments.= Dilator, canaliculus knife (Fig. 164), straight iris
forceps, sharp-pointed scissors.

=Operation.= It is usually performed on the lower canaliculus. The eye
is cocainized as in the previous operation and the patient is made to
look up.

_First step._ The canaliculus is first dilated. The knife is inserted
for a short distance with the handle parallel to the lid margin. The
lower lid being held on the stretch by the thumb, the handle of the
knife is raised towards the brow, thus dividing the canaliculus. The
blade of the knife should be directed upwards and slightly backwards.

_Second step._ As the lips of the wound are liable to reunite, it is
better to remove the posterior lip of the groove. This is performed by
seizing the latter with forceps and dividing it with scissors. The
entrance to the canaliculus should be kept open by means of the dilator
passed twice a week for a month.


SYRINGING THE LACHRYMAL DUCT

=Indications.= (i) To test whether the lachrymal canals are patent.

(ii) By constantly cleansing the sac and washing away all purulent
discharge the mucous membrane may regain a more healthy condition, and
so an obstruction due to an alteration in the mucous lining may be
relieved. In cases with a purulent discharge a small quantity of
protargol (10% solution) may be left in the sac after syringing.

[Illustration: FIG. 165. LACHRYMAL SYRINGE.]

(iii) The injection of adrenalin and cocaine into the sac before its
excision.

=Operation.= The eye is cocainized and the patient made to look up. The
punctum is everted by pulling down the lower lid. The canaliculus is
then dilated. The nozzle of the lachrymal syringe (Fig. 165) should be
passed until it is felt to impinge on the bony outer wall of the sac.
Withdraw the syringe slightly and apply gentle pressure to the piston.
The fluid will either regurgitate through the upper canaliculus or, if
the duct be patent, pass down into the nose and so into the throat.

=Complications.= If too forcible syringing be used extravasation of the
fluid may take place. This is accompanied by pain and swelling in the
lachrymal region. It usually subsides under hot fomentations, but
suppuration and even cellulitis of the orbit have been known to occur.


PROBING THE LACHRYMAL DUCT

=Indications.= (i) In cases of congenital lachrymal obstruction due to
débris blocking the duct.

(ii) When syringing has failed to bring about a cure, a probe may be
passed once or twice to see if dilatation causes any improvement. It is
especially useful in children.

(iii) As a preliminary to the insertion of styles.

Various forms of probes are employed, those of Bowman being in general
use. Too fine a probe should not be used, otherwise a false passage is
liable to be made.

=Operation.= This is performed under adrenalin and cocaine, which should
be injected into the lachrymal sac.

The lower punctum is dilated and the probe passed parallel to the lid
margin until it is felt to impinge upon the lachrymal bone. Keeping the
point applied to the bone, the handle of the probe is rotated upwards
through rather more than a quarter of a circle and passed by a gentle
pressure downwards and slightly outwards into the duct, keeping the
point of the probe close to the bone the whole way. The direction of the
probe after entering the duct should be downwards, outwards, and
backwards in the direction of the first molar tooth on the same side.
The backward direction of the duct is much more marked in young children
than in adults.

=Complications.= A false passage may be made into the antrum of
Highmore. If such an accident should occur, no further attempt should be
made to pass a probe for a few days until the wound has healed.


THE INSERTION OF STYLES

A few surgeons still insert styles into the lachrymal duct with the idea
of continuous dilatation. The hollow styles used by Bickerton are the
ones most frequently employed.

=Instruments= for dilating, slitting the canaliculus, probing, and
styles. Also Stilling’s knife.

=Operation.= A general anæsthetic is desirable.

_First step._ The canaliculus is dilated and slit up, the posterior lip
being removed (see p. 29).

_Second step._ The duct is dilated by probing (_vide supra_) or enlarged
by passing Stilling’s knife down it.

_Third step._ A style is passed down the dilated duct. The lower end of
the style should rest upon the floor of the nose, otherwise there is a
tendency for the style to slip into the duct and disappear. Care should
be taken that the upper end does not rub on the globe. Styles should
generally be left in position from three to six months. A style should
at first be made of lead wire and moulded until a suitable pattern is
obtained, from which a hollow gold style can be made subsequently.

=Complications.= 1. _Dacrocystitis_ may follow the insertion of a style,
which should then be removed until the inflammation has subsided.

2. _The style may slip down the duct._ If this should occur an attempt
should be made to grasp it through the slit canaliculus. The lower end
may present in the nose and the style can then be withdrawn with
forceps. Occasionally styles lodge in the antrum of Highmore, in which
case they must be removed after localization by the X-rays through an
opening from the mouth above the canine tooth.


OPERATIONS FOR THE OBLITERATION OF THE CANALS

When syringing and probing have failed to relieve the lachrymal
obstruction, one of the following operations for the obliteration of the
lachrymal passages may be employed.


OBLITERATION OF THE CANALICULI

=Indications.= In cases of lachrymal obstruction in which an immediate
operation upon the globe is required.

=Operation.= Under cocaine. Fine sutures armed with a small curved
needle are passed beneath both the upper and lower can[al]iculus and
tied so as to include them in the ligature. Permanent obliteration may
be caused by the destruction of the lining membrane with the actual
cautery.


EXCISION OF THE LACHRYMAL SAC

=Indications.= (i) For mucocele in cases of lachrymal obstruction which
have failed to yield to other treatment.

(ii) In all cases of tuberculous disease of the sac.

(iii) For a recurrent lachrymal abscess after subsidence of the acute
inflammation.

(iv) For hypopyon ulcer associated with lachrymal obstruction.

(v) Before operation on the globe in cases of lachrymal obstruction.

(vi) For lachrymal fistula.

=Instruments.= Small scalpel, forceps, Muller’s speculum (Fig. 166),
Axenfeld’s retractor (Fig. 167), straight scissors, horsehair sutures.

=Operation.= Hæmorrhage is the most troublesome part of this operation;
it is best controlled by injecting adrenalin (made from the dried gland,
ʒj, and ℥j of water) and cocaine, 10%, into the sac a quarter of an hour
before operating. Swabs on the end of a glass rod dipped in adrenalin
and cocaine may also be used during the operation. A general anæsthetic
is desirable, but many surgeons perform the operation under local
anæsthesia, produced by injecting 5% cocaine with 1 in 1,000 adrenalin
into the tissue surrounding the sac; but the latter plan has the
disadvantage that the mixture may cause severe toxic effects, and the
patient usually experiences some pain while the upper portion of the
incision is being made and the lower end of the sac is being divided.

_First step._ The internal tarsal ligament is first defined by putting
the lids on the stretch. An incision should be made, 15 millimetres in
length (5 millimetres of which should fall above the tarsal ligament),
backwards and inwards directly over the lachrymal sac. Muller’s
retractor is then inserted to retract the wound laterally, the hooks
being made to engage the margins of the incision by means of forceps.
The superficial fascia and the fibres of the orbicularis muscle are then
divided. The internal tarsal ligament in the upper part of the wound,
together with the glistening deep fascia, is exposed and divided
carefully so as not to injure the lachrymal sac, which is found directly
beneath it (Fig. 168).

[Illustration: FIG. 166. MULLER’S RETRACTOR FOR EXCISION OF THE
LACHRYMAL SAC.]

[Illustration: FIG. 167. AXENFELD’S RETRACTOR FOR EXCISION OF THE
LACHRYMAL SAC.]

_Second step._ With scissors the sac-wall is then separated from the
deep fascia which encloses it, first externally and then internally, the
canaliculi being divided. Axenfeld’s retractor is then inserted in the
longitudinal axis of the wound (Fig. 167). The middle of the sac is
grasped with forceps and pulled forward, and the top of the sac is
defined and detached. This is frequently difficult owing to the
troublesome hæmorrhage which often occurs. The sac is pulled well
forward, and the posterior wall is separated, the neck of the sac being
divided as far down the duct as possible by means of scissors. A large
probe is passed down the duct into the nose. Some surgeons remove the
periosteum of the lachrymal bone as well as the sac, which is
unnecessary. The wound is closed by three sutures, the middle one
including the divided ends of the internal tarsal ligament. A firm
dressing should be applied so as to keep the walls of the cavity in
contact. In tuberculous cases it is desirable to curette the lower end
of the duct after removal of the sac. The stitches are removed on the
seventh day.

=Complications.= These may be immediate or remote.

=Immediate.= 1. _Inability to find the sac._ This may happen to a
beginner, and is generally due to the fact that the dissection is
carried too much inwards towards the nose. It should not occur if the
guides to the sac carefully borne in mind, namely, the internal tarsal
ligament and, on the inner side, the lachrymal crest, which can easily
be felt with the finger or forceps in the wound.

[Illustration: FIG. 168. EXCISION OF THE LACHRYMAL SAC. Showing the
internal tarsal ligament in the upper part of the wound with the sac
lying beneath.]

[Illustration: FIG. 169. EXCISION OF THE LACHRYMAL SAC. Showing the
method of defining the upper end of the sac. The internal tarsal
ligament has been divided and the sac is well pulled forward with
forceps.]

2. _Opening the conjunctival sac._ This may take place when dividing the
canaliculi. It is more likely to occur if the deep fascia has been
imperfectly divided before carrying out the dissection to the inner
side. As a rule the opening heals readily.

3. _Opening of the orbit_, due to the division of the fascia attached to
the posterior lip of the lachrymal groove. It is recognized by the fact
that orbital fat presents in the wound, and for this reason it makes the
operation more difficult. It is most likely to happen when the lower end
of the sac is being divided. It lays the orbit open to the possibility
of septic infection. The internal rectus has been divided, no doubt due
to the fact that the fascia, which passes from the outer surface of this
muscle, is attached to the posterior lip of the lachrymal groove, and
the muscle has been thereby pulled up into the wound; with ordinary
caution such an accident is impossible.

4. _Injuries to the cornea._ Corneal abrasions by the clumsy insertion
of retractors may lead to severe corneal ulceration.

=Remote.= 1. _Epiphora._ Normally the lachrymal secretion is largely
removed from the conjunctival sac by a process of evaporation. It is
only when the hypersecretion of tears takes place that the lachrymal
apparatus is called much into use. As a rule, patients who have had the
lachrymal sac excised do not complain of epiphora, except in a cold
wind. Occasionally this epiphora may be so troublesome that removal of
the palpebral portion of the lachrymal gland is desirable for its
relief. There is no fear of the conjunctival sac becoming dry after this
operation, since there are numerous accessory lachrymal glands (glands
of Waldeyer and Krause) opening on to the superior fornix.

2. _A sinus._ The wound may break down and a sinus may form at the site
of the incision. These cases are nearly always of tuberculous origin and
not infrequently have underlying bone trouble. They can usually be made
to heal by the use of iodoform and scraping.

3. _Recurrence of the mucocele or lachrymal abscess._ Occasionally the
mucocele may re-form, or an abscess result after removal of the sac.
This is due either to a piece of sac-wall being left behind, or to the
relining of the cavity with epithelium from the cut end of the duct. It
is particularly liable to occur in cases of a tuberculous nature. Firm
pressure with the dressings after the operation is the best method of
preventing the cavity relining with epithelium. If the condition has
arisen, the pseudo-sac should be excised.


OPENING A LACHRYMAL ABSCESS

=Indications.= Lachrymal abscess is due to an inflammation around the
sac-wall through which infection of the cellular tissue has taken place.
The abscess should not be opened until pus is present, as even
considerable swelling and œdema will often subside without suppuration;
this is usually about the end of the third day. Further, if the opening
be made too soon, the inflammation takes considerably longer to subside.

=Instruments.= Beer’s knife, forceps, and probe.

=Operation.= Usually performed under gas. An incision is made over the
lachrymal sac and is carried downwards and inwards to the bone by a
single puncture of the knife. The pus is evacuated, and the cavity
stuffed with gauze, which should be changed daily for the first three
days. Hot fomentations should be applied. As soon as the swelling has
subsided, the lachrymal obstruction should be treated by one of the
methods previously described.


OPERATIONS UPON THE LACHRYMAL GLAND

REMOVAL OF THE PALPEBRAL PORTION

=Indications.= For obstinate epiphora after removal of the lachrymal
sac.

=Instruments.= Fixation forceps (two pairs), two sharp hooks, strabismus
scissors, suture.

[Illustration: FIG. 170. EXCISION OF THE PALPEBRAL PORTION OF THE
LACHRYMAL GLAND. The lid is doubly everted and the gland is dissected
out from within outwards.]

=Operation.= Usually performed under adrenalin and cocaine.

_First step._ The upper lid is doubly everted. The eversion is best
carried out by holding the singly everted lid between forceps and then
re-everting it; the forceps are then given to an assistant to hold. With
a syringe a few drops of 5% cocaine are injected through the conjunctiva
into the area to be operated upon.

_Second step._ The gland is seen beneath the conjunctiva at the outer
part of the upper fornix, seized with forceps, and drawn forwards. A
horizontal incision is made with scissors through the conjunctiva, which
is dissected backwards. The edges of the wound are then held apart by
means of sharp hooks (Fig. 170).

_Third step._ The gland, which is seen as a nodule, is drawn forward
with forceps. By means of the scissors the gland is separated from its
attachments along its whole length, starting on the inner side, the
wound being subsequently closed with a few points of catgut suture.


REMOVAL OF THE ORBITAL PORTION

=Indications.= It is usually undertaken for tumours (endotheliomata,
&c.) and retention cysts.

=Instruments.= Knife, artery and dissecting forceps, retractors,
ligatures.

=Operation.= Performed under a general anæsthetic.

_First step._ An incision, three inches long, is made through the skin
immediately below the outer third of the orbital margin. The underlying
orbicularis palpebrarum is divided, and the orbital fascia covering the
gland is defined and incised.

_Second step._ The gland is first separated from the periosteum of the
depression in the bone in which it lies, and is drawn forward and
carefully dissected out from the lid. The wound is then closed with
sutures.

=An abscess in the lachrymal gland= should be opened by an incision
similar to, but not so long as that in the above operation.


OPERATIONS UPON THE ORBIT

EXPLORATION OF THE ORBIT (KRÖNLEIN’S METHOD)

In this operation the bony outer wall of the orbit is divided above and
below, and turned outwards so as to expose the orbital contents without
interfering with the globe; the bony wall, being kept attached to the
overlying tissue, can be replaced subsequently without fear of necrosis.

=Indications.= The operation is performed in cases of a suspected tumour
of the orbit, which, if small and non-malignant, can be removed, the eye
being left _in situ_. If doubt exists as to the nature of the tumour a
piece can be removed and examined microscopically, either at the time of
the operation or later. It is especially suitable for tumours of the
optic nerve and for orbital cysts behind the globe.

=Instruments.= Scalpel, dissecting forceps, artery forceps, scissors,
periosteum detacher, chisel and hammer, or preferably, a motor rotary
saw, and retractors.

=Operation.= Performed under a general anæsthetic.

_First step._ A slightly curved incision with the convexity forwards is
made so as to expose the outer margin of the orbit and carried down to
the bone. The periosteum is separated from the inner surface of the
outer wall of the orbit by means of a periosteum detacher and divided
horizontally, the finger is inserted, and the orbit explored. If a
small tumour or cyst be found it can sometimes be shelled out through
this incision without enlarging the wound further.

_Second step._ The eye and orbital contents are carefully protected with
a large flat retractor. The bone is first divided above, by means of
either a chisel or a saw. The upper incision should pass through the
base of the external angular process of the frontal bone, and run
backwards and slightly downwards to the posterior end of the
spheno-maxillary fissure. The lower incision should run directly
backwards from the lower orbital margin into the spheno-maxillary
fissure. The triangular wedge of bone attached by its outer surface to
the soft tissues in the temporal fossa is then forced outwards. In doing
this care must be taken not to fracture the orbital wall anteriorly,
otherwise the space to work in will be much reduced.

_Third step._ Consists in the removal of the tumour. Care must be taken
to displace the external rectus to one side so as to avoid injury to it
as much as possible. If the case should be one of an optic nerve tumour,
for which the operation is most frequently performed, the optic nerve is
divided close behind the globe. The tumour is freed from the surrounding
ciliary nerves and the ophthalmic artery and brought up into the wound
as much as possible. The optic nerve is then divided at the apex of the
orbit and the tumour removed. The wound in the periosteum of the outer
wall of the orbit is closed with a catgut suture, the bone, together
with the soft parts, replaced in position and the skin wound closed by
sutures. A drainage tube should be inserted for at least twenty-four
hours.

=Complications.= 1. _Proptosis._ The operation is liable to be followed
by great proptosis as the result of hæmorrhage into the orbit. If the
optic nerve has been removed, the globe may be dislocated forwards
between the lids and come in contact with the dressings.

2. _Corneal ulceration._ As the cornea is frequently anæsthetic from
division of the ciliary nerves, ulceration is very liable to follow. It
is, therefore, desirable in many cases to stitch the lids together after
closing the skin wound.

3. _Defective outward movement in the globe_ is of frequent occurrence,
owing either to injury of the external rectus or the sixth nerve, or to
involvement of them in the scar tissue. Stitching the periosteum
together obviates the latter to a certain extent.

4. As the wound cicatrizes a certain amount of _enophthalmos_ is very
liable to result.


EVISCERATION OF THE ORBIT

=Indications.= This operation is usually performed for some form of new
growth originating either in the eye or the orbit.

=Operation.= This may be modified (1) according to the _position_ of the
growth. In severe cases of rodent ulcer and sarcomatous growths, which
involve the lids, it is desirable that the lids should be removed with
the tumour; but in cases of tumour of the optic nerve, or disease
situated far back in the orbit, and not involving the lids or
conjunctiva, these structures may be retained, since a much better
socket is thus obtained. (2) The _nature_ of the growth. In simple
tumours, such as nævi and some cases of arterio-venous aneurism which
have failed to yield to other treatment, the incomplete method, in which
the lids are retained, is all that is necessary, but in malignant cases
they should be removed.

_The Complete Method._ An incision down to the bone is first made,
completely encircling the orbital margin and including any growth that
may be involving the skin. The periosteum is then separated completely,
as near to the optic foramen as possible. Care must be taken in dealing
with the periosteum over the lachrymal bone, as the bone is liable to be
fractured and an opening made into the nose if undue force be used. The
apex of the cone formed by the periosteum is divided, as far back as
possible, with curved scissors, and the whole orbital contents are
removed. The wound is packed with gauze, and skin-grafting is
subsequently performed when the bone has become covered with
granulations; this usually occurs about the end of the second week.

_The Incomplete Method._ The globe is first enucleated and the outer
canthus divided. The lids are well retracted and an incision is carried
down to the bone along the orbital margins. The periosteum is then
stripped up from the walls of the orbit and the apex of the cone divided
as far back as possible, as in the previous operation. The conjunctiva
and outer canthus are then united with sutures. As a rule, skin-grafting
is not necessary after this operation.


OPENING AN ORBITAL ABSCESS

Orbital abscesses should be incised where they point. In the upper lid
care should be taken not to divide the levator palpebræ muscle; the
incision should be placed well to one side. In making an incision over
the inner side of the orbit care should be taken not to detach the
pulley of the superior oblique. The cause of the abscess should be
ascertained if possible. Suppuration in the ethmoidal sinuses coming
through from the nose is the commonest cause, and should be treated
appropriately (see Section V).




                      SECTION III

                OPERATIONS UPON THE EAR

                          BY
  HUNTER F. TOD, M.A., M.D. (Cantab.), F.R.C.S. (Eng.)
          Aural Surgeon to the London Hospital




CHAPTER I

EXAMINATION OF THE EAR: GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS


In order to perform successfully the various operations upon the ear, it
is essential that the surgeon should be familiar with the technique of
its examination, which, for the sake of convenience, will first be
briefly described.


EXAMINATION OF THE EAR

For this purpose it is necessary to make use of certain instruments in
order to obtain a clear view of the deeper parts of the auditory canal
and tympanic membrane. Most important amongst these are the following:--

=Mirror.= A head-mirror, such as the ordinary laryngological mirror with
a focus of eight inches, is to be preferred to the hand-mirror, as it
leaves both hands free for manipulation.

[Illustration: FIG. 171. CLAR’S LAMP.]

=Sources of illumination.= Although the light reflected from the sky on
a bright cloudless day is excellent, it can seldom be made use of, and
so for practical purposes the source of light is usually artificial. It
is wiser always to use the same kind of light--for instance,
electric--as in this way a more accurate comparison can be made of the
various pathological conditions seen on examination. In the consulting
room, the lamp recommended by Dr. Greville Macdonald, furnished either
with a thirty-two candle-power frosted burner or with a Nernst light, is
most suitable. As a portable lamp, it is useful to have an electric
bull’s-eye lamp, run off from a dry-celled battery: it can be held in
the position of the ordinary lamp, the light being reflected into the
ear by means of the head mirror. The ordinary surgical head-lamp,
although not well adapted for inspection of the deeper parts of the
auditory canal, is eminently suited for obtaining good illumination
during the performance of the mastoid operations; or in its stead a
head-mirror with lamp attached may be used, as recommended by Clar (Fig.
171).

=Aural specula.= Of the various aural specula employed, Gruber’s is very
good (Fig. 172). A special speculum in which a portion has been removed
from the narrow end is sometimes useful in order to facilitate operative
procedures within the external meatus.

=Forceps.= The best are angular spring forceps with bulbous points (Fig.
173).

[Illustration: FIG. 172. GRUBER’S AURAL SPECULUM.]

[Illustration: FIG. 173. ANGULAR SPRING FORCEPS.]

=Position of the patient.= The patient should sit upright in a chair
with the side to be examined turned towards the surgeon. To prevent
movement, the head should be supported by an assistant or by a head-rest
fixed to the back of the chair. The lamp is placed a little behind and
to the left of the patient’s head, on a level with the head of the
examiner.

=Technique of examination.= To convert the external meatus into a
straight canal, the auricle has to be pulled backwards and downwards in
an infant, backwards in a child, and backwards and upwards in an adult.
The speculum should be warmed and inserted gently into the meatus by the
thumb and index-finger of the left hand, whilst the pinna is held
between and pulled back by the second and third fingers (Fig. 174). This
leaves the right hand free for manipulation. The largest possible
speculum should be used, in order to give the maximum amount of room and
illumination. It should only be introduced into the meatus as far as the
adaptable cartilaginous portion permits--about half an inch in the
adult--and not forced into the bony portion. The utmost gentleness is
essential in order to obtain the confidence of the patient; this is
absolutely necessary for the performance of the various small operations
upon the auditory canal and tympanic cavity under local anæsthesia.

[Illustration: FIG. 174. EXAMINATION OF THE EAR.]

[Illustration: FIG. 175. AURAL FORCEPS HOLDING COTTON-WOOL.]

=Method of cleansing the ear.= Except when the auditory canal is
completely blocked by inspissated pus, cerumen, or epithelial débris, it
is sufficient to mop out the ear with small pledgets of cotton-wool. To
prevent injury to the walls of the meatus and to the tympanic membrane,
the pledget is held between the blades of the forceps in such a fashion
that it partially projects beyond its points (Fig. 175). The forceps is
passed through the lumen of the speculum along the auditory canal and
then quickly withdrawn. This is repeated with fresh pledgets until the
meatus is cleansed. If there is much purulent discharge, only a brief
moment may be given (after the withdrawal of the forceps) in which to
inspect the deeper parts. Such a view, however, should always be
obtained in order to form an accurate diagnosis. If this method fails to
cleanse the ear, syringing becomes necessary.

=Technique of syringing.= The patient should be sitting down, as
syringing may cause giddiness. The fluid should be aseptic, and at a
temperature of 100° F. The patient’s head is inclined to the affected
side, and the auricle is pulled upwards or backwards. The syringe is
inserted a short distance within the meatus, and applied to the upper
posterior wall so that the stream of lotion flows along the roof of the
canal to the drum, and returns along the floor, thus washing out the
contents. The best syringe is one with a metal plunger, as it can be
easily sterilized. After syringing, the auditory canal should be dried
and again inspected. If the inspissated pus or epithelial débris cannot
be removed by simple syringing, an ear-bath of warm hydrogen peroxide
(10 vols. %) should be given, and the ear again syringed after ten
minutes.

[Illustration: FIG. 176. MILLIGAN’S INTRATYMPANIC SYRINGE.]

=Syringing out of the attic.= In certain cases of chronic attic
suppuration, it is advisable to syringe out the attic. For this a
special syringe is necessary. It consists of a fine canula whose point
is turned up almost at right angles to its shaft (known as Hartmann’s
canula), to which is fitted a piece of india-rubber tubing and a ball
syringe. Milligan’s modification of this instrument is now generally
used, as it permits of the canula being held in the hand, and instead of
having a ball syringe, is connected by rubber tubing to a small
irrigator (Fig. 176).

The patient sits upright in a chair in the ordinary position for
examination of the ear; a speculum is inserted into the meatus, and held
in position with the left hand; the canula, together with the ball
syringe (if Hartmann’s is used), is held in the right hand. Under good
illumination the canula is passed inwards along the auditory canal, and
its point inserted through the perforation. By gently pressing on the
syringe, the fluid is forced into the attic, which is thus washed out.

With Milligan’s instrument, the irrigator is fixed about two feet above
the level of the ear. While the canula is being inserted, the escape of
lotion is prevented by compressing the tube against the shaft of the
instrument by means of the thumb. After the canula has been inserted
into the opening, relaxation of this pressure permits of flow of the
lotion. Milligan’s method is better than Hartmann’s, as the surgeon has
more control over the instrument. Pain due to the introduction of the
canula may be greatly minimized by previously inserting within the
margins of the perforation either a pledget of cotton-wool soaked in a
saturated solution of cocaine, or a crystal of cocaine.

After the cavity has been thoroughly washed out, the auditory canal is
carefully dried as a final step, gentle inflation by Politzer’s method
may be performed in order to expel any fluid still remaining within the
attic.


GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS

In this connexion two points must be borne in mind: (1) The surgeon must
have a good view of the part operated upon. For this reason when
operating upon the auditory canal, the tympanic membrane, and tympanic
cavity, he will usually require to work by reflected light.

(2) There must be no movement of the patient’s head during the
operation. If the operation is performed under a local anæsthetic, it is
therefore very important that the patient’s head should be kept fixed by
means of an assistant.

=Preliminary surgical toilet.= If there be no existing suppuration, the
ear should be cleansed, some twelve hours before the operation, by first
giving an ear-bath of hydrogen peroxide lotion. This is done by making
the patient incline the head to the opposite side so that the affected
ear is uppermost. The warm solution is then poured into the meatus.
After ten minutes the ear is syringed out with a 1 in 5,000 aqueous
solution of biniodide of mercury, and a strip of sterilized gauze is
then inserted into the auditory canal. The auricle and surrounding parts
should also be surgically cleansed, and afterwards protected by a simple
aseptic compress. If, as in furunculosis of the external meatus,
syringing or cleansing of the ear is very painful, drops of a 10%
solution of carbolic acid in glycerine may be instilled frequently into
the meatus instead. If there is an existing otorrhœa, it is obviously
impossible to render the field of operation absolutely aseptic. The ear,
however, should be cleansed, but the auditory canal should not be
plugged with gauze. The existence of a purulent discharge is no excuse
for lack of cleanliness. Failure of such precautions may lead to
disaster; for example, to perichondritis of the auricle as a sequel of
the mastoid operation.

Before the actual operation takes place, if necessary after the
anæsthetic has been given, the ear and surrounding parts should again be
carefully cleansed, and the auditory canal syringed out with biniodide
of mercury solution.

In intrameatal operations the head should be wrapped in a sterilized
towel, and a square of sterilized lint, having an aperture in the centre
so as to expose only the auricle and meatus, should be placed over the
side of the head and face. In operations on the mastoid process, and in
those involving a post-auricular incision, the head should also be
shaved for at least two or three inches beyond the region of the ear.

=Anæsthesia.= Both local and general anæsthesia are used. Unless
contra-indicated for some special reason, and unless the operation is a
very trivial one, it is wiser to give a _general anæsthetic_. Of these,
chloroform is the most suitable in adults and infants, and the A. C. E.
mixture in children. Ether, although it may be safer, is frequently a
source of annoyance to the operator, as it tends to increase the
hæmorrhage.

In order to produce _local anæsthesia_ two methods may be employed: (1)
The instillation of fluids into the meatus; (2) subcutaneous injection
of fluids beneath the lining membrane of the meatus and into the
surrounding parts of the auricle.

The solution usually employed is a sterilized aqueous solution of
cocaine hydrochloride in varying strengths up to 20%, to which may be
added equal parts of 1 in 1,000 adrenalin chloride solution; the latter
not only increases its analgesic properties, but also acts as a powerful
hæmostatic.

_Instillation._ As the auditory canal and the tympanic membrane are
lined with epithelium which is very resistant to the absorption of
fluids, complete anæsthesia is almost impossible to obtain. This method,
therefore, is practically limited to such trivial operations as the
curetting away or snaring off of granulations or polypi from the
external or middle ear. To render anæsthesia more complete, the affected
part may be finally rubbed over with a crystal of solid cocaine
hydrochloride just before the operation--is begun. On the other hand, if
the raw surface is large--for example, the wound left after a recently
performed complete mastoid operation--the cocaine employed should not be
stronger than a 5% solution in order to minimize the risk of poisoning.
Gray of Glasgow has suggested, as a more penetrating anodyne solution, a
mixture consisting of a 10% solution of cocaine hydrochloride in equal
parts of aniline oil and absolute alcohol, a solution which he
especially advocates in order to produce anæsthesia of the tympanic
membrane before doing paracentesis.

_Subcutaneous injection._ This is a modification of Schleich’s method,
and was first introduced by Neumann of Vienna. It consists in injecting
a very weak solution of cocaine and adrenalin chloride subcutaneously
beneath the periosteum lining the auditory canal. By this method even
the complete mastoid operation has been performed, and in certain
clinics it is used continually in the minor operations of paracentesis
of the tympanic membrane, division of intratympanic adhesions,
extraction of polypi, and ossiculectomy. A solution of beta-eucaine or
novocaine may be used in preference to cocaine, as being less dangerous.
According to Neumann, three solutions are necessary: (_a_) a 1 in 2,000
solution of adrenalin chloride containing a 1% solution of beta-eucaine;
(_b_) a 1 in 3,000 solution of adrenalin chloride containing a 1%
solution of cocaine; (_c_) a 20% solution of cocaine.

The syringe for injecting the solution has a capacity of I cubic
centimetre, and for convenience its needle is fixed at an obtuse angle
to the body of the syringe (Fig. 177). The technique of the injection
depends on whether the operation is to be limited to the auditory canal
and tympanic cavity, or is to involve the mastoid process.

[Illustration: FIG. 177. NEUMANN’S SYRINGE FOR SUBCUTANEOUS INJECTION.]

If the complete mastoid operation is going to be performed, the needle
of the syringe, now filled with the eucaine solution, is thrust through
the skin about the middle point of the mastoid process, and a few drops
of the solution are injected. The needle is then forced upwards towards
the temporal ridge, at the same time being thrust in deeply until it
touches the bone, so that a syringeful of the solution is injected
beneath the periosteum. The needle is then withdrawn and reinserted at
the same point, but in a backward direction, the solution being injected
along the posterior portion of the mastoid process; in a similar manner
the solution is injected downwards towards the tip of the mastoid. The
ear being now pulled well forward, the needle is made to pierce the fold
between the auricle and the mastoid process, just above the posterior
ligament, and is pushed inwards between the anterior border of the
mastoid process and the cartilage of the meatus, and a further
syringeful of the solution is injected. A large speculum is now inserted
into the ear, so that by pressing it against the wall of the meatus the
skin, at the termination of the cartilaginous portion, is made to
project in folds. The needle of the syringe, filled with cocaine
solution, is pushed into this fold, and a few drops of the solution
injected. By degrees the needle is still further pushed inwards, keeping
it in close contact with the bony wall so that the fluid is injected
beneath the periosteum. If the injection has been successful, a white
bulging of the superior wall of the auditory canal will be noticed. To
render anæsthesia complete, further injections may be made into the
inferior and anterior walls of the auditory canal. Finally, a pledget of
cotton-wool soaked in a 20% solution of cocaine is pushed into the
tympanic cavity.

In the case of simple opening of the mastoid, subcutaneous injections
into the auditory canal are not necessary. On the other hand, if the
operation is limited to the auditory canal and tympanic cavity, the
injections into the mastoid process are not required, but a primary
injection of a small quantity of eucaine solution into the
auriculo-mastoid fold considerably diminishes the pain produced during
the act of injection into the auditory canal. Fifteen minutes should be
allowed to elapse before the operation is begun. The anæsthesia lasts
about half an hour.

_Difficulties._ It is by no means easy to inject fluid beneath the
periosteum of the auditory canal, owing to its close adherence to the
bone. The needle by mistake may repierce the skin at a point farther in,
so that the fluid, instead of being injected beneath the periosteum, is
injected into the auditory canal itself. In these cases anæsthesia will
not be obtained, and the operator may possibly blame the principle of
subcutaneous injection, rather than his own faulty technique.

In favour of subcutaneous injection it is urged that most of the minor
operations within the tympanic cavity, including ossiculectomy, may be
performed with the patient sitting up in the chair in the consulting
room, and further, that the patient can afterwards go home; that the
operation is rendered more easy owing to there being practically no
bleeding; and that in the case of the more severe operations, such as
opening of the mastoid antrum, the surgeon, in a case of emergency, may
make use of this method if he cannot possibly obtain the services of an
anæsthetist.

Against subcutaneous injection is the pain of the injection, which may
be so great that the patient will not submit to it, and in consequence
the proposed operation may have to be postponed.

In the case of the mastoid operation, it is difficult to believe that
local anæsthesia, however efficient, will be looked upon with favour
either by the surgeon or by the patient, except when a general
anæsthetic is absolutely contra-indicated. The discomfort produced by
retraction of the parts, the jarring caused by chiselling, and the
consciousness of what is taking place, are far more unpleasant and more
of a shock to the patient, than a general anæsthetic carefully given.
Further, it is not always possible to foretell the extent of the
operation, and if repeated injections become necessary, there is danger
of eucaine or cocaine poisoning being produced.


=Position of the patient and the surgeon=

1. In the minor operations the patient may be operated on whilst in the
sitting posture, whether a local anæsthetic or a general one of gas and
oxygen is employed. The relative positions of the patient and the
surgeon are then the same as for the ordinary routine examination of the
ear. Special care, however, should be taken that the patient’s head is
supported by the anæsthetist or assistant in order to prevent
involuntary movements.

2. If the patient is operated on in the recumbent position, the head may
rest comfortably on an ordinary pillow, but if chiselling is going to
take place, the best support is a loosely filled sand-bag. The head
should be turned towards the opposite side so that the affected ear is
uppermost, and the surgeon stands at the side to be operated on. The
lamp, the source of reflected light, should be held about six inches
above the patient’s shoulder on the opposite side.




CHAPTER II

OPERATIONS UPON THE EXTERNAL AUDITORY CANAL


OPERATIONS FOR FURUNCULOSIS

The operative treatment consists in incising the furuncles and, if
necessary, curetting out their contents.

=Indications.= (1) If, in spite of palliative treatment for two days,
the pain be so intense as to prevent sleep, and be accompanied by
pyrexia.

(2) If there be accompanying œdema of the auricle and surrounding parts.

(3) If the furuncles occur during the course of a middle-ear
suppuration, and occlusion of the external meatus prevents free drainage
of the purulent secretion.

When possible, it is always preferable to operate under a general
anæsthetic, such as gas and oxygen. If, however, the patient objects to
a general anæsthetic, it should be explained that, in spite of the
application of anodynes, the operation, although of momentary duration,
will be excessively painful.

=Operation.= After the ear has been thoroughly cleansed, a large aural
speculum is inserted within the meatus and the auditory canal dried with
pledgets of cotton-wool.

The instrument usually used for this operation is a small and narrow
sharp-pointed knife known as Hartmann’s furunculotome (Fig. 178, C).
Equally suitable, however, is a fine bistoury; or, if necessary, a small
tenotome or the ordinary paracentesis knife.

The surgeon holds the speculum in position within the meatus with the
left hand, and with the right inserts the knife through the lumen of the
speculum along the meatus until its point passes the innermost limit of
the furuncle. It is then quickly withdrawn, at the same time _incising
the furuncle_ freely down to its base. Another method is to _transfix
the furuncle_ by passing the knife through its base and making it cut
outwards through the skin. In a similar manner any other furuncles that
may be present are incised or transfixed.

If the inflammatory process, instead of being localized as a furuncle,
extends to the subcutaneous tissues, and especially if it is
accompanied by much pain, pyrexia, and occlusion of the external
meatus, _linear scarification_ may become necessary.

After incision, the contents of the furuncle are rapidly scooped out
with the curette (Fig. 178, A). Slight hæmorrhage may occur, but can be
arrested at once by plugging the meatus for a minute with a strip of
sterilized gauze. The auditory canal is finally syringed out with a warm
aqueous 1 in 5,000 solution of biniodide of mercury and firmly plugged
with gauze soaked in a 10% solution of carbolic acid in glycerine; a hot
fomentation being afterwards applied to the side of the head.

[Illustration: FIG. 178. BURKHARDT-MERIAN’S AURAL INSTRUMENT.

  A. Curette. B. Myringotome. C. Furunculotome.
  D. Hook for removal of foreign body.
]

If the operation has been performed under a local anæsthetic (and this
should only be done if a solitary furuncle is present), the pain is
usually too great to permit of firm packing of the auditory canal. This
after-packing, however, should be carried out, if possible, for the
following reasons: firstly, it presses out the contents of the furuncle;
secondly, it prevents auto-infection from one hair follicle to another;
and thirdly, it tends to dilate the auditory canal.

=After-treatment.= If the furuncles have occurred during the course of a
middle-ear suppuration, the gauze plugging must be removed within a few
hours after the operation. The ear is then syringed out once or twice
daily with a warm solution of lysol or carbolic acid, a small wick of
gauze soaked in a 10% solution of carbolic acid in glycerine being
afterwards inserted along the meatus.

If there be no accompanying middle-ear suppuration, the packing should
not be removed for at least twenty-four hours. The pain produced by the
first dressing may be severe, but can be usually avoided by first
soaking the gauze with 5% solution of cocaine for a few minutes before
removal and then gently withdrawing it whilst the ear is being syringed
with a warm aseptic lotion. For the next two or three days it is
sufficient to insert a drain of gauze soaked in a 1 in 3,000 alcoholic
solution of perchloride of mercury.

=Results.= Although cure may be expected, it is not uncommon for further
furuncles to occur in crops at repeated intervals. This is due to
auto-infection of the hair follicles, which to a large extent may be
prevented by painting the surface of the auditory canal daily, for at
least two or three weeks, with an oil containing a drachm of nitrate of
mercury to the ounce.

In the case of diffuse inflammation, although relapses are uncommon,
superficial necrosis of a portion of the bony meatus may afterwards
occur as a result of involvement of its periosteal lining. If this takes
place, stenosis of the auditory canal may afterwards occur from
subsequent cicatrization.

=Dangers.= With ordinary precautions no accident should occur, but the
following may be mentioned: (1) if the furuncles are deeply placed, the
tympanic membrane may be incised inadvertently, and a middle-ear
suppuration may result; (2) a too violent incision may cut through the
meatal cartilage posteriorly, and, as a result of septic infection, may
give rise to perichondritis of the auricle. This, fortunately, is rare.


REMOVAL OF EXOSTOSES FROM THE EXTERNAL MEATUS

=Indications.= The indications vary, depending on whether there is a
coexisting middle-ear suppuration or not.

=If there be no middle-ear suppuration.= Operation is not urgent, but is
justifiable under the following conditions:--

(i) _When one ear only is affected._ (_a_) If there be complete deafness
due to obstruction of the auditory canal. The question of operation,
however, should be decided by the patient, because it may be postponed
indefinitely so long as no symptoms occur.

(_b_) If there be recurring attacks of discomfort or of pain in the ear
as a result of eczema, of otitis externa, or of actual pressure of the
growth itself. The patient may desire operation to obtain permanent
relief.

(_c_) If there be deafness of the opposite side from other causes, and
the presence of the exostoses is causing deafness of the functionally
good ear.

(ii) _When both ears are affected._ In addition to the indications
already given, operation is advisable on the worse side if there be
almost complete obstruction on both sides, accompanied by recurrent
attacks of deafness, owing to the narrowed passage of the auditory
canal becoming repeatedly blocked from accumulation of cerumen or
epithelial débris.

_Operation is contra-indicated_ if previous examination indicates that
the deafness is due to a chronic middle-ear catarrh or internal-ear
disease, as in these cases restoration of hearing, which is the primary
object of the operation, will be impossible.

=If middle-ear suppuration be present= operation is generally advisable.

(i) _In acute middle-ear suppuration_ operation is urgent if there are
signs of retention of pus, _provided_ it is impossible to dilate the
lumen of the auditory canal. Before resorting to operation an attempt
should always first be made to obtain free drainage, as the obstruction
may be due merely to inflammatory swelling of the tissues lining the
auditory canal. With cessation of the acute inflammation, this swelling
may subside and the lumen of the auditory canal again become patent; and
if recovery with healing of the tympanic membrane takes place the
hearing may again become normal, rendering the operation no longer
necessary.

(ii) _In chronic middle-ear suppuration_ operation is always indicated
if there are symptoms of retention of pus. It is also advisable as a
prophylactic measure, although not urgent, even although no acute
symptoms are present.

=Operation.= =When there is no middle-ear suppuration.=

The operation may be performed either (_a_) through the external meatus
or (_b_) by reflecting the auricle forward by a post-auricular incision.

=Through the external meatus.= This method is only indicated if the
exostosis is situated at the entrance of the meatus and is pedunculated.

A general anæsthetic is given, the patient being in the recumbent
position. The surgeon works by reflected light. After the ear has been
thoroughly cleansed a large-sized aural speculum is inserted into the
meatus and the outlines of the exostosis are defined with a probe. A
small gouge or chisel is used. It is inserted into the meatus in such a
fashion that its point presses between the pedicle of the exostosis and
the wall of the bony meatus. With successive sharp taps of the mallet,
the gouge is made to cut through the pedicle, care being taken that the
instrument is not driven in too deeply, on to the tympanic membrane.

The growth, which can now be felt to be movable within the meatus, can
usually be removed by grasping it between the blades of forceps, or can
be expelled by syringing the ear. After its removal the auditory canal
should be plugged for a few minutes with a solution of cocaine and
adrenalin chloride. This checks all hæmorrhage, and at the same time
enables the surgeon to get a good view of the deeper parts to see if
further growths are situated more deeply within the meatus. Such
growths, provided they are pedunculated and do not abut on the tympanic
membrane, can sometimes also be removed by the same method; much depends
on their shape and situation. If sessile or too deeply placed, the
operation may have to be completed by reflecting forward the auricle.
Before terminating the operation a clear view of the tympanic membrane
should always be obtained.

The meatus is finally syringed out with a 1 in 5,000 aqueous solution of
biniodide of mercury and dried, a strip of sterilized gauze being
inserted into the auditory canal. A simple dressing is then applied to
the side of the head.

_Other methods of operation through the external meatus._

(_a_) Perforation of the exostosis, or enlargement of the small passage
existing between multiple exostoses, by means of the burr.

Although successful results have been recorded, this method is not
advised, as cicatricial tissue almost invariably causes closure of the
opening made. To keep the opening patent it is necessary to insert a
small lead or silver canula, frequently a source of great discomfort.

(_b_) If the exostosis has a very fine pedicle, it may be possible to
nip through its base with a pair of forceps, but it is not so sure a
method as the employment of a gouge and mallet.

(_c_) Such methods as attempts to destroy the growth by means of the
galvano-cautery or by the pressure of laminaria tents should be avoided;
they are useless and unsurgical.

=By reflecting the auricle forward.= This is indicated if the exostoses
are multiple, have a broad base, and are deeply situated.

The position of the patient, and the anæsthetic, are the same as in the
previous operation. Reflected light may not be necessary.

The ear and the surrounding parts are carefully cleansed and the head is
shaved for a short distance over and beyond the mastoid process. A
curved incision is made _close behind_ the auricle (Fig. 226), beginning
at the upper level of its attachment and extending downwards along the
retro-auricular fold. The incision goes down to the bone. The auricle is
reflected forward and the soft tissues are separated from the bone until
Henle’s spine and the posterior upper margin of the auditory canal are
brought into view. Any bleeding, chiefly from branches of the posterior
auricular artery, is at once arrested by pressure forceps, ligatures
being afterwards applied. The assistant’s duty is to hold the auricle
well forward and at the same time to keep the wound dry by swabbing.

The fibrous portion of the canal is carefully separated from the bony
portion with the periosteal elevator, the growth, if possible, being
exposed without tearing through the thin layer of skin which covers it.

The method of procedure now depends on the character and number of the
exostoses present.

(_a_) If situated superficially, they are removed by chiselling through
their base with a gouge. They should be thoroughly removed, if necessary
cutting through the normal bone well behind their base.

(_b_) If deeply placed, they are more easily removed by first chiselling
away a part of the upper posterior wall of the external meatus. This is
done in the same manner as in the early stage of the complete mastoid
operation (see p. 397). If possible the antrum should not be exposed,
and care should be taken not to cut too deeply for fear of injuring the
tympanic membrane.

(_c_) If the exostoses spring from the anterior wall, it is necessary to
make a T-shaped incision through the posterior membranous portion of the
auditory canal in order to bring them into view clearly. This is done
with a tenotomy knife, the flaps being held apart by means of forceps.
The growths can now be removed by means of the gouge and mallet.

(_d_) If the obstruction is due to multiple small exostoses forming an
annular stricture within the bony canal, it is better to separate the
membranous portion completely from the bony meatus. In doing so the skin
over the exostoses tears through, so that the membranous portion can be
reflected outwards as a finger-like process. To give greater room for
the operation, the auricle and fibrous portion are pulled well forward
by means of a loop of gauze passed through the lumen of the
cartilaginous meatus.

If necessary, reflected light should now be used. To reach the exostoses
it may be necessary, as in the previous case, to remove part of the
posterior bony wall. With the gouge and mallet the exostoses are
carefully chiselled away. They frequently abut on the tympanic membrane,
so that their removal without injuring it may be well-nigh impossible.
It is of the utmost importance that the field of operation should be
kept dry, if necessary by repeatedly mopping out the canal with pledgets
of cotton-wool soaked in adrenalin solution. The chief difficulty is to
determine the situation of the tympanic membrane. A fine probe is used
to discover any existing chink between the growths; this will be a guide
to show the direction in which to work. As soon as a small passage has
been made, sufficient to allow of a view of the deeper-lying parts, the
ear should be syringed out and dried, and a thorough inspection made.
The tympanic membrane can usually be seen as a greyish-blue membrane;
at other times it can be recognized by touching it with a probe. After
making certain of the position of the membrane, the rest of the
operation is easy. A small seeker (Fig. 219), such as is used in the
mastoid operation, is passed through the opening already made, and with
it the deeper limits of the exostoses can be felt. The opening is
gradually enlarged by removing the growths piecemeal with the chisel or
gouge.

Although the burr is contra-indicated when operating through the
external meatus, it is frequently of great service in these cases in
rendering the walls of the canal smooth. The disadvantages of using a
burr are, that it is less easy to control (unless the surgeon has had
considerable experience in using it), and that it destroys all the
epithelial lining of the auditory canal with which it comes in contact.
It should, therefore, only be used in those cases in which there is a
complete ring of exostoses, but should be avoided if the exostoses are
limited and if it is still possible to leave untouched a portion of the
epithelial lining of the auditory canal.

When the surgeon considers he has successfully removed the obstruction,
he should verify this fact by syringing out and drying the ear, and
again obtaining a clear view of the tympanic membrane.

The fibrous portion is now replaced by inserting a finger into the
cartilaginous meatus and pressing it back into the bony canal, the
auricle being meanwhile pulled back into its normal position. The edges
of the posterior wound are sutured together and the auditory canal is
gently packed with gauze which should be inserted right down to the
tympanic membrane. It is not necessary to make special meatal skin
flaps, as careful packing of the auditory canal should be sufficient to
keep the parts in apposition.

=When middle-ear suppuration is present.= _In acute middle-ear
suppuration_ the chief difficulty is to decide what operation to
perform. As operation is only indicated if there is retention of pus, it
is wiser to open the mastoid antrum; the exostosis, if superficial and
pedunculated, can also be removed at the same time. If, however, the
obstruction is due to multiple and deeply placed exostoses, this part of
the operation should be deferred to a later date, that is, after the
acute symptoms have subsided.

_In chronic middle-ear suppuration_ the only operation to be recommended
is the complete mastoid operation (see p. 392).

=After-treatment.= The after-treatment is practically the same whatever
operation has been performed. The first dressing need not be done until
the third day. The gauze plugging is then withdrawn and the auditory
canal is syringed out and dried. If only a single exostosis has been
removed the wound surface is small, and it is usually sufficient to
puff in some boracic powder and again insert a piece of gauze. This may
be repeated every second day, healing usually taking place within two or
three weeks. In the case of deeply situated multiple exostoses,
especially if removed from the anterior wall, considerable swelling of
the soft parts lining the auditory canal may occur as a result of the
manipulations. In such cases, after syringing out any existing
blood-clots, some cocaine and adrenalin solution should be instilled
into the meatus. An aural speculum is then gradually worked into the
auditory canal, which is gently mopped out with small pledgets of
cotton-wool, and the deeper parts are carefully inspected. Sometimes the
torn ends of the fibrous portion, instead of covering the bony walls,
are found to project into the auditory canal and to cause considerable
narrowing of its lumen. By careful manipulations with the probe or by
stroking the edges with tiny pledgets of cotton-wool, these rough
surfaces may be smoothed down. It is very important, in the early days
of the after-treatment, to prevent any narrowing at the site of the
operation. This is one of the chief causes of subsequent failure. The
gauze should always be reinserted right down to the tympanic membrane,
and if there is not much secretion it should be packed firmly against
the posterior and outer portion of the canal in order to prevent
subsequent stenosis from the tendency of the cartilage to prolapse
forward owing to the soft parts having been separated from the bony
canal at the time of the operation.

The wound behind the ear heals very quickly and the stitches can
generally be removed on the third or fourth day. Subsequent treatment
consists in preventing the formation of granulations over the wound
area. This is best accomplished by keeping the auditory canal aseptic
and dry. If granulations occur they should be touched from time to time
with a saturated solution of trichloracetic acid. If healing has not
taken place within two weeks, it will frequently be advantageous to
discontinue the gauze packing and, in its stead, to instil drops of pure
rectified spirit.

If a middle-ear catarrh with secretion of fluid occurs, owing to the
tympanic membrane having been injured, it may be impossible to continue
the gauze packing. In these cases only a fine drain of gauze should be
inserted into the meatus, the dressing being changed as frequently as
may be necessary.

Provided asepsis is maintained, the middle-ear inflammation usually
subsides rapidly with healing of the membrane. After healing has taken
place, inflation of the middle ear is recommended twice a week, for two
or three weeks, in order to aid recovery and to prevent adhesions
forming within the tympanic cavity.

=Dangers.= 1. If the exostoses be deeply situated, the tympanic membrane
may be injured.

2. If much of the anterior wall of the auditory canal be removed, the
temporo-maxillary joint may be opened.

3. It is possible that the tympanic membrane may not be recognized, and,
by working too deeply, the labyrinth or the facial nerve may be injured.

=Prognosis.= Provided no accident has occurred during the operation, a
successful result should be obtained. Stenosis, however, may occur from
cicatricial contraction if the operation has been incompletely
performed.


REMOVAL OF FOREIGN BODIES

Before considering the question of removal of foreign bodies, the
following points cannot be emphasized too forcibly:--(1) No attempt
should be made to remove a foreign body until it is certain that one
really exists. (2) Provided there is no middle-ear suppuration, a
foreign body left in the ear will very rarely cause any immediate harm.
(3) The most serious complications are due almost invariably to
ill-advised haphazard attempts to remove the foreign body; as a rule
from working blindly in the dark without making use of reflected light.

If a foreign body be suspected, the surgeon should first carefully
examine the auditory canal in order to determine its character and
position and the condition of its walls. On this will depend the
treatment to be employed.

If the object be a living insect it should be killed at once by the
instillation of warm oil, rectified spirit, or chloroform. This will
cause immediate relief of the intense pain and tinnitus which may have
been set up by its movements against the sensitive tympanic membrane.

The methods employed for the removal of a foreign body are syringing,
extraction by instruments through the external meatus, and removal by
operation by making a post-auricular incision and reflecting forward the
auricle.

=By syringing.= In the vast majority of cases syringing is successful,
and therefore should always be tried except under the following
conditions:--(_a_) If the foreign body be of such a nature that it may
be driven inwards; for example, a percussion cap for a toy pistol, lying
with its concavity outwards.

(_b_) If there be much inflammation and swelling of the walls of the
external meatus, unfortunately frequently due to previous unsuccessful
attempts at extraction by instruments. In such cases forcible syringing
may cause considerable pain, and in addition immediate removal of the
foreign body may be impossible owing to the temporary occlusion of the
meatus.

Unless urgent symptoms of retention of pus behind the foreign body are
present, it is wiser to wait for a few days until the inflammation has
subsided, in order that the canal may become more patent and permit of a
more favourable opportunity for removal of the foreign body. The
auditory canal, in the meanwhile, may be mopped out two or three times a
day with pledgets of cotton-wool, and a 1 in 5,000 alcoholic solution of
biniodide of mercury afterwards instilled into the ear.

The method of syringing has already been described (see p. 308). The
syringe should be a large one with its tip protected by some
india-rubber tubing. The point is inserted within the meatus up against
the foreign body and the stream of lotion is directed towards any chink
which may exist between it and the auditory canal. It may be necessary
to use many syringefuls with considerable force before the foreign body
can be expelled, but the syringing should be stopped if pain or
giddiness are caused.

If the foreign body cannot be removed at the first attempt, drops of
rectified spirit may be instilled into the ear several times a day,
provided there are no urgent symptoms. This will tend to diminish any
swelling of the soft tissues of the external meatus and of the foreign
body if it is a vegetable substance. The ear should again be syringed
after two or three days. In many cases this will now be successful; if
not, the foreign body may be moved gently with a probe (using a speculum
and reflected light), great care being taken not to push it further into
the auditory canal, and another attempt may be made to remove it by
prolonged syringing. If this fails it may be left _in situ_ for a still
longer period, provided there are still no symptoms requiring its
immediate removal. In some cases, instead of the instillation of
alcohol, a 5% solution of carbolic acid in glycerine or olive oil proves
more effectual.

In the case of a hard substance, repeated attempts may be made to
dislodge it before resorting to further measures; but in the case of a
soft vegetable substance like a pea, it must not be forgotten that
moisture tends to make it swell and perhaps will necessitate almost
immediate extraction by instruments.

Extraction by instruments.

=Indications.= (i) If inspection shows that the foreign body can at once
be removed by a suitable instrument: for example, a percussion cap the
edge of which may be grasped by a pair of forceps (Figs. 179 and 193);
or a small boot button whose shank, if it faces outwards, may be caught
by a small hook.

(ii) If repeated attempts have failed to remove the foreign body by
syringing.

(iii) If previous attempts by others have failed, and the foreign body
has been pushed in beyond the isthmus, and cannot be removed after
prolonged syringing.

(iv) If syringing produces violent giddiness, showing the probable
presence of a perforation of the tympanic membrane.

(v) If there be symptoms of acute inflammation of the middle ear or of
pus being pent up behind the foreign body.

[Illustration: FIG. 179. CROCODILE FORCEPS. Two-thirds size.

  A, Points of crocodile forceps, full size.
  B and C, Aural punch-forceps.
  D, Aural scissors.
]

=Operation.= An anæsthetic may not be necessary in adults if the foreign
body is not too deeply placed within the ear, if its removal appears to
be a simple matter, and if the patient is of a placid temperament.
Otherwise, unless contra-indicated for some special reason, a general
anæsthetic should always be given in children, and it is also preferable
in adults for the following reasons:--(1) Inability to remove the
foreign body after repeated attempts by syringing usually means that its
extraction by instruments will be a somewhat difficult matter. (2) The
risk of injury to the meatal walls or tympanic membrane from involuntary
movements of the patient during the operation is far greater than the
risk of the anæsthetic. (3) If the foreign body cannot be removed
through the meatus by means of instruments, the post-meatal operation is
indicated. This, if necessary, can be done at once if the patient is
under a general anæsthetic.

If no anæsthetic is given the patient may sit up in a chair; otherwise,
the recumbent position is advised.

It is usually necessary to use an aural speculum, but if the foreign
body be situated near the entrance of the meatus a sufficient view may
be obtained by pulling the tragus forward and the auricle backward. Good
illumination is essential.

(i) _If the body be a soft substance_, such as a pea, the core of an
onion, or a fragment of wood, it is best removed by fixing into it some
form of sharp hook (Fig. 178, D). These hooks vary in shape. They may be
curved, or shaped like a crochet-hook, or have the sharp point placed at
right angles to the shaft of the instrument.

In the case of a round substance like a pea, especially if it is tightly
impacted within the meatus, its removal is sometimes facilitated by
first slicing it into pieces by means of a small bistoury.

As a rule, the foreign body is impacted at the junction of the
cartilaginous and bony portion of the auditory canal; sometimes,
however, it is more deeply situated within the osseous meatus, usually
the result of previous attempts to extract it.

[Illustration: FIG. 180. IMRAY’S SCOOP FOR EXTRACTING A FOREIGN BODY.]

In the former case, the instrument is passed along the upper posterior
wall of the canal between it and the foreign body, the point of the hook
being kept upwards or downwards so as not to project into the auditory
canal. The instrument is first passed well beyond the foreign body, and
then the shaft is twisted round so that the hook projects into the
auditory canal. With a quick movement it is drawn outwards a short
distance so that the point of the hook pierces the impacted substance.
Gentle traction is now used and in the majority of cases the foreign
body can be extracted.

If this fails, a slightly curved fenestrated scoop (Fig. 180) or curette
should be passed, if possible, between the foreign body and the anterior
wall of the auditory canal. The hook already fixed into the foreign body
prevents it from being driven further within the meatus, whilst the
scoop, if it can be got beyond the foreign body, can usually lever it
out.

If the foreign body has been pushed in beyond the isthmus and lies
deeply within the osseous canal, it is better to pass the hook along the
anterior inferior wall of the meatus, because owing to the inclination
of the tympanic membrane its anterior inferior margin is much more
deeply placed than its upper posterior part.

(ii) _In the case of a hard substance_, such as a piece of stone, coal,
or a bead, blunt hooks may be used instead of sharp ones. They should
be passed into the meatus _beyond_ the foreign body in the manner
already described.

(iii) _In other cases_, depending on its shape and position, the foreign
body is better removed by means of a snare, the loop of which is
manipulated round it and then drawn tight in the same manner as in the
extraction of a polypus.

The chief points to observe in these manipulations are (_a_) not to push
the foreign body farther in and (_b_) not to injure the walls of the
meatus or the tympanic membrane.

=Other methods of extraction= are--(1) _Drilling through the foreign
body_, if it is a hard substance, and then inserting a fine hook into
the opening so made. (2) _The agglutinative method_, which consists in
dipping a small paint-brush into a concentrated solution of seccotine or
glue and then inserting it into the meatus until it comes in contact
with the foreign body. The brush is left in this position for several
hours in the hope that it may become adherent to the foreign body; if
so, on withdrawing the brush from the ear, the foreign body should be
extracted with it. This method can only be used provided the ear is kept
dry.

These procedures, although said to be successful in a few cases, are not
recommended.

=After-treatment.= If the tympanic membrane and auditory canal have not
been injured, it is sufficient to dry the meatus and puff in a little
boracic powder. If there be abrasions of the canal, a small strip of
gauze should be inserted and changed as frequently as it becomes moist
with secretion, the meatus, if necessary, being also syringed out with
an aseptic lotion. If there be acute inflammation of the walls of the
canal, accompanied by much swelling and purulent discharge, drops of
glycerine of carbolic (1 in 10) may be instilled frequently. After the
inflammation has subsided, an alcoholic solution of 1 in 3,000 biniodide
of mercury may be employed. If the tympanic membrane has been injured,
either from the presence of the foreign body itself or from the attempts
at extracting it, the treatment is similar to that for an ordinary
middle-ear suppuration.

=Removal by operation.= This may be done in the following ways:--

=By means of a post-aural incision.=

=Indications.= (i) If prolonged attempts to remove the foreign body by
instruments have failed. This operation becomes imperative if there are
signs of retention of pus within the middle ear.

(ii) If the foreign body has been pushed into the tympanic cavity and
cannot be removed otherwise. In such cases, if the perforation is large
and the foreign body is small, an attempt may first be made to dislodge
the substance by injecting fluid into the middle ear through the
Eustachian tube by means of the catheter and syringe (see p. 372). This
method, however, is rarely successful.

=Operation.= The procedure is the same as for the removal of exostoses
(see p. 318). After separating the fibrous from the bony portion of the
canal, an incision is made through it and the cut edges are held aside
with forceps. Usually the foreign body can now be seen lying within the
canal. It is best removed by passing a small fenestrated curette beyond
it and levering it out. In some cases one of the hooks already mentioned
will be found to be more suitable. Forceps should not be used, as they
may inadvertently push the foreign body farther in. If the foreign body
be very deeply placed, removal of the upper posterior portion of the
bony meatus may be necessary. The subsequent steps of the operation and
its after-treatment are similar to that already described in the case of
an exostosis.

=By means of an operation upon the mastoid.=

=Indications.= (i) If the above measures fail to remove the foreign
body.

(ii) If there be symptoms of inflammation of the mastoid process, or of
internal-ear or of intracranial suppuration.

(iii) If there be facial nerve paralysis the result of pressure from the
foreign body.

=Operation.= The operation performed depends on the condition found.
Simple opening of the mastoid antrum may be sufficient in a case of
recent middle-ear suppuration, although it is usually necessary also to
remove a considerable portion of the posterior wall of the auditory
canal before the foreign body can be extracted. If these measures fail,
an attempt may be made to dislodge the foreign body by forcibly
syringing through the aditus, or by the insertion of a probe through it,
into the tympanic cavity. If this likewise ends in failure, it will then
be necessary to perform the complete operation. These cases fortunately
are rare.

If it be certain that chronic middle-ear suppuration already exists, the
complete mastoid operation is indicated.

If it becomes necessary to operate on the mastoid process, owing to
other means having failed to dislodge the foreign body, it is wiser, as
a rule, to perform the complete operation at once, because, under these
circumstances, irreparable destruction must have taken place within the
tympanic cavity.

The technique of these operations and their after-treatment are
described in the chapter on operations upon the mastoid process (see p.
390).


OPERATIONS FOR STENOSIS OF THE EXTERNAL MEATUS

Stenosis, or stricture of the auditory canal, is practically always the
result of traumatism or inflammatory conditions; it is only very rarely
congenital.

=Indications.= (i) If there be deafness of the other ear, and the
functionally good ear periodically becomes deaf from obstruction of the
narrow passage by cerumen or epithelial débris, and the patient is weary
of conservative treatment.

(ii) If there be recurrent attacks of otitis externa.

(iii) If there be retention of pus, the result of inflammation of the
external or middle ear, which is not relieved by conservative treatment.

_The operation is contra-indicated_ if there is accompanying deafness,
due to chronic middle-ear or to internal-ear disease, provided there is
no suppuration within the external or middle ear.

=Operation.= The method of operation depends on whether the stricture is
membranous, fibrous, or bony in consistence, or whether it is limited or
is causing a general narrowing of the auditory canal. It may take one of
the following forms:--

_Dilatation._ This method is not very satisfactory, and is limited to
recent cases of membranous or fibrous stricture of the annular variety.
After cleansing the meatus, a small laminaria tent is inserted through
the stricture, and if the pain is not too severe it is left _in situ_
for at least twenty-four hours and then withdrawn. The ear is again
carefully cleansed, and if possible a larger laminaria tent is
substituted. This procedure is repeated until the maximum amount of
dilatation has been obtained.

_Incision of the stricture._ This also is limited to membranous or to
fibrous strictures of the annular variety.

The operation, if necessary, may be performed under a local anæsthetic,
produced by subcutaneous injections, although usually a general
anæsthetic is preferable.

The ear and surrounding parts are surgically cleansed by the ordinary
methods. The surgeon works by reflected light. The patient may be in
either the sitting or the recumbent position, depending on whether a
local or general anæsthetic is given. In the latter case the auditory
canal should be filled with cocaine and adrenalin solution before the
anæsthetic is administered in order to diminish bleeding as far as
possible.

The ear having been dried, a conveniently large aural speculum is
inserted, and with a tenotome or a furunculotome radiating incisions
are made through the stricture. One of the small flaps thus made is
grasped with a fine pair of tenaculum forceps, and the surgeon cuts
through its base, keeping the knife as close as possible to the wall of
the auditory canal. Each flap is treated in a similar fashion. Instead
of making radiating incisions, the tissue forming the obstruction may be
transfixed through its base, the knife being made to cut in a circular
fashion right round the auditory canal, keeping as close as possible to
its wall.

On completion of the operation, a piece of india-rubber tubing, of as
large a size as possible, is inserted into the dilated canal. It should
only be removed for the purpose of cleansing and should be at once
reinserted. A silver canula, if necessary, can afterwards replace the
india-rubber tubing. This canula may have to be worn for months.

This operation is often most unsatisfactory, as the stricture, instead
of being annular as first supposed, may be found, on operation, to
extend a considerable distance along the auditory canal and, in
addition, to be partially due to a general thickening of the underlying
bone.

_Excision of the stricture._ The auricle is reflected forward and the
preliminary steps of the operation are performed as already described
for removal of a deep-seated exostosis (see p. 319). The surgeon makes a
transverse incision with a knife through the fibrous portion of the
auditory canal, just external to the stricture, and carries it right
round the meatus, thus separating the outer portion of the membranous
from the bony canal. The fibrous portion is now pulled outwards by means
of a retractor, and the thickened tissue, forming the stricture, is
peeled off from the surrounding bony meatus with a small periosteal
elevator and so removed. If the stenosis is partially due to thickening
of the walls of the canal itself, it may also be necessary to chisel
away a considerable portion of its upper posterior part. After
completion of the operation a clear view of the tympanic membrane should
be obtained.

In this operation a considerable portion of the bony canal is denuded of
its epithelial lining membrane, so that there is a special tendency to
the re-formation of cicatricial tissue. To prevent this taking place two
methods may be employed:--(1) If much of the upper posterior wall of the
bony meatus be removed, a post-meatal flap should be made and kept in
position by means of a catgut suture carried through the skin behind the
auricle. The formation of such a flap is described as a step in the
complete mastoid operation (see p. 401).

(2) If no bone be removed, the membranous portion is replaced _in situ_,
the posterior auricular wound closed, and as large an india-rubber tube
as possible is inserted into the meatus. A week or ten days later, as
soon as granulations begin to form, skin-grafting may be undertaken (see
p. 410).

If grafting be not successful, the india-rubber tube or silver canula
must be kept constantly within the meatus (only being removed for
cleansing purposes) until healing takes place.

_The complete mastoid operation_ is indicated in the case of stenosis
occurring in chronic middle-ear suppuration if symptoms of retention of
pus occur.

In acute middle-ear suppuration, however, every attempt should be made
to avoid operation, as the lumen of the auditory canal may again become
patent after the acute inflammation has subsided.


OPERATIONS FOR ATRESIA

Atresia of the external meatus may be either congenital or acquired.

=Indications.= (i) _In congenital cases_ operation is only justifiable
if the atresia is due to a _membranous web_ situated in the outer part
of the auditory canal and if, as a result of tuning-fork tests and of
inflation through the Eustachian tube, it is fairly certain that the
middle ear is normal.

_Operation is contra-indicated in cases of bony atresia._ Although
attempts have been made to make an artificial canal in order to restore
the hearing power, a successful result has not yet been obtained. Apart
from the difficulty of retaining the patency of any canal so made, the
accompanying malformation of the middle ear renders a successful result
impossible (Paper by author, _Journal of Laryngology, &c._, March,
1901). Although the tympanic membrane is said to have been exposed by
operation in a few cases, experience has shown that the supposed
tympanic membrane was really the capsule of the temporo-maxillary joint.

(ii) _In acquired cases_ operation is indicated if the other ear is
deaf; if the site of the occlusion of the auditory canal is in its outer
part and is due to membranous or fibrous tissue, and if there is no
previous history of middle-ear disease, and if the labyrinth is still
intact.

Operation is not advised if the other ear is normal, unless the patient
particularly desires it.

_Operation is contra-indicated_ if there is internal-ear deafness on the
affected side and if the other ear is normal; or if there is a definite
history of the closure of the auditory canal having been the result of a
previous middle-ear suppuration. In the latter case the destructive
changes within the tympanic cavity will be so marked that the chances of
improving the hearing will be very slight in spite of the most
successful operation.

=Operation.= If the obstruction be due to a fibrous band, an attempt may
be made to remove it by excising it by the intrameatal method. In other
cases the post-auricular method is necessary.

The chief point to remember is to make a large opening. For this reason
the post-auricular method is to be preferred, as a considerable portion
of the upper posterior wall can be removed and a large meatal flap
fashioned (see p. 401).

=Results.= If the stricture or point of occlusion of the auditory canal
is limited and composed of membranous and fibrous tissues, a good result
can be usually obtained, and there is no reason why complete recovery of
hearing should not take place if the labyrinth and tympanic cavity are
normal.

Unfortunately, as in all cases of stricture, there is a tendency for it
to recur.


OPERATIONS FOR AURAL POLYPUS

In this section only the aural polypi which project from the tympanic
cavity into the external auditory meatus will be considered; whereas the
treatment of granulations, and with them the minute polypi which are
still limited to the tympanic cavity, will be discussed in the chapter
on operations within the middle ear.

=Indications.= An aural polypus should _always_ be removed because,
apart from the fact that it is a symptom of underlying disease, it may
obstruct free drainage of the purulent discharge, and therefore become a
source of danger.

=Operation.= The simplest and the best method is _removal by the snare_.

In the case of small and soft polypi, the polypus is removed by
traction--formerly called =avulsion=--after the snare has been tightened
round its pedicle; with a large, tough, fibrous polypus considerable
force may be required to tear through its pedicle. This procedure in the
case of polypi arising from the region of the tegmen tympani has been
known to give rise to fatal meningitis. In such cases the pedicle of the
polypus should be cleanly cut through by the snare--so-called
=excision=.

As aural polypi are always associated with suppuration, it is especially
necessary that the ear should be thoroughly cleansed before operation.

A local anæsthetic (see p. 310) is sufficient in the case of smaller
polypi, but if the polypus be large and tough, it is wiser to give a
general anæsthetic, such as gas and oxygen. Or a 3% solution of cocaine
may be injected into the growth, which, according to Frey of Vienna,
renders removal absolutely painless; this, however, has not always been
my experience.

The size of the polypus and the origin of its pedicle should be
determined before operating, if necessary by using a probe (Fig. 181);
also it must be diagnosed from a bulging congested tympanic membrane, or
from the inner surface of the tympanic cavity, which may be exposed to
view owing to complete destruction of the membrane having already
occurred.

[Illustration: FIG. 181. AURAL PROBE.]

[Illustration: FIG. 182. WILDE’S AURAL SNARE. The snare is held in the
usual position for extraction of a polypus.]

A Wilde’s snare is generally used. It is a fine angular snare fitted
with soft copper wire. The loop of the snare should be bent downwards
and forwards and should be of such a size as to just surround the
growth. The snare is held between the thumb and the first and second
finger of the right hand (Fig. 182). Under good illumination, and using
the speculum and reflected light if necessary, the shaft of the snare is
passed along the upper portion of the auditory canal until the edge of
the polypus is reached. The loop is made to encircle the polypus (Fig.
183), the snare is gradually pushed inwards with a gentle sinuous
movement until it reaches the point of attachment of the growth. The
loop is then tightened until it firmly grasps the neck of the polypus
(Fig. 184). The friable tissue is torn through by gentle traction and
the polypus is withdrawn in the snare. Care must be taken not to injure
the tympanic membrane through which the polypus may be projecting; it is
for this reason that the loop is bent at an angle to the shaft of the
snare so that it may lie parallel to the tympanic membrane whilst in the
act of grasping the polypus. If the polypus be very small its pedicle
may be clearly defined before operation, and the snare passed round it
directly (Fig. 185).

If the polypus be very large and tough, the snare is made to cut clean
through its pedicle as near to its attachment as possible, instead of
employing traction. The snare is then withdrawn, the polypus being
afterwards grasped and removed by means of forceps. In this latter case
it may be necessary to use a stronger snare fitted with piano steel wire
instead of the ordinary copper wire. On removal of the polypus there may
be considerable hæmorrhage. After it has ceased the ear is syringed out
and dried. The auditory canal is then inspected, and if it is found that
the growth has not been removed completely, this can be done now by
reapplication of the snare.

After final cleansing of the meatus, a strip of gauze is inserted, and
the ear protected with a pad of cotton-wool and a bandage.

=After-treatment.= The dressing should be removed within twenty-four
hours, and the ear cleansed by syringing. After mopping it dry drops of
rectified spirits should be instilled.

On removal of the first dressing, any polypoid tissue which remains may
be cauterized under cocaine anæsthesia by the actual cautery, or by a
bead of chromic or trichloracetic acid (see p. 348).

[Illustration: FIG. 183. WILDE’S SNARE BEING PASSED ROUND AN AURAL
POLYPUS. (_Semi-diagrammatic._)]

Further treatment consists in keeping the ear clean and dry. For the
first few days it should be syringed daily, dried, and spirit drops
instilled. As the secretion becomes less the syringing should be
diminished. If the perforation be large, instead of instilling drops,
some finely powdered boric acid may be puffed in.

=Other methods of removal.= These are not recommended, but merely
mentioned for the sake of completeness.

_By forceps._ The rough and ready method of extracting a polypus
forcibly from the ear by means of forceps, although practised formerly,
has now been discarded as being unsurgical and dangerous.

_Ligation._ The operation consisted in passing a snare over the polypus
and grasping it tightly as near to its base as possible. The snare was
then twisted round its axis in order to tighten the loop further and so
obliterate the blood-supply of the growth, the wire of the snare being
afterwards cut through with pliers and the snare withdrawn. After a few
days the polypus became gangrenous from want of blood-supply, and
separated from its deep attachments.

_Curetting._ This method, which should only be made use of in the case
of small multiple polypi within the tympanic cavity, will be considered
when discussing the treatment of granulations within the middle ear (see
p. 398).

=Dangers.= Hæmorrhage is seldom profuse, but if it is, it can always be
arrested by packing the meatus with cocaine and adrenalin solution.

[Illustration: FIG. 184. WILDE’S SNARE GRIPPING THE NECK OF POLYPUS.
(_Semi-diagrammatic._)]

[Illustration: FIG. 185. POLYPUS ARISING FROM THE ATTIC REGION. The
snare is in position for the extraction of the polypus.
(_Semi-diagrammatic._)]

The chief dangers are injury to the contents of the tympanic cavity,
such as dislocation or removal of the ossicles; or subsequent
meningitis. These mishaps are usually the result of forcible extraction,
or of blindly curetting the ear after this has been done. Meningitis,
however, has been known to occur, in spite of every precaution being
taken, if, owing to caries of the tegmen tympani, the polypus has its
origin from the dura mater of the middle fossa.

=Prognosis.= If the polypus be single and of recent origin, the result
probably of acute inflammation of the middle ear, its removal may cause
complete recovery and cessation of the middle-ear suppuration.

In the case, however, of multiple polypi associated with chronic
middle-ear suppuration and usually signifying underlying bone disease,
recurrences may be frequent and further operations may become necessary.

It may here be emphasized that a polypus in itself is not a disease, but
merely a symptom of disease.

After removal of a large polypus, the patient should always be kept
under observation for a day or two in case of symptoms of acute
inflammation of the mastoid process arising and necessitating further
operation.




CHAPTER III

OPERATIONS UPON THE TYMPANIC MEMBRANE AND WITHIN THE TYMPANIC CAVITY


SURGICAL ANATOMY OF THE TYMPANUM

=The tympanic membrane.= The chief points to notice when operating on
the tympanic membrane are its inclination and its relation to the inner
wall of the tympanic cavity.

The normal membrane is inclined obliquely downwards and forwards so that
it forms an obtuse angle of 140 degrees with the roof and an acute angle
of 27 degrees with the floor of the external meatus. In infants the
inclination is even greater.

Its relation to the tympanic cavity varies in its different parts. It
lies nearest to the inner wall in the region of the umbo, being only 2
millimetres distant from the promontory, and is furthest from it in the
posterior quadrant.

Running backwards, just below the posterior fold, is the chorda tympani
nerve, which may be cut through in the act of paracentesis and in
division of the posterior fold.

=The tympanic cavity.= For the purpose of description the portion of the
tympanic cavity above the level of the tympanic membrane is known as the
_attic_ or _epitympanic cavity_; whilst the part below its level is
called the _cellar_ or _hypotympanic cavity_ (Fig. 186).

The =attic= contains the head of the malleus and the body and short
process of the incus, and communicates posteriorly with the antrum by a
variable sized opening--the aditus. Its roof, the tegmen tympani, a
plate of bone frequently of extreme thinness, separates the cavity of
the middle ear from the middle fossa of the cranium. The facial canal
extends backwards along the inner and upper border of the tympanic
cavity, passing above the vestibule and the fenestra ovalis to curve
downwards posteriorly beneath the external semicircular canal, which at
this point forms the inner and inferior boundary of the aditus.

The =ossicles= form a movable chain fixed at three points: namely, the
attachment of the handle of the malleus to the tympanic membrane; the
posterior ligament of the incus, a feeble structure, binding its short
process to the entrance of the antrum; and the strong annular ligament
connecting the footplate of the stapes to the margins of the fenestra
ovalis.

In addition, the anterior, external, and superior ligaments of the
malleus also tend to keep it in position and limit its movements.

[Illustration: FIG. 186. ANATOMICAL PREPARATION OF THE MIDDLE EAR. 1-1/2
nat. size. 1, Antrum; 2, Aditus; 3, Attic, containing head of malleus
and body of incus; 4, Chorda tympani nerve; 5, Middle fossa of
intracranial cavity; 6, Eustachian tube; 7, Carotid canal; 8, Jugular
vein in jugular fossa; 9, ‘Cellar’ or floor of tympanic cavity; 10,
Canal of facial nerve; 11, Sigmoid groove for lateral sinus. (From the
Author’s _Diseases of the Ear_.)]

The tensor tympani muscle, extending from the processus cochleariformis,
crosses the tympanic cavity to be inserted into the inner margin of the
neck of the malleus; and the stapedius muscle emerging from the apex of
the eminentia pyramidalis is inserted into the head of the stapes.

These ligaments and muscles partially divide the cavity into smaller
compartments, such as the outer attic and Prussak’s space, so that in
some cases inflammation may be limited to only a part of the tympanic
cavity; a fact to be remembered in considering the question of operative
procedures.


OPERATIONS UPON THE TYMPANIC MEMBRANE

PARACENTESIS

=Indications.= The chief object of paracentesis (myringotomy or simple
incision) is to permit of escape of fluid from the tympanic cavity.

(i) _In acute inflammation of the middle ear_, if the acute symptoms
continue in spite of palliative treatment, and the following conditions
are present:--(_a_) An increasing congestion and bulging of the tympanic
membrane, especially if accompanied by earache and pyrexia. (_b_) The
obvious presence of pus within the tympanic cavity, shown by a
circumscribed, angry red or yellow protuberance on the tympanic
membrane. (_c_) Accompanying cerebral symptoms, such as drowsiness,
vomiting, vertigo, and convulsions. (_d_) Tenderness over the mastoid
process. (_e_) Paroxysms of pain acute enough to prevent sleep.

Paracentesis should be done early in infants and in specific fevers. In
the former case even a slight middle-ear inflammation may give rise to
all the cardinal symptoms of meningitis, which frequently subside
rapidly as the result of simple paracentesis; in the latter, there may
be rapid destruction of the drum, which a timely incision may possibly
prevent.

(ii) _In middle-ear catarrh with exudation._ Paracentesis is justifiable
in order to remove the secretion, if the hearing does not improve after
a month’s treatment, owing to the existence of exudation within the
tympanic cavity.

(iii) _As a preliminary to intratympanic operations._

=Operation.= The auricle and surrounding parts are surgically cleansed
(see p. 309), the preliminary toilet, if possible, being carried out at
least half an hour before the operation is performed.

Although apparently a trivial matter, it is of the utmost importance to
render the auditory canal as aseptic as possible in order to prevent
secondary infection of the tympanic cavity from without.

It is wiser to give a general anæsthetic, such as gas and oxygen, as the
pain of the operation may be intense. If this is refused, local
anæsthesia by Gray’s solution (see p. 310) or by a subcutaneous
injection of cocaine and adrenalin may be employed. In infants an
anæsthetic is not necessary.

The patient may be sitting up or lying down. If a general anæsthetic has
not been given, the patient’s head must be held firmly by an assistant
in order to prevent sudden movement. The surgeon works by reflected
light in order to obtain a clear view of the tympanic membrane.

The point of election for the incision is through the posterior part of
the membrane, excepting when it is obvious from the bulging and
appearance of the membrane that the incision must be made in the
anterior inferior quadrant.

The incision is made by means of a paracentesis knife, which is shaped
like a tiny bistoury set at an angle to its handle (Fig. 187). The
double-edged spear-shaped knife is now seldom used, as with it there is
a tendency to puncture rather than to incise the membrane.

The tympanic membrane is pierced by the paracentesis knife at its
inferior posterior margin. With a quick movement the drum is incised
freely, the incision being carried in an upward direction midway between
the malleus and the circumference of the membrane posteriorly, until it
reaches Shrapnell’s membrane (Fig. 188). In making this incision the
inclination of the membrane must not be forgotten. Owing to its lower
margin being more deeply placed than the upper, there is a tendency for
those who have not had much practice in doing a paracentesis to begin
their incision too high up, as they fail to realize the greater depth of
the canal at this point. The soft tissues of the upper posterior wall of
the external meatus close to the membrane, if much congested, may be
incised also in the act of withdrawing the knife. In doing this the
chorda tympani nerve may perhaps also be cut, resulting in loss of taste
on the affected side for a time; this is a matter of no importance. As a
result of this free incision, drainage is given to the contents of the
tympanic cavity, attic, and antrum.

[Illustration: FIG. 187. PARACENTESIS KNIFE HELD IN POSITION IN THE
HAND.]

In order to prevent rapid closure of the perforation and to give better
drainage, some authorities advise making a flap-shaped incision. To do
this, the membrane is incised upwards, nearly to its upper border; the
knife is then carried backwards and downwards before it is withdrawn
from the wound.

Occasionally the acute inflammation is limited to the attic, Shrapnell’s
membrane appearing deeply congested and bulging outwards so as to cover
the processus brevis, whilst the rest of the membrane may be only
slightly injected. In such cases it is sufficient to incise the bulging
area, beginning the incision just above the region of the processus
brevis and carrying it horizontally backwards to its posterior extremity
(Fig. 189).

=After-treatment.= In acute middle-ear inflammation, after the first
rush of blood and discharge has been mopped away, a small drain of
sterilized gauze should be inserted into the auditory canal and the ear
protected with a pad of sterilized gauze. The dressing and gauze drain
should be changed as often as may be necessary, depending on the amount
of discharge. The ear should not be syringed out unless the discharge
becomes very profuse and thick.

In acute middle-ear catarrh with exudation, a Siegle’s speculum (Fig.
194) should be inserted into the meatus after free incision of the
membrane, and as much fluid as possible extracted by suction. In
addition, gentle inflation by means of Politzer’s method will help to
expel from the middle ear the fluid, which should then be mopped out of
the external meatus. This should be repeated daily.

=Difficulties and dangers.= The usual fault is to mistake the congested
posterior wall of the external meatus for the membrane.

[Illustration: FIG. 188. TYMPANIC MEMBRANE SHOWING INCISION IN ACUTE
SUPPURATION OF THE MIDDLE EAR. Usual line of incision; dotted line shows
continuance of incision to make a flap opening for drainage.]

[Illustration: FIG. 189. LINE OF INCISION IN ACUTE SUPPURATION OF THE
ATTIC.]

If the patient is not under an anæsthetic, the incision may be made too
timidly, the membrane being only scratched. The pain thus inflicted will
cause the patient to jerk away the head and probably prevent the
membrane from being incised freely. The incision, therefore, must be
made in a bold and rapid manner. It is better to make the incision too
free than too small.

Care must be taken not to plunge in the knife too deeply for fear of
wounding the mucous membrane of the inner wall of the tympanic cavity.
This may result in adhesions between it and the membrane.

Further, cases have been recorded in which a too violent incision has
injured or dislodged the ossicles, or in which severe hæmorrhage has
occurred, presumably from puncturing the bulb of the jugular vein, which
was projecting abnormally through the floor of the tympanic cavity.

The two chief causes of failure are insufficient drainage from too small
an incision, which may necessitate a further operation, and secondary
infection from without.

=Results.= In the majority of cases, provided free drainage is
established, the discharge ceases and healing of the membrane takes
place from within a day or two to four weeks, depending on the character
of the case. If the symptoms continue it may become necessary to perform
the mastoid operation (see p. 373).


ARTIFICIAL PERFORATION OF THE TYMPANIC MEMBRANE

The object of the operation is to equalize the pressure within the
tympanic cavity and external meatus so as to enable vibrations of sound
to be transmitted more readily by the membrane and chain of ossicles to
the inner ear.

=Indications.= (i) In the case of an extremely calcified membrane which
apparently cannot vibrate.

(ii) To relieve tinnitus or vertigo which appears to be due to an
alteration of tension within the tympanic cavity, the result of an
impermeable stricture of the Eustachian tube.

(iii) As a means of diagnosis. If the hearing be improved or the
subjective symptoms relieved as a result of the artificial opening,
then, if the perforation closes (as it probably will do), the surgeon is
in a position to suggest some more radical measure, such as
ossiculectomy (see p. 351).

=Operation.= Two methods are employed: (i) The knife; (ii) The
galvano-cautery. The perforation should be made in the postero-inferior
quadrant.

In favour of the galvano-cautery is the fact that the perforation does
not tend to close so rapidly. On the other hand, considerable damage may
be done unless it is applied with extreme care. For this reason it is
wiser to operate under a general anæsthetic, such as gas and oxygen.

If the _paracentesis knife_ be used it is not sufficient to make a
simple incision; a small triangular flap must be excised. The operation
should be performed under good illumination. The paracentesis knife is
inserted boldly through the membrane a little behind and above the umbo.
The membrane is incised in an upward and slightly backward direction
towards its margin; then downwards parallel to its posterior border;
then horizontally forward, meeting the original point of the incision.
The excised portion of the membrane is removed by seizing it with a fine
pair of crocodile forceps, or by means of a fine snare, if it has not
been completely detached.

The _galvano-cautery_ is applied cold; when it is in contact with the
drum, the circuit is closed so that the point of the cautery becomes
red-hot. After the membrane has been burnt through it is withdrawn
rapidly so as not to scorch the surrounding tissues. In using the
cautery care must be taken to push it only just through the membrane for
fear of injuring the inner wall of the tympanic cavity.

=After-treatment.= The after-treatment consists in protecting the ear by
a strip of gauze, which is changed as often as may be necessary.


DIVISION OF THE ANTERIOR LIGAMENT

=Indication.= It is advised by Politzer in those cases of marked
retraction of the drum in which inflation causes an immediate
improvement in hearing, which, however, only lasts a short time. In
several cases Politzer found the cause of this to be due to tension of
the anterior ligament causing retraction of the malleus.

[Illustration: FIG. 190. LINES OF INCISIONS IN INTRATYMPANIC OPERATIONS.
A, Removal of membrane in ossiculectomy; B, Division of posterior fold;
C, Division of anterior ligament.]

=Operation.= The anterior fold is divided with the paracentesis knife
just in front of the processus brevis of the malleus. The knife is then
introduced 2 millimetres inwards through the incision and made to cut in
an upward direction as far as Shrapnell’s membrane (Fig. 190, C). This
should divide the ligament.

If the operation be successful, improvement in hearing and also
diminution of the subjective noises should take place.


DIVISION OF THE POSTERIOR FOLD

=Indication.= The same as for the anterior ligament. Owing to the
increased tension of the upper posterior quadrant of the tympanic
membrane, it is assumed that the movements of the malleus are
diminished, and with this the hearing power. Seeing, however, that the
prominence of the posterior fold is due to the projection outwards of
the processus brevis as a result of the handle of the malleus having
become indrawn with the membrane, it is difficult to understand how its
division can possibly be a means of restoring the retracted membrane to
its normal condition.

On the few occasions on which I have performed this operation, no
improvement has followed. Others, however, maintain that it may do good
in certain cases. This, perhaps, may be possible if it is combined with
other intratympanic operations, such as division of the anterior
ligament or of the tensor tympani muscle.

=Operation.= The paracentesis knife is inserted through the most
prominent part of the fold and is made to cut through it from above
downwards (Fig. 190, B). If this is successful, gaping of the cut edges
takes place and the membrane assumes a less retracted position, and
increased hearing and diminution of the subjective symptoms should occur
on inflation and rarefying of air within the external ear.


INTRATYMPANIC OPERATIONS

=General considerations with regard to intratympanic operations and
their results.= The chief difficulty, from a clinical point of view, is
to determine beforehand the exact pathological changes which already
exist within the tympanic cavity. For this reason the indications given
with regard to operation are of necessity somewhat empirical. For
example, retraction of the tympanic membrane may be due to closure of
the Eustachian tube; to adhesions between it and the promontory; to
contraction of the tensor tympani, of the anterior ligament, or of the
posterior fold. An operation to remove only _one_ of these causes may,
therefore, be insufficient; the difficulty is to know what to do. Even
if further operations are performed, the result may be negative owing to
adhesions having taken place already between the ossicles themselves, or
from binding down of the incudo-stapedial joint or of the stapes to the
inner wall of the tympanic cavity. And apart from this, even if
temporary benefit is obtained, the final result may be worse than that
which existed before operation owing to the natural tendency for
adhesions to re-form.

The prognosis is better in the case of post-suppurative conditions than
in the non-suppurative ones.

Improvement by operation may be hoped for if a temporary increase in the
hearing power, with diminution of the subjective symptoms, is obtained
as a result of inflation; especially in those cases in which the malleus
is only locally adherent to the promontory.

Generally speaking, however, these operations are not recommended, owing
to the impossibility of being able to give a good prognosis, and
therefore they can only be considered as experimental.

_These operations are contra-indicated_--(1) If there be internal-ear
deafness.

(2) If the stapes (as shown by tuning-fork tests and Gellé’s test) be
ankylosed within the fenestra ovalis, especially in the case of
otosclerosis.

(3) If the membrane be completely adherent to the inner wall at its
upper posterior quadrant, especially if this is of long standing, as the
stapes will almost certainly also be fixed by adhesions.


DIVISION OF INTRATYMPANIC ADHESIONS

The position and extent of the intratympanic adhesions vary exceedingly,
and may be the result either of middle-ear catarrh or suppuration. The
following conditions may be found:--

(i) Adhesion of the handle of the malleus to the promontory, the rest of
the tympanic membrane being movable.

(ii) Adhesions between other parts of the tympanic membrane and the
inner wall of the tympanic cavity, either by bridles or bands of fibrous
tissue, or by the membrane itself being adherent over a large area.

(iii) Adhesion of the edge of a perforation to the inner wall.

(iv) Adhesions surrounding the articulation between the incus and
stapes, and the stapes itself.

[Illustration: FIG. 191. CUTTING THROUGH INTRATYMPANIC ADHESIONS. The
malleus is adherent to the promontory. A, Surface view; B, Vertical
section. _a_, Handle of the malleus; _b_, Membrane adherent to the
promontory; _c_, Line of incision to cut through the membrane.]

=Indications.= Operation is justifiable in the case of adhesion of the
malleus to the promontory if the rest of the membrane is freely movable;
if the membrane bulges outwards and there is temporary improvement in
hearing on inflation; and if examination shows that the labyrinth is
intact. This operation is all the more indicated if there is marked
deafness on both sides: it should then be attempted on the worse side.
If, however, the intratympanic adhesions are extensive, it is very
doubtful whether an attempt to separate the free part of the membrane
from the part adherent to the inner wall is worthy of consideration.

It must also be remembered that adhesions in the region of the stapes
cannot be seen, unless a large perforation of the membrane already
exists. Operation is then only justifiable as a last resource if there
is extreme deafness accompanied by distressing subjective symptoms.

=Operation.= Unless the patient is very sensitive or nervous, local
anæsthesia is sufficient. It is more convenient for the patient to be
sitting up in a chair than to be in the recumbent position. The surgeon
works by reflected light. Before the operation is begun, the ear must be
surgically cleansed and carefully dried.

(i) _Adhesion of the handle of the malleus to the promontory._ With a
paracentesis knife the membrane is incised round the handle of the
malleus (Fig. 191). A small sickle-shaped knife, fixed at right angles
to its shaft, is then inserted through the incision (in front of or
behind the malleus as may be most convenient to the operator) and is
made to cut through the adhesions between the malleus and the promontory
(Fig. 192). In order to make sure that this has been accomplished, a
small ring-knife, such as is used in the operation of ossiculectomy, is
passed round the tip of the malleus, between it and the inner wall of
the promontory, and slight traction is then exerted in order to pull the
handle of the malleus outwards from the inner wall.

[Illustration: FIG. 192. FREE EDGE OF TYMPANIC MEMBRANE CUT THROUGH. A,
Surface view; B, Vertical section. _a_, Malleus adherent; _b_, Membrane
adherent; _c_, Free edge of membrane; _d_, Spatula freeing membrane.]

Provided asepsis has been maintained, this small operation seldom gives
rise to any inflammatory reaction. The after-treatment consists in
inserting a strip of gauze into the auditory canal; if it becomes moist
with secretion, it should be changed.

Many methods have been devised to prevent recurrence of adhesions, but
few are successful. Amongst these are daily inflation of the ear by
means of Politzer’s method or the catheter; the injection of oil into
the middle ear; and the insertion of small pieces of celluloid between
the malleus and inner wall of the promontory according to the method of
Gomperz. Another method is to _resect the handle of the malleus_ (Fig.
195). After being freed from the promontory as above described, the
manubrium is cut through with a pair of fine scissors (Fig. 174) just
below the processus brevis, and the lower fragment is removed by means
of Sexton’s forceps (Fig. 193).

(ii) _Adhesion between the membrane and the inner wall of the tympanic
cavity._ Siegle’s speculum should be used to determine the position and
extent of the adhesions (Fig. 194).

[Illustration: FIG. 193. SEXTON’S INSTRUMENT. A, For removal of a
foreign body; B and C, For removal of the malleus; D, Scissors.]

There are two methods of operation:--

(_a_) In the case of bands forming a bridle between the tympanic
membrane and inner wall, an attempt may be made to cut through them.
This is done by incising the membrane with a paracentesis knife in front
of or behind the adherent portion, and then inserting through this
incision the sickle-shaped knife. By rotating it upwards or downwards,
as the case may be, the bands forming the adhesions are cut through. If
this has been successfully performed, and if the retraction of the
membrane was solely due to these bands, the tympanic membrane will be
found to be freely movable on diminishing the pressure of air within the
external meatus by means of Siegle’s speculum.

(_b_) If the adhesions be extensive, the only method affording a chance
of success is to separate the free portion of the tympanic membrane from
the part adherent to the inner wall, leaving the latter _in situ_. To do
this the membrane is incised with a paracentesis knife just beyond the
margin of the adherent portion, the incision being carried right round
the affected part. A tiny spatula, bent at right angles to its shaft, is
then inserted through the incision and passed round beneath the movable
portion of the membrane so as to free it completely (Fig. 192).

[Illustration: FIG. 194. METHOD OF USING SIEGLE’S SPECULUM.]

(iii) _Adhesion of the edge of a perforation to the inner wall._ If the
middle-ear suppuration has only recently ceased, it may be sufficient
to divide the adhesion with a small knife curved on the flat and
afterwards force the tympanic membrane outwards by means of inflation
through the Eustachian tube, and by rarefaction of the air within the
external meatus. In the majority of cases, however, it is necessary to
excise the adhesion, especially in the more chronic conditions. This is
done by cutting through the movable part of the membrane just beyond the
adherent portion (_vide supra_).

[Illustration: FIG. 195. DIVISION OF INTRATYMPANIC ADHESION WITH
EXCISION OF HANDLE OF MALLEUS. A, Surface view; B, vertical section.
_a_, Remains of malleus (handle already excised); _c_, Free edge of
membrane; _d_, Scar tissue on promontory, at which point malleus and
membrane were previously adherent.]

(iv) _Adhesions surrounding the articulation between the incus and
stapes, and the stapes itself._ These adhesions can only be observed if
a large perforation involves the upper posterior quadrant. Even then it
may be anatomically impossible to see the stapes. The operation should
only be performed if definite bands of adhesions can be seen. Sometimes,
although rarely, it happens that such adhesions are present. If the
incudo-stapedial joint be fixed to the inner wall of the tympanic
cavity, the adhesions are separated from it by passing the knife between
the joint and the inner wall. In order to cut through adhesions
surrounding the base of the stapes, a small horizontal incision should
be made along its upper margin, and also along the lower, if this is in
view. This operation, however, is seldom of any value.


TENOTOMY OF THE TENSOR TYMPANI

=Indication.= The chief indication for this operation is marked
retraction of the tympanic membrane, in a case of middle-ear deafness,
in which there are no adhesions between the membrane and the inner wall
of the middle ear, and in which it is assumed that the retraction is due
to shortening of the tensor tympani muscle.

=Operation.= The first step of the operation is to incise the tympanic
membrane with a paracentesis knife in a vertical direction just behind
the margin of the malleus. At the same time the posterior fold can be
cut through, if required, by continuing the incision upwards. Through
the incision thus made Schwartze’s tenotomy knife (a very fine
blunt-pointed instrument curved on the flat (Fig. 196)) is inserted, its
point being directed upwards. The knife is pushed upwards until its
shaft is on a level with the processus brevis. The handle is then
rotated in a forward direction so that the sharp edge of the knife,
which is kept close to the posterior border of the neck of the malleus,
makes a circular movement forwards and downwards and thus cuts through
the tendon of the muscle. If the knife has been too deeply inserted, the
attempt to rotate the shaft forwards will be resisted by the projecting
processus cochleariformis. To overcome this difficulty the shaft of the
instrument is rotated backwards so as to raise the point of the tenotomy
knife and thus free it; the instrument is then withdrawn slightly and
the shaft again rotated forwards. The division of the tendon can be
distinctly felt, and may be accompanied by a slight crackling noise;
after this has been effected, the knife is rotated backwards and
withdrawn through the incision in the tympanic membrane.

[Illustration: FIG. 196. SCHWARTZE’S TENOTOMY KNIFE.]

=After-treatment.= There is usually a slight effusion of blood within
the tympanic cavity, but no special treatment is required beyond keeping
the ear aseptic. Absorption takes place rapidly.

The _result_ of the operation is disappointing. There is seldom any
improvement with regard to hearing; a few cases, however, have been
reported in which the attacks of vertigo have diminished in intensity.


TENOTOMY OF THE STAPEDIUS

=Indications.= They are limited.

(i) As the result of middle-ear suppuration the malleus and incus may
become exfoliated. The theory has been advanced that the unopposed
action of the stapedius muscle prevents free movement of the stapes in
these cases, and for this reason tenotomy of its tendon is advocated.

This operation, however, should only be performed provided that the edge
of the membrane is not adherent to the inner wall of the tympanic
cavity, and there is no internal-ear deafness.

(ii) The operation is also performed as a preliminary measure to removal
of the stapes (see p. 361).

=Operation.= The operation is simple, as the head of the stapes and the
tendon of the stapedius muscle are usually within view in consequence of
the destruction of the tympanic membrane. The ear is cleansed and dried,
and the part rendered insensitive by the previous application of a
pledget of cotton-wool soaked in cocaine solution. The tiny tendon is
severed with a snick of the paracentesis knife, cutting through it from
above downwards under good illumination.

=Results.= These vary; usually there is no improvement, but sometimes
marked increase of hearing occurs. As the operation can do no harm and
can be done without any inconvenience to the patient, it may be
attempted subject to the restrictions given above.


REMOVAL OF GRANULATIONS FROM THE TYMPANIC CAVITY

=Indications.= Granulations should always be removed if conservative
treatment fails.

=Operations.= (_a_) _Cauterizing_; (_b_) _Curetting._ The former method
is employed when the granulations are very small and localized; the
latter when they are multiple and larger.

=Cauterization.= The tympanic cavity is cleansed and rendered anæsthetic
(see p. 310). The auditory canal and tympanic cavity are then carefully
dried. This is of importance in order to prevent scalding of the
surrounding tissues during the act of cauterization. The ordinary
electric cautery is used; only a weak current is necessary as the point
of the cautery, of necessity, is very small. Under good illumination,
the cautery is inserted cold along the auditory canal until it just
touches the granulation. The circuit is then closed, and on the point of
the cautery becoming white-hot, it is pressed against the granulation
and then rapidly withdrawn from the ear. The current should not be shut
off until the cautery is withdrawn, otherwise it will adhere, on
cooling, to the tissues with which it is in contact, and on withdrawal
will cause bleeding.

Instead of the electric cautery, the granulations may be touched with a
bead of chromic acid fused on to a probe, or with a saturated solution
of trichloracetic acid. The galvano-cautery has the greatest effect.
Chromic acid has the disadvantage that unless it is very accurately
applied it tends to affect a larger area than was possibly intended.
Trichloracetic acid, although more localized in effect, is not so
potent.

_After-treatment_ consists in blowing in a slight amount of boric acid
powder and keeping the ear dry.

=Curetting.= This is performed by means of small ring-knives (Fig. 178)
or sharp spoons. They vary in size, and are either straight or bent in
different directions to the shaft of the instrument. The instrument
selected depends on the position and size of the granulation.

To minimize the hæmorrhage, adrenalin may be added to the cocaine
solution. The curette is made to encircle the granulation and cuts
through its attachment with a firm movement, limited to the area of the
granulation. Curetting should not be done in a haphazard fashion, but
deliberately under good illumination. If bleeding occurs it must be
arrested before further curetting takes place.

_After-treatment._ The ear is syringed out to remove any fragments of
granulation tissue or blood-clot. It is then dried and a strip of
sterilized gauze inserted. After twenty-four hours this is removed and
drops of rectified spirits, if necessary containing ten grains of boric
acid or a drachm of the perchloride of mercury lotion to the ounce, may
be instilled into the ear three or four times a day.

=Dangers.= With due care none should occur. The following mishaps,
however, have occurred from too violent curetting: (1) Injury or
displacement of the ossicles; (2) internal-ear suppuration from
dislodging of the stapes or injury to the promontory; (3) facial
paralysis; (4) meningitis from injury to the tegmen tympani; (5) acute
inflammation of the mastoid process.

=Results.= Provided that the granulations are localized and due to
inflammation of the mucous membrane, a good result may be anticipated.
If, however, there be underlying bone disease of the tympanic walls, or
if the mastoid process be already affected, recurrences are usual, and
further operative treatment may become necessary.


OPERATIONS UPON THE OSSICLES

DIRECT MOBILIZATION OF THE OSSICLES

The object of the operation is to improve the hearing by breaking down
the fibrous adhesions with the tympanic cavity, which diminish the
mobility of the ossicles.

=Direct massage of the malleus.= =Indications.= (i) As a therapeutic
measure. If the malleus be adherent to the promontory and there is no
improvement on inflation, but perhaps slight improvement as a result of
pneumatic massage.

(ii) As a means of diagnosis. If temporary improvement takes place it
may be assumed that the stapes is not absolutely fixed, and that the
deafness is partly due to adhesions preventing movements of the
ossicles, a condition which may point to the advisability of performing
ossiculectomy in suitable cases.

=Operation.= The ear is rendered insensitive by means of cocaine or
Gray’s solution (see p. 310).

The manipulation is carried out with a Lucae’s probe (Fig. 197). Within
its handle is a spring to render its movements resilient; and at its tip
is a cuplike depression to embrace the point of the processus brevis of
the malleus. The tip of the probe may be covered by a fine layer of
cotton-wool or india-rubber.

The probe is inserted, under good illumination, into the auditory meatus
and is applied to the processus brevis of the malleus. The vibrations
are given by the rapid movements of the hand from the wrist, the arm
being kept fixed. This procedure, which may be painful, should not last
longer than one minute. Frequently there is considerable reaction, shown
by congestion about the processus brevis and Shrapnell’s membrane. It is
therefore wiser not to repeat the procedure at shorter intervals than
one week.

[Illustration: FIG. 197. LUCAE’S PROBE.]

=Results.= It is difficult to foretell what the result will be, as it is
chiefly dependent on the extent of the adhesions already existing within
the tympanic cavity and on the mobility of the stapes within the
fenestra ovalis. If the latter is already fixed, then improvement is
impossible. If, however, the adhesions are limited, a better result may
be obtained by this method than by pneumo-massage and inflation. The
surgeon must be guided by the extent and duration of the improvement as
to how long to continue the treatment. Unfortunately, relapses are not
uncommon, though temporary benefit may be obtained.

=Massage of the stapes.= This is only done as a last resource in the
hope of obtaining some improvement in hearing.

=Indications.= (i) In cases in which mobilization of the malleus has
caused no improvement, and it is hoped, from the history of the case,
that this is due to fibrous adhesions fixing the stapes within the
fenestra ovalis. This condition must be carefully distinguished from
otosclerosis or bony ankylosis of the stapes, in which latter conditions
any such procedure is absolutely contra-indicated.

(ii) Direct mobilization may be undertaken as a preliminary step
previous to removal of the stapes itself. If the stapes is movable and
slight improvement occurs, then its removal may be justifiable under
certain conditions. If, however, the stapes is fixed and no improvement
occurs, then its removal will be attended with such difficulty as to
almost negative this being attempted.

=Operation.= If a perforation of the upper posterior quadrant be
present, a small pledget of cotton-wool soaked in a 20% solution of
cocaine is brought into contact with the inner wall of the tympanic
cavity. After a few minutes Lucae’s probe is placed in position against
the head of the stapes and the vibratory movements are carried out. If
no perforation of the drum exists, then it is first necessary to excise
a flap in the upper posterior quadrant of the membrane.

=Difficulties.= The chief difficulty is anatomical. Projection forward
of the upper posterior part of the tympanic ring or a deeply placed
niche of the fenestra ovalis may prevent a view of the stapes.

If the membrane has to be incised, the slight amount of bleeding may
also prevent a good view being obtained.

There is no actual danger in the operation, but if the stapes is fixed
or if much force is used, it is by no means difficult to fracture the
crura of the stapes.

[Illustration: FIG. 198. TO SHOW SITES OF PERFORATION IN ATTIC
SUPPURATION AND CARIES OF THE OSSICLES. 1. Perforation in front of
malleus. 2. Perforation behind malleus. 3. Perforation involving
posterior attic region and upper posterior part of membrane. (From the
Author’s _Diseases of the Ear_.)]


REMOVAL OF THE OSSICLES

Except under the most rare conditions only the malleus and incus are
removed; the stapes, if possible, being left undisturbed.

These operations will therefore be considered separately.

=Removal of the malleus and incus.= This operation was first proposed by
Schwartze in 1873, and later by Kessel, Ludewig, Sexton, and Zeroni.

=Indications.= The indications for operation may be considered with
regard to (1) chronic middle-ear suppuration and (2) non-suppurative
middle-ear disease, whether the result of a previous middle-ear
suppuration or of a chronic middle-ear catarrh.

In chronic middle-ear suppuration, the chief object of the operation is
to ensure drainage and if possible to remove the cause of the
suppuration; in non-suppurative conditions, to improve the hearing.

It may here be mentioned that the position of the perforation in the
attic region is frequently of importance when considering the question
of treatment. If situated in front of the malleus, the disease is
probably limited to the outer attic region and malleus; if just behind
the malleus, then probably both the malleus and incus are affected; but
if the perforation extends farther back, involving the upper posterior
quadrant of the drum, especially its bony margin, it suggests disease
not only of the ossicles together with the walls of the aditus and
antrum, but perhaps also of the mastoid process (Fig. 198).

(i) _In chronic middle-ear suppuration._ Before operation is considered,
it is presumed that conservative measures, such as syringing,
instillation of astringent and antiseptic drops, and washing out of the
attic by means of Hartmann’s canula with various solutions, have been
given a thorough trial and failed.

(_a_) If the suppuration be limited to the attic region (although the
main portion of the tympanic membrane is intact), provided there is
marked deafness and there are symptoms of lack of free drainage
indicated by recurrent attacks of headache, a feeling of heaviness or
giddiness, or pain radiating up the head on the affected side.

(_b_) If there be caries of the malleus and incus, and the outer attic
wall, with recurrence of granulations after repeated removal, especially
if accompanied by cholesteatomatous formation, provided there is no
evidence of disease of the mastoid process itself.

(_c_) Although the general symptoms and the condition found on
examination justify the complete mastoid operation, yet if the patient
refuses to have this operation performed, the simpler operation of
ossiculectomy may be undertaken if desired. This will permit of free
drainage and diminish the risk of future intracranial complications. It
should, however, be clearly explained to the patient that no guarantee
can be given with regard to effecting a permanent cure as a result of
this operation.

(ii) _In non-suppurative conditions._

(_a_) If there be marked middle-ear deafness, the result of adhesions,
and the malleus is fixed to the promontory. Operation is justifiable if
it is found that after each inflation of the middle ear, improvement of
hearing is obtained which, however, is not permanent but only temporary.

(_b_) If, as the result of artificial perforation, made under the
conditions already laid down, improvement takes place temporarily, but a
relapse occurs from closure of the perforation (see p. 340).

(_c_) If tinnitus and attacks of vertigo, due to marked retraction of
the membrane, are temporarily relieved by inflation. In this case
operation should only be carried out as a last resource after all other
measures have failed to cure and if the symptoms are very severe and
distressing.

(_d_) If there be marked middle-ear deafness with extensive adhesions on
both sides and evidence points to the stapes being freely movable. The
operation is justifiable, as an experiment, on the worse side.

=Operation.= The only operation to be considered is the intrameatal
one. Stacke originally suggested a post-auricular incision, and
reflecting the auricle forward, and, after removing the ossicle, to
remove also the outer attic-wall by means of the chisel. This method,
however, has now been given up as being too radical, but will be
mentioned later on in connexion with the mastoid operation (see p. 397).

Unless contra-indicated, a general anæsthetic should be given, as it is
not always possible to foretell whether the operation will be difficult
or easy. In addition it may be necessary to curette out granulations and
also to remove the outer wall of the attic. Unless the patient is very
insensitive, this is almost impossible under local anæsthesia (see p.
311).

Before the anæsthetic is given, the ear should be filled with a 5%
solution of cocaine containing a 1 in 2,000 solution of adrenalin
chloride in order to diminish the bleeding during the operation.

The field of operation is isolated from the surrounding parts by
covering the head with a sterilized towel having an opening cut in it
just sufficient to expose the auricle and meatus.

The following are the steps of the operation: (1) freeing the malleus
from its attachments to the tympanic membrane, and from the inner wall
of the middle ear, if adherent to it; (2) cutting through the tendon of
the tensor tympani muscle; (3) removal of the malleus; (4) removal of
the incus; (5) removal of the outer wall of the attic; (6) curetting out
of granulations, if present. The method of operation varies slightly
according to the condition found.

=Removal of the malleus.= In post-suppurative and non-suppurative
conditions the chief cause of failure is the recurrence of adhesions, so
for this reason it is wisest to remove the membrane as completely as
possible.

With a paracentesis knife, the membrane is incised below and behind the
malleus. The incision is then carried upwards along its posterior border
to the posterior fold, then round the complete margin of the tympanic
membrane and along the anterior fold and border of the malleus, so as to
meet the original point of the incision. The knife is then reinserted
just in front of the processus brevis and cuts through the anterior
ligament in an upward direction; in a similar fashion the posterior fold
is also cut through (Fig. 190).

The next step is tenotomy of the tensor tympani muscle (see p. 345).

The malleus thus freed can easily be removed by seizing its handle with
a pair of Sexton’s (Fig. 193) or crocodile forceps (Fig. 179). In
removing the malleus it is necessary to remember that its head is
situated within the attic and therefore cannot be pulled out directly,
but must first be drawn downwards until it is seen within the tympanic
cavity. If this precaution be not taken, the neck of the malleus may be
broken, leaving the head behind. If this takes place its extraction may
be a matter of difficulty.

[Illustration: FIG. 199. REMOVAL OF THE MALLEUS BY WILDE’S SNARE. _First
position._ After cutting through the tensor tympani muscle by
Schwartze’s method.]

[Illustration: FIG. 200. REMOVAL OF THE MALLEUS BY WILDE’S SNARE.
_Second position._ Malleus pulled down from attic--about to be withdrawn
from auditory canal.]

Instead of using Sexton’s forceps, the malleus may be removed by means
of Wilde’s snare. This is the method advocated by Schwartze. After
cutting through the tensor tympani muscle, the loop of the snare is
threaded over the head of the malleus and guided upwards until it
embraces its neck. The loop is then drawn tight so as to hold the
malleus firmly in its grasp. The ossicle is extracted by first pulling
it downwards (Fig. 199), so as to dislodge it from the attic, and then
outwards (Fig. 200).

[Illustration: FIG. 201. DELSTANCHE’S RING-KNIFE.]

Another method of extracting the malleus, and in my opinion the one to
be preferred, is by Delstanche’s ring-knife (Fig. 201). This instrument
differs from the ordinary ring-knife in that the upper border of its
anterior part is especially sharpened so as to form a fine cutting
surface. After the malleus has been freed from the membrane by means of
the paracentesis knife, Delstanche’s ring-knife is made to encircle its
handle. It is then pushed gradually upwards, keeping as close to the
posterior border of the malleus as possible, until it cuts through the
attachment of the tensor tympani. In doing this the instrument will
embrace the neck of the malleus (Fig. 202). This permits of sufficient
leverage to extract the malleus by gentle traction in a downward and
outward direction without danger of fracturing its shaft. If much
resistance be felt, probably the tensor tympani muscle has not been cut
through, and another attempt should be made to do this before trying
further extraction. The advantage of this instrument is, that once the
knife has encircled the malleus it should be possible not only to cut
through the tensor tympani, but to extract the bone itself without the
use of any other instrument. If Schwartze’s tenotomy knife be used, two
tenotomy knives are required, one for the right and one for the left
ear. Delstanche’s ring-knife is equally good for either ear.

[Illustration: FIG. 202. REMOVAL OF MALLEUS BY DELSTANCHE’S RING-KNIFE.
A, Curette inserted round handle of malleus; B, Curette pushed upwards,
in act of cutting through tendon of tensor tympani muscle.]

=Extraction of the incus.= Although it is frequently stated that
extraction of the incus is more difficult than that of the malleus, in
reality it is the easier part of the operation as, unlike the malleus,
it has no firm attachments.

After removal of the malleus all hæmorrhage must be arrested and a view
obtained of the inner wall of the tympanic cavity. If it be possible to
see the long process of the incus and its articulation with the head of
the stapes, the articulation should be cut through with a small
sickle-shaped knife. The knife is inserted just in front of the long
process of the incus and, keeping close to it posteriorly, is made to
cut downwards and backwards, thus separating its connexion with the
stapes. Frequently the long process cannot be seen, or it may indeed
have already disappeared as a result of caries. Theoretically this
delicate manœuvre is performed in order to prevent injury or dislodgment
of the stapes during the act of removal of the incus. From a practical
point of view, however, it does not appear to make any difference
whether the incudo-stapedial articulation is cut through or not.

[Illustration: FIG. 203. LUDEWIG’S INCUS HOOK.]

[Illustration: FIG. 204. ZERONI’S INCUS HOOK.]

A variety of instruments have been described for the purpose of removal
of the incus. Ludewig’s incus hook (named after Ludewig, who was one of
the first to draw attention to this operation) is still recommended by
many as being the best. It consists of a solid curved hook, having a
length of 5 millimetres and a width of 2 millimetres, bent at right
angles to its shaft (Fig. 203). A pair of these are necessary, one for
each ear; also several sets of different sizes may be required owing to
the variation in depth, height, and roof of the attic region. I,
however, prefer Zeroni’s (Fig. 204). This hook, instead of being solid,
consists of a steel eyelet having a backward curve similar to that of
Ludewig’s.

[Illustration: FIG. 205. REMOVAL OF INCUS BY ZERONI’S HOOK. A,
Diagrammatic section showing opening in tegmen tympani: _b_, processus
cochleariformis; _c_, external semicircular canal; _d_, aditus and
antrum. B, Diagrammatic section, through the auditory canal, just beyond
the tympanic membrane: _e_, long process of incus; _f_, incudo-stapedial
joint; _g_, tympanic ring; _h_, remains of the tympanic membrane; _i_,
fenestra rotunda; above it is the promontory.]

The technique is the same whichever pattern is employed. The instrument
is inserted in such a fashion that the hook is directed upwards, having
its concavity backwards. It is passed into the attic at the point
previously occupied by the head of the malleus. The shaft of the
instrument is then rotated backwards so that the hook passes over the
body of the incus (Fig. 205). As the rotatory action is continued
downwards and finally forwards, the incus is dislodged from its position
and forced into the tympanic cavity. It can now be seized by a pair of
Sexton’s or crocodile forceps and removed. If it falls into the floor
of the tympanum, it can usually be dislodged by syringing, or else by
means of a small hook passed in circular fashion along the floor of the
cavity.

=Removal of the outer wall of the attic.= In the majority of cases of
chronic middle-ear suppuration, it is advisable to remove the outer wall
of the attic in addition to performing the simple operation of
ossiculectomy. If granulations be present they should first be removed,
in order to give a clear view of the inner wall of the tympanic cavity,
which can usually be obtained, owing to the fact that a large
perforation of the membrane is probably present. The malleus and incus
are then removed.

[Illustration: FIG. 206. PFAU’S ATTIC PUNCH FORCEPS.]

To remove the outer wall of the attic a small but strong pair of
punch-forceps is required (Fig. 206). The instrument is directed along
the roof of the auditory canal, its cutting edge held upwards and the
blades kept slightly open, until the outer blade is felt to pass over
the outer wall of the attic. The handle is then depressed so that the
end of the forceps is forced upwards and embraces the outer wall between
its points (Fig. 207). This is confirmed by attempting to withdraw the
forceps, which the outer bony wall of the attic will now prevent. The
position of the forceps being assured, its blades are brought together
by pressure on the handle, and in this manner a small portion of the
bone is punched out. In this way the outer wall of the attic is
gradually cut away in small fragments. Sometimes this is extremely easy,
owing to the auditory canal being large and the outer wall of the attic
being thin and easily cut through. In other cases, owing to the
thickness of the bony walls or to the narrowness of the canal, it is
extremely difficult. If the outer wall of the attic has been completely
removed, a fine probe, whose point is bent upwards, can be inserted into
the attic and then withdrawn without encountering any obstruction, owing
to the roof of the attic and outer wall of the auditory canal being now
continuous. In some cases this part of the operation may not be
necessary, as the outer wall of the attic may have already disappeared
as a result of the caries.

[Illustration: FIG. 207. REMOVAL OF OUTER ATTIC-WALL WITH FORCEPS. A,
Outer attic-wall.]

Into the larger opening thus made, small curettes are passed upwards and
backwards and any granulations in the region of the aditus and entrance
to the antrum are curetted away. Finally the cavity is thoroughly
swabbed out with the pledgets of cotton-wool soaked in a 1 in 2,000
alcoholic solution of biniodide of mercury. The cavity is then dried and
a small drain of sterilized gauze inserted within the auditory canal,
the ear being afterwards covered with a pad of gauze kept in position by
a bandage.

=After-treatment.= In cases of non-suppuration there is rarely any pain,
and if asepsis has been maintained, there is seldom much discharge
beyond slight sanious oozing. Unless there is considerable discomfort
the dressing need not be changed for two or three days. If possible the
ear should not be syringed, but merely mopped out with pledgets of
cotton-wool moistened with boric lotion and then dried, the gauze drain
being afterwards inserted. This process may be repeated daily until
healing is complete.

In middle-ear suppuration there may be considerable pain, owing to the
forcible bruising of the tissues of the inner part of the auditory canal
during the act of removal of the outer wall of the attic. Sometimes,
indeed, there is much swelling of the lining membrane of the canal, with
the occurrence of furuncles as the result of septic infection.

If there be no pain, the after-treatment is the same as above described,
excepting that it may be necessary to syringe out the ear at each
dressing owing to the discharge. If there be much pain, with swelling of
the canal, the gauze drain should be removed and a 10% solution of
carbolic acid in glycerine frequently instilled into the meatus.
Subsequently drops of rectified spirit may be substituted.

=Difficulties.= 1. If the auditory canal be very small there may not be
sufficient room to insert the instruments through the speculum. In such
cases, if there be no middle-ear suppuration, it is wiser to leave the
condition alone. If, however, suppuration exists, either the
conservative treatment must be continued or the complete mastoid
operation recommended.

2. Hæmorrhage, especially on curetting away the granulations, may be
sufficient to prevent a view of the deeper parts. It can, however,
usually be arrested quickly by plugging the auditory canal with gauze
soaked in adrenalin and cocaine solution. Even if the surgeon has to
wait a few moments, this must be done, as it is very necessary to obtain
a clear view of the field of operation.

3. Extensive adhesions between the membrane and inner wall may render it
difficult to separate the shaft of the malleus without fracturing its
neck.

4. In old-standing cases in which there is a large perforation of the
membrane, the malleus may be so retracted as not only to be difficult to
see but difficult to seize. In this particular case, division of the
tensor tympani with Schwartze’s tenotome and then extraction of the
malleus by means of Sexton’s forceps is a better procedure than trying
to encircle its shaft with Delstanche’s ring-knife.

5. Removal of the incus by the ordinary instruments may be rendered
impossible owing to the narrowness of the attic posteriorly from chronic
thickening of its walls. In these cases a seeker, such as Schwartze uses
in the mastoid operation (Fig. 219), may be employed with advantage. It
is passed over the incus in the same manner as an incus hook.

=Accidents.= 1. _Fracture of the handle of the malleus._ This is the
result of too forcible extraction. If a Delstanche’s ring-knife has been
used, this may be due to the tensor tympani not having been cut through;
this should now be done. The head of the malleus is then removed either
by means of a small hook or some form of curette bent at right angles to
its shaft, depending on what is most suitable for the case in question.

2. _Failure to extract the incus._ In the course of a chronic middle-ear
suppuration, the incus may become exfoliated or gradually disappear as
the result of caries. It does not therefore always follow that inability
to extract the incus means that the surgeon has failed in his
manipulations, although frequently this is the case, the instruments
failing to extract the incus, or perhaps dislodging it into the mastoid
antrum, a fact which is difficult to determine and may only be
discovered if the subsequent performance of the complete mastoid
operation becomes necessary.

3. _Facial paralysis._ This accident is usually due to the incus hook
not being inserted high enough up, so that, instead of entering the
attic, it presses on the inner upper border of the tympanic cavity, and
on being rotated in a backward and downward direction, it follows the
line of the facial canal (Fig. 208). If much force be employed the frail
wall of the facial canal will be fractured or pressed in on the
underlying facial nerve. It is very rarely, however, that the nerve is
completely crushed or torn through, and therefore recovery almost
invariably takes place.

The facial nerve may also be injured whilst curetting away granulations
in the upper posterior part of the tympanic cavity.

[Illustration: FIG. 208. DIAGRAMMATIC SECTION TO SHOW CORRECT AND WRONG
POSITIONS OF INCUS HOOK. A, Facial nerve canal; A', Facial nerve, in
section; B, Antrum; C, External semicircular canal; D, Incus hook in its
correct position in the attic, _above_ facial canal; E, Incus hook in
wrong position, about to press on facial canal; F, Promontory.]

4. _Injury to or removal of the stapes._ This very rarely occurs during
the act of removal of the incus, but is generally the result of too
violent curetting. If only the crura be broken off, it does not matter;
but if the stapes itself be dislodged from the fenestra ovalis, the
subsequent symptoms may be attacks of vertigo, nausea, and vomiting. As
a rule these symptoms subside. If, however, the internal ear becomes
infected (although judging from literature and my own experience this is
of very rare occurrence), complete deafness or even meningitis may occur
as the result of labyrinthine inflammation or suppuration.

=Results.= (_a_) _With regard to arrest of the disease._ If the disease
be limited to the ossicles themselves and to the anterior and outer part
of the attic, a favourable prognosis may be given. Complete cessation of
the discharge and scarring over of the affected part may take place
within a month, or after a much longer period.

If, however, the disease be more extensive and involves the walls of the
attic posteriorly and the region of the aditus, as shown by the presence
of a fistula or granulations, the prognosis is uncertain and continuance
of the discharge and recurrence of the granulations may eventually
necessitate the complete mastoid operation.

(_b_) _With regard to hearing._ In the case of chronic attic suppuration
the hearing power may be increased to a distance of 12 feet off for
conversation, provided the internal ear is not affected and the stapes
is not fixed within the fenestra ovalis; occasionally the result is much
better. On the other hand, the hearing power may be made worse.

In post-suppurative conditions, the prognosis is not so favourable, as
frequently the stapes is already bound down by adhesions; this is the
more probable in the case of chronic middle-ear catarrh. In both these
conditions the operation should never be performed without first
explaining to the patient that it is practically experimental. The chief
cause of failure is the recurrence of adhesions, which even the most
complete and careful operation cannot always prevent.

=Removal of the stapes.= This operation is still in its infancy and it
is, as yet, impossible to express an opinion with regard to its success
or failure, and therefore the indications laid down are only tentative.

The objects of the operation are: (1) to improve the hearing in cases of
deafness presumably due to fixation of the stapes within the fenestra
ovalis, and (2) to relieve symptoms of tinnitus and vertigo due to the
same cause.

Before this operation is advised careful examination must be made in
order to determine whether the labyrinth is intact, especially if the
operation is undertaken with the view of improving the hearing.

=Indications.= (i) If there be ankylosis of the stapes on both sides,
accompanied by marked deafness and distressing subjective symptoms,
operation is justifiable on the worse side.

(ii) In a one-sided affection provided the subjective symptoms of noises
and giddiness are so oppressive as to render the patient’s life
unbearable. The operation, of course, must not be attempted unless every
other form of treatment has failed.

=Operation.= The operation may be performed either through the meatus,
or by reflecting forward the auricle by means of the post-aural
incision, and chiselling away the upper posterior part of the bony
meatus in the manner suggested by Stacke (see p. 397).

The choice of the operation depends principally on the existing
anatomical and pathological conditions.

If the meatus be very narrow the intrameatal method may fail to bring
the stapes into view. If, on the other hand, the meatus be wide and
there be a large perforation, the result of previous middle-ear
suppuration, the incudo-stapedial joint or the head of the stapes itself
may be actually within the field of operation.

_The intrameatal method._ The patient should be fully anæsthetized and
the operation performed under good illumination. A portion of the
tympanic membrane in its upper posterior quadrant is excised in order to
bring into view the incudo-stapedial joint. The incision is begun just
behind the handle of the malleus and is carried upwards and backwards in
a circular fashion through the tympanic membrane along the posterior
fold, and then downwards for a little distance along its margin. The
flap so made either falls downwards, or can be pressed downwards so as
to expose to view the inner wall of the tympanic cavity. With a small
knife, curved on the flat, the incudo-stapedial joint is cut through.
With a fine hook the long leg of the incus is dislocated forwards or
backwards from the stapes. The head of the stapes will now be seen, with
the tendon of the stapedius muscle running horizontally backwards. With
a paracentesis knife, the tendon is cut through close to its attachment
to the stapes.

A fine, blunt-pointed hook is now inserted between the crura of the
stapes. If the stapes be not firmly ankylosed it can usually be removed
by slight traction. If, however, it be firmly fixed, its crura will
probably be broken. To determine whether the stapes is ankylosed or not,
direct pressure of the probe on the head of the stapes may be necessary.
If the head of the stapes cannot be seen, it is advisable, as suggested
by Dench of America, to punch out part of the upper posterior margin of
the attic-wall with the attic forceps (see p. 357).

_The post-aural method._ The preliminary steps of the operation are the
same as have been already described for removal of an exostosis (see p.
318).

After separating and reflecting forward the membranous from the bony
portion, the upper posterior part of the tympanic ring is chiselled away
until a view of the stapes can be obtained. The incus is then
disarticulated from the stapes.

If the stapes be ankylosed by fibrous adhesions to the margins of the
fenestra ovalis, an attempt may be made to free it by cutting through
the adhesions with a fine bistoury. If this be impossible, a sharp hook
may be fixed into the margin of the plate of the stapes in the hope of
forcibly extracting it. Some authorities advise chiselling away of the
margins of the fenestra ovalis. If an opening can be made into the
vestibule by this means, it is hoped that the resulting scar tissue will
form a membrane more resilient than the ankylosed stapes, and, in this
way, permit vibrations of sound to enter the labyrinth. This operation,
however, necessitates the complete mastoid operation in order to freely
expose the region of the fenestra ovalis.

=After-treatment.= It is sufficient to protect the ear with a small
gauze drain. Occasionally there may be considerable vomiting and vertigo
as an immediate result of the operation; this usually passes off within
two or three days. Meanwhile the patient should be kept in a recumbent
position and, if necessary, given small subcutaneous injections of
morphine.

=Difficulties.= The chief difficulty is to obtain a good view; even if
this be obtained it is difficult to extract the stapes without fracture
of its crura.

=Dangers.= As a result of opening up the labyrinth, one would expect
considerable risk of infecting the internal ear. Judging from recorded
cases, this, however, seldom occurs.

=Results.= The chief advocate of the removal of the stapes is Jack of
Boston (_Boston Med. and Surg. Journ._, January, 1895), who again in
1902 (_Archives of Otology_, vol. xxxi, p. 407) stated: (1) that removal
of the stapes did not destroy the hearing but sometimes improved it; (2)
that the operation upon cases of moderate deafness might give brilliant
results but was also attended with some risk to the hearing; (3) that
the operation on the profoundly deaf was not advisable, as usually the
stapes could not be removed owing to surrounding adhesions, and even if
it were, no improvement was likely to occur owing to the
sound-perceiving apparatus having probably already undergone
irremediable changes.

Blake (_Archives of Otology_, vol. xxii), on the other hand, states
emphatically that stapedectomy is harmful rather than beneficial.

The question, therefore, of removal of the stapes from the point of view
of hearing is purely experimental. If there be bony ankylosis, it will
be found impossible to remove the bone, and an attempt to do so will
result in fracture of its crura. If, on the other hand, it be not
ankylosed but movable, probably massage or, in cases of perforation of
the tympanic membrane, direct mobilization of the bone will give results
as good as those following stapedectomy.

The most favourable results are to be expected in those cases in which
the operation is performed to relieve symptoms the result of previous
middle-ear suppuration. In otosclerosis no benefit is ever obtained, and
therefore the operation is absolutely contra-indicated.

On the other hand, there is ample evidence that the hearing power, in
spite of removal of the stapes, may be retained. As an example may be
quoted a case in which the stapes was removed accidentally in curetting
out the ear after the removal of the malleus and incus, and in which I
afterwards performed the complete mastoid operation owing to the
continuance of the middle-ear suppuration. In spite of this, whispering
could be heard at a distance of 20 feet (_Journal of Laryngology, &c._,
vol. xxii, p. 33).




CHAPTER IV

OPERATIONS UPON THE EUSTACHIAN TUBE


Under this heading may be considered manipulations requiring special
technical knowledge and skill: (1) Catheterization; (2) passing of
bougies; and (3) washing out the tympanic cavity through the Eustachian
tube.


CATHETERIZATION OF THE EUSTACHIAN TUBE.

=Indications.= (i) _As a means of diagnosis_ in order to determine (_a_)
the amount and character of the obstruction within the Eustachian tube;
(_b_) the condition of the mucous membrane and whether any exudation is
present within the middle ear.

(ii) _For the purpose of treatment._ (_a_) In order to instil medicated
drops or vapours into the Eustachian tube and tympanic cavity; (_b_) as
a preliminary measure to the passage of bougies into the Eustachian tube
or to washing out the tympanic cavity through the Eustachian tube.

(iii) _Catheterization is preferable to Politzer’s method_ if only one
ear is affected. Politzer’s method, on the other hand, is preferable to
catheterization (_a_) in small children; (_b_) in the case of slight
middle-ear catarrh if both ears are affected; (_c_) if the passing of
the catheter is very difficult and causes pain owing to nasal
obstruction; (_d_) in nervous individuals who object to the catheter;
(_e_) if the sudden inflation by means of Politzer’s method is more
effectual than by catheterization.

_Points to notice before inflation._ 1. Care must be taken that the
lumen of the catheter is not obstructed, and that the compressed air bag
and auscultation tube are also in working order.

2. The nose must be cleansed of all secretion; if filled with crusts or
in a septic condition, inflation must be avoided.

3. The patient should be sitting. Sometimes on inflation of the ear,
especially for the first time, an attack of giddiness or faintness may
occur.

4. The nose should always be examined to see that the passage is free.
If it be obstructed catheterization may be impossible, or some special
manipulation will be required in order to pass the catheter through the
nose.

5. In order to prevent muscular contraction of the palatal muscles,
which may grip the end of the catheter and so prevent its entrance into
the orifice of the Eustachian tube, the patient should be told to
breathe quietly and keep the eyes open.

A short silver or plated catheter is usually used. It is 5 inches in
length and curved at its extremity. To indicate the position of the
point of the catheter in the post-nasal space, a ring is attached to its
outer and wider extremity corresponding with the concavity of the
curvature of its beak (Fig. 209). The size of the catheter varies in
diameter from Nos. 1 to 4 English size, that is, the same scale as used
for urethral catheters. The source of compressed air used for the
inflation is usually a Politzer bag having an india-rubber tube
attached. At its end is a vulcanite pointed nozzle which accurately fits
into the wider extremity of the catheter.

=Technique.= The patient is seated facing the surgeon, the head being
supported by a prop or by an assistant. If the patient be at all
sensitive, it is wiser to spray a very small quantity of a 2 or 5%
solution of cocaine or eucaine into the nose, or, better still, to pass
gently a probe tipped with a small pledget of cotton-wool soaked in the
cocaine solution along the inferior meatus. This will effectively
anæsthetize the region of the pharyngeal orifice of the Eustachian tube,
which is the most sensitive part.

[Illustration: FIG. 209. EUSTACHIAN CATHETER.]

The surgeon stands in front of the patient. The larger extremity of the
catheter is held lightly between the thumb and first finger of the right
hand, its beak being turned downwards, whilst the tip of the nose is
tilted up by the thumb of the left hand (Fig. 210). In introducing the
catheter into the nostril, the right hand is kept low down so that the
stem of the catheter is almost in a vertical position. In this way the
tip passes over the floor of the vestibule. As the catheter is gently
pushed through the nose the right hand is raised so that the instrument
assumes the horizontal position and passes backwards between the septum
and the inferior turbinal, its beak being kept in close contact with the
floor of the nose (Fig. 211). As the beak of the catheter enters the
post-nasal space, it will be felt to glide over the soft palate.

With regard to the best method of introducing the beak of the catheter
into the orifice of the Eustachian tube, opinions vary. Of the many
methods advised only two will be given.

The first is more suitable to those who have not had much experience in
using a catheter; the second is the one naturally adopted by an expert.

_The first method._ The catheter is pushed backwards until it is felt to
impinge against the posterior wall of the naso-pharynx. The beak, which
at this stage is directed downwards, is next rotated a quarter of a
circle inwards so that it points horizontally towards the opposite side;
the position is shown by the ring at its outer extremity (Fig. 212). The
catheter is now gently withdrawn until the beak is felt to catch against
the posterior edge of the vomer. During these procedures the stem of the
catheter should rest on the floor of the nasal cavity. The manipulations
are carried out with the right hand whilst the outer extremity of the
catheter is kept fixed in position by means of the thumb and finger of
the left hand.

[Illustration: FIG. 210. PASSING THE EUSTACHIAN CATHETER. Introduction
of the catheter within the nostril.]

[Illustration: FIG. 211. PASSING THE EUSTACHIAN CATHETER. Passage of the
catheter along the floor of the nose.]

The catheter is next pushed a short distance backwards to free it from
the soft palate and rotated downwards, and finally round in an outward
direction until the ring points to the outer canthus of the eye on the
side to be catheterized (Fig. 213).

The point of the instrument should now engage the Eustachian tube; if,
however, inflation shows this not to be the case the probability is
that the catheter has been pushed too far backwards and rests on its
posterior lip. This can be remedied by drawing it a little further
outwards.

_The second method._ The catheter, with its beak turned downwards, is
passed gently and rapidly along the inferior meatus of the nasal cavity,
and at the same time rotated slightly outwards against the inferior
turbinal bone. Whilst the catheter is within the nose, this outward
rotation is prevented by the narrowness of the inferior meatus, but as
soon as the beak of the catheter has passed behind the level of the
inferior turbinal into the free post-nasal space, it will revolve
outwards and upwards and in so doing will enter the Eustachian tube,
which lies just behind and above the posterior end of the inferior
turbinal bone.

[Illustration: FIG. 212. PASSING THE EUSTACHIAN CATHETER. Beak of the
catheter in the post-nasal space. The catheter is turned to the opposite
side so that its beak impinges against the posterior border of the
septum.]

[Illustration: FIG. 213. PASSING THE EUSTACHIAN CATHETER. Catheter in
position; act of inflation.]

Provided there be no abnormal obstruction within the nose, this method
is an exceedingly simple one. With the practised hand the manipulation
can be carried out so smoothly and quickly that the catheter will be in
position before the patient has had time to realize the fact.

=Difficulties.= 1. _Irritability of the mucous membrane._ The passing of
the catheter through the nose may set up a violent spasm of sneezing or
coughing. When the beak has entered the post-nasal space, the irritation
may cause such intense contraction of the palatal muscles that the
point of the catheter may become fixed and its movement rendered
impossible. If this takes place, the catheter should be withdrawn and
the part anæsthetized by means of cocaine and eucaine solution, which is
best applied locally on a pledget of wool at the end of a probe.

2. _Partial nasal obstruction._ On inspecting the nose the obstruction
is usually found to be due to a deviated septum or spur, or to adhesions
situated at its anterior part. Sometimes a passage can be effected by
simply diminishing the curve of the catheter. At other times the
obstruction can be overcome by introducing the catheter with its stem
held upwards and outwards, so that on entering the nose the beak dips in
beneath the anterior end of the inferior turbinal. As the catheter is
pushed gently inwards its outer extremity is brought round with a
circular movement so that it gradually assumes the horizontal position.
No force must be used. As the catheter is pushed farther in, it may
rotate to a varying degree according to the formation of the nasal
cavity. Sometimes, indeed, the catheter may make a complete rotation
during its passage through the nose. At other times, after the
obstruction is passed, the catheter is best pushed through the nose with
the beak pointing directly upwards. The great point is gentleness; the
catheter should be allowed to take whatever position suits it best, but
after the beak has entered the post-nasal space the stem should lie
horizontally along the floor of the nose and its beak should point
downwards.

3. _Complete nasal obstruction._ If the obstruction be one-sided, then
the catheter must be introduced into the nasal space through the
opposite side.

This is performed in the ordinary manner, except that the catheter must
be longer and possess a larger curvature. On reaching the post-nasal
space, its beak is turned round so as to point towards the outer canthus
of the eye on the affected side. It may be necessary to alter the curve
more than once in order to get the point of the catheter to exactly
engage into the orifice of the Eustachian tube.

If both sides be completely obstructed, the only method to adopt is
catheterization from the mouth. The ordinary catheter is used. It is
passed into the mouth, its beak being directed upwards, until it reaches
the posterior wall of the pharynx. The catheter is then pushed directly
upwards until its stem impinges against the soft palate. The beak is
then turned outwards until it lies almost horizontally. In this position
it should enter Rosenmüller’s fossa. The catheter is now withdrawn a
little and should be felt to pass over a slight obstruction--the
posterior lip of the Eustachian orifice. By gently pressing the beak
slightly outwards, it should engage within the entrance of the
Eustachian canal.

4. _Obstruction within the post-nasal space._ A common error in
introducing the catheter is to push it too far backwards, so that on
rotation of the beak outwards it passes behind the Eustachian tube and
lies in Rosenmüller’s fossa. In this position the sounds referred to the
examiner’s ear through the auscultation tube during the act of inflation
differ from the normal sounds in that they are soft and distant. In a
case of doubt inflation should again be practised with the catheter in
varying positions. If the catheter be in the correct position, the
patient should be able to talk without discomfort, and there should be
no tendency to retching or coughing. If, however, the beak lies in
Rosenmüller’s fossa, considerable irritation is caused, and on inflation
the patient feels the air in the throat and not in the ear.

Catheterization may be rendered difficult by the presence of a large pad
of adenoids or of a tumour; or inflation of air into the Eustachian tube
may be quite impossible owing to the occlusion of its pharyngeal
orifice, the result of scarring.

=Mishaps.= 1. _Rupture of the tympanic membrane._ With a normal membrane
this is difficult to produce, in spite of even forcible inflation. Such
an accident usually occurs at the site of some previous scar or atrophic
patch in the membrane. If it occurs, there may be a temporary feeling of
giddiness, noises, and pain in the ear. Inflation, of course, should be
stopped at once and the ear protected for a day or two by plugging the
meatus with a piece of cotton-wool.

2. _Severe epistaxis._ This is usually the result of trying to force the
catheter through an obstructed nose, but it may also take place, though
rarely, when manipulations have been carried out in a gentle fashion.

3. _Syncope._ This is fortunately of rare occurrence and usually only
happens on the first occasion that the catheter is passed. For this
reason the patient should always be in a sitting posture, and on the
slightest appearance of pallor or faintness the catheter should be
withdrawn. The attack invariably passes off, but for the moment it is
very unpleasant.

4. _Surgical emphysema._ If the point of the catheter lacerates the
mucous membrane, the air may be forced into the submucous tissue. This
mishap, however, rarely occurs as the result of simple catheterization,
but is more likely to follow forcible attempts to pass a bougie into the
Eustachian tube.


PASSING OF THE EUSTACHIAN BOUGIE

=Indications.= This may be done for the following reasons:--

(i) As a means of diagnosis, to demonstrate the existence and position
of a stricture.

(ii) To dilate a stricture.

(iii) As a therapeutic measure, to treat the mucous membrane of the
Eustachian tube by means of a medicated bougie.

Bougies are made of various materials, but for ordinary purposes the
gum-elastic is the best. They are about 7 inches in length with a
slightly bulbous point.

In the adult the length of the Eustachian tube is approximately 1-1/2
inches, of which 1 inch forms the cartilaginous and 1/2 inch the osseous
portion. The narrowest part of its lumen is known as the isthmus, and is
situated at the junction of its cartilaginous and bony portion. On
passing the bougie through the catheter into the Eustachian tube, it is
essential to know how far its point is projecting beyond the point of
the catheter. For this purpose the bougie may be marked at its outer
extremity. Five inches from the point of the bougie, that is, the same
length as the catheter, is a black band a centimetre in length; a
centimetre farther up is another black band; and again after an
intervening space of a centimetre is a third black band (Fig. 214).

[Illustration: FIG. 214. AUTHOR’S GRADUATED EUSTACHIAN BOUGIE.]

=Technique.= The catheter is introduced in the ordinary way, and its
position within the entrance of the Eustachian orifice is verified by
means of inflation. It is kept fixed with the left hand, and the bougie
is pushed into the catheter until the beginning of the first mark on the
former just reaches the outer extremity of the latter; the tip of the
bougie will now be flush with the point of the catheter. If there be no
pain and no resistance, the bougie is very gently pushed on until the
beginning of its second black band just enters the catheter. Its point
will now project 2 centimetres within the Eustachian tube; that is, to
about the region of the isthmus. If the bougie has been successfully
introduced into the Eustachian tube, the patient generally states that
the instrument is felt within the ear itself. No force should be used
for fear of making a false passage, and with gentle manipulation it is
very rare for actual pain to occur. On reaching the isthmus resistance
may be met with, but by the exercise of slight pressure the bougie can
usually be made to pass through it; if there be much resistance the
bougie should be withdrawn and a finer one substituted. After passing
through the isthmus, the bougie may be pushed in another centimetre, but
no further, in case it may actually enter and injure the contents of the
tympanic cavity.

After the tip of the bougie has passed through the isthmus the surgeon
will hear its movements through the auscultation tube as a rub or
crackling sound. It is left in position for five or ten minutes and
then withdrawn. The ear should then be gently inflated, when the air
entry into the tympanic cavity will probably be found to be much more
free.

As the passage of the bougie causes a certain amount of reaction, it
should not be passed oftener than once a week. Although no force should
ever be employed, the largest possible bougie should be passed at each
successive sitting until complete dilatation has been obtained.

=Difficulties.= 1. If the catheter be not in position, the bougie may
pass behind the tip of the Eustachian orifice and enter Rosenmüller’s
fossa. This can usually be felt by the patient as a pricking sensation
in the throat, and may produce retching and coughing.

2. A stricture of the Eustachian tube may be so great as to prevent
entrance of the bougie.

=Dangers.= (_a_) Surgical emphysema. If the mucous membrane be lacerated
by the bougie, air may be forced into the subcutaneous tissues on
inflation, after its withdrawal. In some cases the surgical emphysema is
so considerable as to involve the side of the neck and face, and indeed
has been known to necessitate the performance of laryngotomy.

The best treatment is to make the patient suck ice and to forbid all
attempts at blowing the nose and coughing. Sometimes it is also
necessary to scarify the pharynx and soft palate with a small bistoury.
Recovery may be hastened by gentle massage of the neck and face.
Inflation should not be attempted again for at least a week.

(_b_) The bougie may be pushed in too far and cause injury to the
contents of the tympanic cavity.

(_c_) The tip of the bougie may break off whilst in the Eustachian tube.
With a gum-elastic bougie this is very rare, but it is more likely to
occur if the brittle celluloid bougies are used. To prevent this
unfortunate disaster the bougie should be carefully examined before
passing it, to see that it is not cracked nor broken. If such an
accident does happen it is wiser to do nothing, because as a rule the
fragment is afterwards expelled spontaneously.

=Results.= If the obstruction be fairly recent and limited to the
pharyngeal end of the Eustachian tube, excellent results may be obtained
by using either the simple bougie or the catgut variety moistened with a
5% solution of silver nitrate.

Owing to the general thickening of the tube, there is a marked tendency
for further stricture to take place in the more chronic cases, even if a
temporary improvement is obtained, and for this reason the use of the
bougie is seldom to be recommended.


WASHING OUT THE TYMPANIC CAVITY THROUGH THE EUSTACHIAN TUBE

=Indications.= (i) In chronic middle-ear suppuration in which the
perforation is situated in the anterior inferior quadrant and the
continuance of the otorrhœa is apparently due to the secretion not being
able to drain from the tympanic cavity. This method may be employed to
effect drainage and in order to cleanse the tympanic cavity thoroughly
before the instillation of medicated drops. In these cases the floor of
the tympanic cavity is usually at a considerable depth beneath the lower
limit of the membrane (Fig. 186).

(ii) In order to remove a small foreign body lying on the floor of the
tympanic cavity which cannot be expelled by syringing. The operation is
only tentative and is seldom successful.

=Contra-indications.= (i) If there be acute middle-ear suppuration; (ii)
if the perforation be very small, as there will be a considerable risk
of the fluid being driven into the mastoid antrum and further infecting
it.

=Technique.= A catheter of wide calibre is passed in the ordinary
manner. Inflation is practised to see if it is in the right position.
The left hand fixes the outer extremity of the catheter at its entrance
within the nose and keeps it in position. The patient inclines the head
over to the affected side and holds a receiver beneath the ear. A small
brass syringe whose nozzle accurately fits the outer extremity of the
catheter is used. Slight force may be required during the act of
syringing, but must not be sufficient to cause pain within the ear. A
certain amount of fluid always escapes into the throat although the
catheter is in its right position, and this may set up an attack of
retching and coughing. To avoid this the patient should incline his head
slightly forward as well as to the affected side and breathe gently with
the mouth open. If the manipulation be successful the fluid will trickle
out of the external meatus.

A foreign body is rarely expelled by this method, as the force of fluid
syringed into the Eustachian tube is seldom sufficient, and it is not
wise to use too great pressure. In order to expel all the fluid from the
tympanic cavity, the ear is afterwards inflated by Politzer’s method,
and at the same time the fluid is mopped out of the ear by means of
pledgets of cotton-wool.

=Results.= If the continuance of the middle-ear suppuration has been
chiefly due to the retention of the purulent secretion in the lower part
of the tympanic cavity, this method of treatment is frequently most
satisfactory. In other cases no benefit is obtained owing to the
suppuration being due to other causes.

=Dangers.= The chief danger is the infection of the mastoid cells.




CHAPTER V

OPERATIONS UPON THE MASTOID PROCESS: WILDE’S INCISION AND SCHWARTZE’S
OPERATION


With few exceptions the conditions requiring operative procedures on the
mastoid process are the result of some suppurative lesion which has
originated within the tympanic cavity.

The object of such operations is to arrest or eradicate the disease
which, by further extension through the bony walls of the temporal bone,
might eventually cause death by giving rise to some suppurative
intracranial complication.

For their successful performance a knowledge of the anatomical
relationships of the mastoid process is essential. It is sufficient here
to remind the reader of the main surgical points in this connexion (Fig.
215).


SURGICAL ANATOMY OF THE MASTOID AREA

=The mastoid antrum.= At birth the mastoid antrum is almost fully
developed. In infancy it is situated superficially and at a much higher
level in relation to the auditory canal than in the adult. In the
infant, also, the petro-squamous and the squamo-mastoid suture are still
patent. As the mastoid cells develop, the antrum gradually becomes more
deeply placed, so that in the adult it is from half to three-quarters of
an inch from the surface.

Its roof, the tegmen tympani, is continuous with that of the attic.
Anteriorly it is separated from the external auditory meatus by the
posterior wall of the auditory canal, whose innermost margin forms the
outer wall of the aditus. On its inner wall lie the semicircular canals,
whilst posteriorly the lateral sinus is separated from it by an
intervening layer of mastoid cells or compact bone. Between the
semicircular canals and the lateral sinus is a small area composed of a
thin layer of bone, separating the antrum from the posterior fossa of
the cranial cavity.

=The mastoid process.= In the infant this is undeveloped and is merely
represented by a small bony protuberance. By the fourth year it has
practically reached the adult type.

Anatomically the mastoid process can be subdivided into three chief
types: (1) the pneumatic, in which the cells are few and large; (2) the
diploic, containing numerous small cells; and (3) the compact, in which
the bone is extremely dense. Mixed types are frequently found, the
cortex, as a rule, being more dense than the deeper portion.
Occasionally it is uniformly sclerosed, almost of the consistence of
ivory, but in these cases the condition is usually pathological, the
result of chronic inflammation of the mastoid process.

[Illustration: FIG. 215. LEFT TEMPORAL BONE, SHOWING ANATOMY OF THE
MIDDLE EAR AND MASTOID PROCESS. 1, Anterior wall of external meatus,
partly removed; 2, Canal for tensor tympani muscle, ending in processus
cochleariformis; 3, Attic; 4, Aditus; 5, External semicircular canal; 6,
Posterior root of zygoma; 7, Tegmen tympani; 8, Antrum; 9, Fallopian
canal for facial nerve; 9', Stylo-mastoid foramen; 10, Mastoid cells;
11, Fenestra rotunda; 12, Fenestra ovalis; 13, Promontory. Dotted line
shows outline of sigmoid groove for lateral sinus.]

The mastoid cells converge towards the antrum and may be divided into
two groups: (1) those extending vertically downwards to the tip of the
mastoid process; and (2) those lying between the antrum and the sigmoid
process of the lateral sinus. In addition to these two groups, it must
not be forgotten that cells may extend in other directions; for
instance, (_a_) anteriorly, along the root of the zygoma; (_b_)
posteriorly, communicating with the cells of the occipital bone; (_c_)
inferiorly, between the floor of the tympanic cavity and the jugular
fossa; (_d_) internally, spreading inwards towards the apex of the
petrous bone and surrounding the labyrinth; or (_e_) enveloping the
orifice of the Eustachian tube.

_The facial nerve_, after dipping beneath the external semicircular
canal, passes vertically downwards through the mastoid process to emerge
at the stylo-mastoid foramen. Entering this foramen and running along
the canal are the stylo-mastoid branches of the posterior auricular
artery. These vessels, if cut through by the chisel, may bleed in a
marked manner, thus drawing the attention of the operator to the fact
that he is in close proximity to the facial canal and nerve.

=Surface anatomy.= Although it is impossible to foretell with certainty
before operation what the anatomical structure of the mastoid process
may be, yet some information may be gathered from the formation of the
skull.

In the dolichocephalic type, the mastoid process is broad and frequently
contains large cells, especially at its tip and round the lateral sinus,
which is usually deeply placed. In the brachycephalic type, on the other
hand, there is a greater tendency for the mastoid process to be narrow
and to consist of dense bone, for the middle fossa to extend low down
and to overlap the outer wall of the antrum, and for the lateral sinus
to project forward and superficially, even to within 2 or 3 millimetres
of the posterior border of the external meatus.

The posterior root of the zygoma may be considered approximately the
line of demarcation between the roof of the antrum and mastoid process,
and the floor of the middle fossa of the skull. This, however, is only a
rough guide, as in some cases, especially of the brachycephalic type,
the middle fossa may dip below this point. If this ridge is not well
marked, then Reid’s base-line must be taken as the guide.

Just behind the auditory meatus, at its upper posterior margin, is the
spine of Henle, which forms the anterior boundary of the suprameatal
triangle. Macewen, who first described this triangle, gave it as a guide
for the exposure of the antrum. Experience, however, has shown that no
reliance can be placed on this as a landmark, as, if the bone is
chiselled through at this point, it is by no means uncommon to expose
the dura mater of the middle fossa. A point 10 millimetres (two-fifths
of an inch) behind the spine of Henle corresponds to the anterior border
of the sigmoid sinus. Behind the suprameatal triangle and beneath the
zygomatic ridge is the body of the mastoid process, which has a smooth
surface and is perforated by small foramina through which pass tiny
vessels.

The antrum, in the adult, is situated at a slightly higher level than
the tympanic membrane, its floor roughly corresponding with a line drawn
horizontally backwards through the middle of the posterior wall of the
bony meatus.


HISTORY OF THE MASTOID OPERATION

Although opening of the mastoid process as an operative measure dates
back to the eighteenth century, yet Schwartze, in 1873, was the first to
establish the operation as a practical procedure.

Schwartze’s operation consisted in the simple opening of the antrum and
mastoid cells, leaving the middle ear untouched. This procedure was
carried out no matter whether the disease was recent or long standing.
It soon became recognized, however, that this operation did not effect a
cure in all cases, more especially in those in which the disease
involved the walls of the tympanic cavity.

Küster, in 1889, suggested removal of the posterior wall of the external
auditory meatus, and about the same time von Bergmann advocated removal
of the outer attic-wall. The Küster-Bergmann operation, first practised
by Zaufal, may therefore be considered to be the origin of the complete
mastoid operation.

Stacke’s name is frequently though wrongly mentioned in association with
the complete operation, which is sometimes termed the Schwartze-Stacke
operation. Stacke’s operation was devised with a view to removal of the
ossicles and outer wall of the attic in those cases in which the bone
disease was limited to these regions. This operation, however, is
occasionally of service in the performance of the complete mastoid
operation (see p. 397).

Thus the year 1889 may be considered as the starting-point of the
complete mastoid operation. Since that date many modifications have been
introduced, the majority of which are not worthy of reference.

After the technique of the operation had been developed and practised
for some time, more careful attention was directed to the
after-treatment. In the earlier days of the radical operation it was the
rule to leave the wound open and to plug it with gauze, or to insert a
drainage tube which was carried through the membranous portion of the
external meatus.

The next step was the making of post-meatal skin flaps, with closure of
the posterior incision and packing of the wound through the auditory
canal; and the names most prominently associated with this are Panse,
Körner, and Stacke.

Still more recently, in order to shorten the after-treatment, the wound
cavity has been skin-grafted by the method first suggested by Siebenmann
and afterwards amplified by Charles Ballance.

The operations which will be considered are:--

1. Wilde’s incision.

2. Opening of the mastoid process and antrum.

3. The complete or radical mastoid operation.

Although definite indications for the above operations will be given, it
must be remembered that in many cases the extent of the operation will
depend very largely on the pathological condition found during the
course of the operation itself, as frequently the clinical symptoms are
not sufficient to determine beforehand what operation is indicated.

In comparing the simple opening of the mastoid cells and antrum with
that of the complete or radical operation, the fundamental difference is
that in the former the tympanic cavity and its contents are not
interfered with, whereas in the complete operation the middle ear,
antrum, and mastoid cells are converted into one large cavity. In
consequence, complete recovery of hearing may take place in the former
case; in the latter, however, this is not possible.

Although these operations, especially in the more acute conditions, are
performed from the point of view of saving the life of the patient, due
regard must also be given to the preservation or restoration of the
hearing power, if this indeed is possible. If the hearing power be very
poor, that is, if conversation cannot be heard more than 12 feet off,
and especially if the deafness be partially due to changes having
already taken place within the labyrinth, then the complete operation is
to be preferred if it be doubtful whether Schwartze’s operation will be
sufficient to eradicate the disease. If, on the other hand, the hearing
power of the affected ear be fairly good, and with this there is
deafness of the opposite side, then, unless it is absolutely essential
that the complete operation should be performed, an attempt should be
made to effect a cure by the simpler operation, provided it is first
explained to the patient that it may perhaps be necessary to perform the
complete operation afterwards.


WILDE’S INCISION

In cases of acute inflammation of the mastoid process or of a
subperiosteal abscess lying over it, Wilde made a post-aural incision,
incising the tissues down to the bone. The indications for doing this
are now considered to be very few, but it must be remembered that in
Wilde’s day the mastoid operation had not been developed.

=Indications.= (i) In infants it is sometimes justifiable, as the pus
may have escaped to the surface of the mastoid process either through
the squamo-mastoid suture or along the posterior wall of the auditory
canal, between the periosteum and bone, without there being any actual
disease of the bone.

(ii) As a temporary measure, to permit of drainage of a subperiosteal
abscess, if the operation on the mastoid process cannot be performed for
twenty-four hours or more.

(iii) In acute middle-ear suppuration a free incision down to the bone
may relieve the pain if there are symptoms of periostitis of the mastoid
process; it is, however, rarely necessary.

=Contra-indications.= In older children and adults (with the above
exceptions) this operation is not sufficient, as the periostitis or
subperiosteal abscess over the mastoid process is secondary to
underlying bone disease which can only be eradicated by an operation on
the mastoid process itself. Although healing may apparently take place,
fistulæ or other evidences of mastoid disease almost invariably occur
afterwards.

=Operation.= In an infant a general anæsthetic is not necessary, but in
an adult gas anæsthesia is advisable. The mastoid region is surgically
cleansed; the auricle is pulled forward and a free incision is carried
down to the bone, in a curved direction downwards over the mastoid
process. Originally Wilde made a vertical incision; but it is better, if
possible, that the incision should be the same as would be made in
performing the mastoid operation, which indeed will probably have to be
carried out afterwards. After the hæmorrhage has ceased and the purulent
contents of the abscess, if present, have drained away, fomentations
should be applied and changed frequently during the first twenty-four
hours. After this a simple dry dressing is sufficient.

=Results.= Except in the case of tiny infants, this procedure is seldom
successful in curing the condition, and must be considered as only a
temporary measure.


SCHWARTZE’S OPERATION

(Opening of the mastoid process and antrum)

=Indications.= (a) _In acute middle-ear suppuration._ (i) If, in spite
of free drainage, earache, pyrexia, and tenderness over the _body_ of
the mastoid do not abate within three days. This is all the more urgent
if the condition is the result of scarlet fever or influenza, as in
these cases the disease may spread with extreme rapidity.

(ii) If there be an obvious abscess over the mastoid process; except in
infants, in whom Wilde’s incision may be attempted as a tentative
measure, although it is not recommended.

(iii) If there be symptoms of meningeal irritation.

(iv) If a profuse otorrhœa has continued for over four weeks and is
accompanied by sagging downwards of the upper posterior wall of the
external meatus, a definite sign that the antrum is involved.

(v) If a profuse otorrhœa has continued for over eight weeks, with no
sign of abatement, even although the temperature may be normal and
although there may be no symptoms of inflammation of the mastoid
process. The continuance of the otorrhœa is presumably due to
accumulation of pus in a large antral cavity. The object of the
operation is to permit of free drainage and to prevent involvement of
the mastoid process itself. The question of operation, however, must be
considered very carefully. There is no doubt that in many cases
conservative measures may effect a cure even although the suppuration
has already existed for many months.

(_b_) _In chronic middle-ear suppuration._ Although the complete mastoid
operation is usually indicated, yet the simple opening of the mastoid
antrum may be advised under the following conditions, provided there are
no symptoms of inflammation of the mastoid process nor signs of disease
of the bony walls of the tympanic cavity:--

(i) If the perforation, however large, be surrounded by a rim of
tympanic membrane (showing that there is no disease of its bony
margins), and if the malleus be not adherent to the inner wall of the
tympanic cavity.

(ii) If the hearing be good, that is, if speech is heard farther off
than 12 feet, especially if the other ear (from whatever cause) be quite
deaf.

Politzer, among others, still maintains that there is frequently no
communication between the affected mastoid cells and the antrum if the
mastoid abscess is the result of acute middle-ear suppuration. For this
reason he considers that the antral cavity should only be opened if
there be definite evidence of bone disease between the abscess cavity
and the antrum, or if symptoms of extra-dural abscess or some
intracranial complication be present. It is, however, difficult to
believe that some communication, however microscopic, does not always
exist between the antrum and the mastoid cells, seeing that the latter
originally developed as outgrowths from the antrum itself, and must have
become infected by direct extension from it. At the same time there is
no doubt that complete recovery takes place in a certain number of cases
in which the antrum has not been opened.

In my opinion, however, it is always wiser in such cases to open the
antrum. Politzer considers that if this be done, healing does not take
place so rapidly as in those cases in which the antrum has not been
opened. On the other hand, if the antrum be not opened, the main object
of the operation, that is, free drainage of the contents of the aural
cavity, is not attained.

=Operation.= _Preparation of the patient._ The head should be shaved for
a space of 2 inches around the mastoid region, twenty-four hours before
the operation if possible. In women the hair in front of the ear,
instead of being shaved off, should be combed forward and plastered down
with carbolic soap. By doing this the hair can be arranged so as to
cover the bald area during convalescence, a matter of great satisfaction
to the patient.

The area of the operation and surrounding parts should be thoroughly
washed with ethereal soap solution and afterwards protected with a
compress of 1 in 2,000 solution of biniodide of mercury. After the
patient has been anæsthetized, the cleansing process should be repeated,
and the auditory canal syringed out with the lotion. The head is then
covered with a sterilized towel drawn tightly over the ear and scalp, a
portion of the towel being afterwards cut away so as to expose only the
field of operation. The patient should be in the recumbent position, the
head resting on some hard substance, such as a partially-filled
sand-bag, and turned over to the opposite side, so that the affected ear
is uppermost.

In addition to the ordinary instruments, those specially required for
this operation are a well-balanced mallet and several gouges and chisels
of varying size, one or two sharp spoons, a seeker, and a malleable
blunt-pointed silver probe. They should be sterilized in the ordinary
manner.

[Illustration: FIG. 216. DIAGRAM SHOWING POSITION OF SKIN INCISIONS IN
POST-AURAL OPERATIONS. 1, For removal of foreign bodies or exostoses, or
for excision of a stricture within auditory canal; 2, Usual incision for
the mastoid operation; 3, Prolongation of incision upwards for exposure
of temporo-sphenoidal lobe; 4, Extension of incision backwards, for
exposure of lateral sinus or cerebellum.]

_The incision._ The surgeon stands at the side to be operated upon,
facing the patient’s head. The auricle is pulled forward. An incision is
made through the skin, beginning just above the pinna, and is carried
downwards in a curved direction towards the tip of the mastoid process,
lying about half an inch behind the insertion of the auricle (Fig. 216).
Before making the incision, the tip of the mastoid process should be
determined. Care must be taken not to let the knife slip at the end of
the incision and so incise the neck tissues. The line of incision should
correspond to what will afterwards be the middle of the wound cavity in
the bone. If the incision be made too far forwards or too far backwards,
one of the edges of the skin incision may afterwards tend to overlap the
opening in the bone and in this way hinder the dressing and perhaps lead
to the formation of a sinus. If there be much thickening of the soft
tissues and periosteum, it may be necessary to make the incision longer
than usual in order to expose the field of operation sufficiently.

In the upper angle of the incision the temporal fascia and the
underlying temporal muscle will be exposed. Except in very muscular
subjects, in whom the muscle comes low down into the wound and has to be
cut through, it is better to push the lower border of the muscle upwards
by means of a periosteal elevator. The incision is now carried right
down to the bone throughout its length.

If there be an abscess over the mastoid process, its purulent contents
should be allowed to drain away, the abscess cavity being then irrigated
with a weak solution of biniodide of mercury (see p. 389).

[Illustration: FIG. 217. SCHWARTZE’S OPERATION. Showing field of
operation with anatomical landmarks and gouge in position for opening of
antrum.

A, Zygomatic ridge; B, Spine of Henle: behind and above it is the
suprameatal triangle; C, Fibrous portion of cartilaginous meatus, not
separated from bony. (In this and the following diagrams the gouge or
chisel is drawn small. In actual practice they may be much larger.)
]

_Exposure of the field of operation._ The periosteum and overlying soft
tissues are then reflected forwards and backwards with a rugine, until
the following points are brought into view: namely, the upper posterior
margin of the bony meatus (taking care not to separate the fibrous from
the bony portion of the meatus) and Henle’s spine in front, the
zygomatic ridge above, and the fibres of the sterno-mastoid muscle below
(Fig. 217). The tip of the mastoid process should just be seen. To do
this it may be necessary to cut away some of the fibres of the
sterno-mastoid muscle.

If the surgeon has two assistants, the duty of one of them is to hold
apart the edges of the wound by means of retractors, whilst the other is
employed in keeping the wound dry. If there be only one assistant, the
edges of the wound may be held apart by metal retractors.

Careful examination of the field of operation should now be made. There
may be no external signs of disease. As a rule, however, as a result of
the inflammatory process having already extended to the surface, the
periosteum is found to be much thickened, with extreme vascularity of
the underlying bone, or there may be a subperiosteal mastoid abscess of
varying size.

Excepting in infants, in whom pus may escape through the squamo-mastoid
suture, a subperiosteal abscess is always secondary to a fistula in the
bone, which is usually situated over the body of the mastoid process
just behind the suprameatal triangle. It may, however, occupy some other
position.

In the case of Bezold’s mastoid abscess (see p. 389), although no
fistula may be seen on the surface of the bone, pus may be found to well
up from beneath the mastoid process on cutting through the fibres of the
sterno-mastoid muscle. In other cases there may be actual necrosis of
the bone, as a rule involving the lower margin of the squamous portion
of the temporal bone (see p. 390).

The method of opening the antrum in a straightforward case will first be
described.

_Opening the antrum._ The approximate surface marking of the antrum is
the suprameatal triangle and the region just behind it, which, however,
as has been mentioned, is an uncertain guide. It is wiser, therefore, in
all cases of operation on the mastoid process to assume that the case is
one in which the lateral sinus extends far forward and is superficial,
and that the middle intracranial fossa is low lying.

The area of bone to be removed depends on the age of the patient; in the
adult it is about half an inch square, having as its boundaries the
zygomatic ridge above and Henle’s spine in front.

The bone should be removed by short decided taps of the mallet on the
gouge or chisel, held in contact with the bone in a sloping direction
(Fig. 217). This precaution is specially indicated whilst in the act of
removing the bone from above downwards and from behind forwards, in
order to prevent injury to the middle fossa, which may be low lying, or
the lateral sinus, which may project abnormally far forward (Fig. 218).

To permit of better control over the instrument, the hand holding it may
rest lightly against the patient’s head, which is now covered with a
sterilized towel. This control should always be sufficient to prevent
the chisel or gouge being driven unexpectedly too far inwards, an
accident which may easily happen if, by chance, there is a sudden
diminished resistance to the stroke owing to unexpected softening of the
bone or the inadvertent exposure of the dura mater. It is this
accidental slipping of the instrument which is often responsible for
injury to the lateral sinus or the facial nerve. With regard to choice
of instruments, I prefer the gouge, as it is safer than the chisel,
owing to it having rounded edges.

On removal of the superficial part of the cortex, the mastoid process
may be found to be sclerosed, or to consist of small or large cells
filled with granulations or purulent secretion.

(_a_) _If the bone be sclerosed._ The operation may be extremely
difficult, as the antrum is frequently of small size and very deeply
placed. As the tympanic cavity must not be interfered with, it is not
permissible to insert the seeker along the auditory canal into the attic
in order to determine the position of the aditus. The only guides,
therefore, are the anatomical landmarks.

The best method is to chisel away the bone close to and parallel to the
upper posterior margin of the external meatus. In chiselling along the
upper wall of the opening, the gouge, instead of being directed
downwards, as was the case in removal of the outer portion of the
cortex, is now directed inwards and at the same time slightly upwards
and forwards. In enlarging the lower part of the opening, the bone is
chiselled away obliquely inwards and upwards. The strokes of the gouge
are made alternately from above and below, so that gradually a
funnel-shaped opening is formed, having its point directed towards the
aditus.

[Illustration: FIG. 218. SCHWARTZE’S OPERATION. Showing exposure of the
antrum. Note sloping position of gouge in removal of bone in region of
lateral sinus.]

Anteriorly, the bone is removed as close to the posterior wall of the
auditory canal as possible, including the suprameatal spine. Above, the
line of chiselling must not extend beyond the zygomatic ridge, whilst
below sufficient bone should be removed towards the tip of the mastoid
process to permit of inspection of the deeper parts of the wound.

From time to time the operator makes use of the _seeker_ (Fig. 219).
This is a blunt-pointed probe whose tip is bent at right angles to its
shaft. With it any opening is probed carefully to see whether it is
merely a mastoid cell, or dura mater covering the outer wall of the
lateral sinus, or the middle cranial fossa, or if indeed it is the
antrum itself. The chief mistake is to work too low down. If the antrum
be small it may be missed, and the bone may be chiselled away too
deeply in endeavouring to discover it and the facial nerve or the
external semicircular canal injured. It is wiser, therefore, to work
high even if the dura mater of the middle fossa is exposed by doing so.
This should not lead to any harmful result provided the dura mater is
not injured.

As soon as the antrum is reached, pus will be seen to ooze through the
opening made, especially if it is under tension. The probe or seeker can
now be passed into a cavity of varying size. The antrum is recognized by
its smooth surface, which has quite a different appearance to that of
the mastoid cells.

[Illustration: FIG. 219. SCHWARTZE’S SEEKER.]

(_b_) _If the mastoid be not sclerosed._ The pathological condition
found on removal of the superficial cortical layer depends on the
anatomical structure and on the extent and virulence of the inflammatory
process. Only a few cells may be involved, or on the other hand the
whole mastoid process, if it be of the pneumatic type, may be converted
into a mere shell of bone, forming a large cavity filled with masses of
septic granulation tissue, carious bone, and pus. Sometimes, indeed,
owing to the tegmen tympani or bony wall of the sigmoid sinus being
already destroyed, the dura mater above or the lateral sinus posteriorly
may be found already exposed within the cavity. If this is the case the
pus may pulsate if present in large quantity. Any patches of soft
carious bone or granulation tissue should be removed with the curette.

If the disease be limited to a few superficial mastoid cells, it is
sufficient, according to those who do not always explore the antrum, to
expose and curette the cavity freely and to do nothing further. This,
however, should only be done if the bone surrounding the abscess cavity
is hard and apparently normal, and if there is no tract of granulations
leading from it in any direction. If an opening be found leading
directly into the antrum, it should be enlarged with the curette or
gouge. The extent of the antrum is next defined with the seeker, any
overlapping ledges of bone being removed by the gouge until the whole of
its inner surface is exposed.

The region of the aditus is now inspected under good illumination, using
a head-light if necessary. It is recognized as a small opening at the
anterior inner part of the antrum, on the floor of which may be seen the
posterior border of the external semicircular canal, standing out as a
whitish rounded eminence. Bone may be removed from its upper inner
margins, but the lower portion should not be interfered with for fear of
injuring or displacing the incus. To confirm the opening into the
aditus, a blunt-pointed curved probe may be passed for a short distance
through the aditus into the attic (Fig. 220).

With the curette all granulations should be removed.

_Treatment of the mastoid process._ The question now arises as to how
much bone to remove. This depends on the condition found; the chief
point is to make certain of removing all the infected cells.

In the case of marked sclerosis, the opening need not be large because,
if the bone between the cortex and the antrum be solid, it is hardly
probable that infection can spread through it to any outlying cells in
the tip of the mastoid or elsewhere.

[Illustration: FIG. 220. SCHWARTZE’S OPERATION COMPLETED. The seeker is
being passed through the aditus into the attic. Note the posterior
border of the external semicircular canal which forms the inner and
lower margin of the aditus.]

In the diploic and pneumatic varieties, the seeker must be used
constantly in order to discover any outlying cells, which are then
opened freely. If this be done systematically, infected cells may be
found some distance away from the antrum itself, although an area of
apparently healthy bone lies between them and the antrum. It must not be
forgotten that cells may extend posteriorly as far as the occipital
bone, or anteriorly along the zygomatic process, or even into the upper
posterior part of the auditory canal itself (see p. 374). If such
infected cells be not discovered, healing will be prevented.

However small or large the opening may be, all rough corners must be
removed, so that at the end of the operation a smooth funnel-shaped
cavity exists. To obtain this _a burr_ may be used, worked either by the
electric motor or, if a portable one, by an assistant. The burrs are of
various sizes and of the cross-cut variety recommended by Ballance. Some
operators perform the operation by burring throughout. Personally,
during the earlier stages of the operation, I prefer to use the gouge
and mallet. If the operator has not had much experience in the use of
the burr there is always a slight risk, if it be not kept sufficiently
under control, and especially if too great pressure be used, of it being
driven through the dura mater above or into the lateral sinus
posteriorly, or of it injuring the contents of the tympanic cavity. As a
means of finishing the operation no instrument could be better. In
private practice, however, few surgeons keep one. For this reason it is
advisable to become accustomed to the chisel and gouge.

_Removal of part of the posterior wall of the auditory canal._ This may
be necessary if the anterior wall of the antrum and mastoid process be
affected. The fibrous portion of the auditory canal is partially
separated from the bony portion and held forward by means of a
retractor. The upper posterior portion of the bony meatus can now be
removed either by means of punch-forceps or by the chisel, to what
extent does not matter so long as its innermost portion, ‘the bridge,’
is not interfered with, that is, so long as the tympanic cavity and
aditus are not encroached upon.

_Exposure of the dura mater and lateral sinus._ This may have already
occurred before the operation, as a result of extension of the bone
disease, or it may be necessary to do so during the course of the
operation. Owing to the fact that an extra-dural abscess is a frequent
complication of acute inflammation of the mastoid process, Victor
Horsley and Körner advocate the exposure of the dura mater and the
lateral sinus in every case, especially if a tract of carious bone leads
in their direction. No harm is done in exposing these structures, and it
precludes missing an extra-dural abscess.

It is better to expose the dura mater than to leave it covered with
infected bone and septic granulations.

_Final step of the operation._ In order to make certain that a free
opening exists between the antrum and the tympanic cavity, some warm
boric lotion should be syringed through the opening of the aditus. A
small syringe is used, having a fine piece of india-rubber tubing fixed
on to its point. The end of the tubing is pushed into the entrance of
the aditus. The fluid is then syringed through and should emerge from
the external meatus. This is also beneficial in order to cleanse the
tympanic cavity of its purulent secretion. To expel all the fluid from
the middle ear the syringe is emptied and the piston withdrawn to its
full extent. Its point is again placed within the entrance of the aditus
and the piston pressed home, so that air is forced through and so drives
out any remaining fluid from the tympanic cavity into the external
meatus, which in its turn should be carefully dried. If there be no
perforation, or if it be very small, the membrane should be freely
incised before fluid is syringed through the aditus.

_Immediate treatment of the wound cavity._ The wound cavity is lightly
packed with sterilized ribbon gauze, half an inch in width. Care must be
taken to introduce the gauze right down to the aditus and to pack the
cavity evenly.

The wound should be left open for a few days until the acute
inflammation of the soft tissues has subsided, after which the upper and
lower angles of the wound can be partially closed by sutures. A strip of
gauze is also inserted into the auditory canal and a light dressing of
plain sterilized gauze and a pad of cotton-wool covers the ear and
surrounding parts. The bandage should be passed round the head and not
beneath the chin, as the latter method is often a source of great
discomfort to the patient during the stage of vomiting following the
anæsthetic.

Blake of America has suggested that the wound should be allowed to fill
with blood-clot on the supposition that the subsequent organization of
the clot will result in a rapid closure of the wound. This method cannot
be considered seriously owing to the impossibility of keeping the wound
sterile.

=After-treatment.= There is seldom any shock, but there may be
considerable pain during the next twenty-four hours.

If there has been no subperiosteal abscess, the dressing need not be
removed for forty-eight hours. If an abscess has been present the dry
dressing should be removed after twenty-four hours, and if there is much
œdema and inflammation of the surrounding region, a compress of wet
boric lint, kept in position by a few turns of a bandage, should be
substituted, and changed every four hours.

Drainage tubes should be shortened and removed as soon as possible. The
gauze within the wound cavity should be changed every second day, or
daily if there be much secretion. If there be much discharge and the
condition be very septic, an ear-bath of hydrogen peroxide may be given
at each dressing and the cavity syringed out with a weak solution of
biniodide of mercury; otherwise it is sufficient to use boric acid
lotion.

If the operation has been successful, the purulent discharge from the
tympanic cavity rapidly diminishes, frequently ceasing before the third
day. The auditory canal is then firmly packed with gauze, especially in
its outer part, in order to prevent stenosis of its lumen, which is
liable to occur if the posterior fibrous portion of the canal has been
separated from the bony meatus during the operation. Granulations very
quickly block the aditus and so separate the antrum and mastoid cavity
from the tympanic cavity. The wound can now be treated as an ordinary
deep surgical wound, care being taken that it is packed from the bottom
at each dressing.

If all the diseased bone has been removed, smooth healthy granulations
will cover the wound. The continuance of pus from any spot, or the
local growth of exuberant granulations, suggest the presence of an
infected cell or a fragment of carious bone. Under cocaine anæsthesia,
the part should be inspected carefully, and, if necessary, curetted
freely. In other cases the local application of chromic or
trichloracetic acid is sufficient.

After the second week the wound becomes shallower, actual healing of the
wound depending on the size of the cavity.

Unless a very large amount of bone had to be removed, the resulting
deformity is not great and usually only consists of slight sinking in of
the skin. In some cases the final result is only a fine scar, which can
generally be concealed by the hair.

The difficulties and dangers of the operation are considered in the next
chapter (see p. 412).

=Results.= 1. If the operation has been successful (and this is usually
the case), pyrexia and pain rapidly disappear, the patient experiencing
remarkable relief from the head symptoms, so that within twenty-four
hours he feels almost well. Healing of the wound is usually complete
within six weeks, and before this date the hearing power will probably
have been restored to normal.

2. The operation may not have been successful and the following
unfavourable symptoms may occur:--

(_a_) The pyrexia may continue irregularly for a few days. If there be
no other symptoms, this is probably due to septic absorption from the
wound and need not cause very great alarm. If accompanied by pain, it
may either mean that all the infected mastoid cells have not been
opened, or suggest the onset of osteomyelitis of the temporal bone. If,
in addition, such symptoms as rigors, delirium, optic neuritis,
headaches, or vomiting occur, they indicate some intracranial
complication.

In cases of doubt it is wiser to explore the wound under a general
anæsthetic and then to determine what operation will be necessary.

(_b_) The general condition of the patient may be excellent, but
otorrhœa or a fistula over the mastoid process may persist. Continuance
of otorrhœa, in spite of healing of the wound posteriorly, means that
although the disease involving the mastoid process has been eradicated,
yet the walls of the tympanic cavity are themselves involved. This will
probably necessitate the subsequent performance of the complete mastoid
operation.

On the other hand, the suppuration may cease from the middle ear with
complete recovery of hearing, and yet a fistula of the mastoid may
remain. This means that all the diseased bone has not been removed. This
should now be done.


TREATMENT OF SPECIAL CONDITIONS

=In an infant.= In an infant under two years of age the incision should
be somewhat higher than usual. In making it, too much pressure should
not be used, as the bone is frequently thin at this age, and if carious
it may be so soft that the knife may possibly enter the intracranial
cavity. In exposing the area of operation, it must be remembered that
the posterior root of the zygoma and the antrum lie at a much higher
level than in the adult. The opening into the antrum, therefore, is made
almost above rather than behind the margin of the auditory canal. In
these cases a fistula is usually present, and the bone is so soft that
it can generally be removed by means of a sharp spoon or curette. At the
same time, however, the aditus should be exposed and the opening made
funnel-shaped in order to allow of proper dressing.

=Subperiosteal abscess.= The treatment depends on the extent of the
abscess. If it be small, the lining membrane may be dissected away, the
wound being afterwards treated in the ordinary manner. If the abscess
cavity extends upwards towards the parietal region, or forwards along
the temporal fossa, then drainage tubes should be inserted, their ends
being brought out into the mastoid wound. It is rarely necessary to make
counter-incisions. The completion of the operation is seldom difficult,
as the fistula actually leads into the antrum. If the fistula be a large
one and the bone is carious a sharp spoon may be used; otherwise a gouge
is necessary.

=Bezold’s mastoid abscess.= If the lower portion of the mastoid process
be composed of large cells, the abscess within the mastoid may break
through the bone at its inner surface in the region of the digastric
fossa. In consequence of this the pus may infiltrate the neck tissues
beneath the fascia of the sterno-mastoid muscle and form a large abscess
recognized clinically as a hard and painful swelling situated below the
mastoid process instead of over it. This condition was first described
by Bezold.

After exposing the antrum in the ordinary way, the tip of the mastoid
process is opened freely. It is usually found to contain large cells
filled with pus. Any granulation tissue is curetted away and the cavity
dried. The inner surface of the bone is then inspected carefully in
order to find the opening, which usually leads into the digastric fossa.
The margins of the fistula should be curetted freely and the opening
enlarged, if necessary. If the deep-lying cervical abscess be large, the
finger may be passed into the abscess cavity behind the mastoid process,
between it and the cut fibres of the sterno-mastoid muscle. In this way
the limits of the cavity can be made out, and any septa forming pockets
within it can be broken down. A counter-incision should be made through
the tissues of the neck at the lower limit of the abscess. The opening
should be sufficiently large to permit the insertion of a large drainage
tube into the cavity. If the abscess be small it may not be necessary to
make a counter-opening, but merely to insert a drainage tube into it,
passing it from above downwards along the passage made by the finger.

=Necrosis.= In children necrosis of the temporal bone is not uncommon,
especially if the middle-ear suppuration occurs in the course of a
specific fever or is the result of tuberculous infection.

The part usually affected is the lower margin of the squamous portion of
the temporal bone and the tympanic ring. Sometimes, however, the
necrosis is very extensive, involving a large area of the petrous bone,
including the labyrinth. These cases are always grave, and if a fatal
result occurs it is usually in consequence of meningitis.

In adults necrosis is rare excepting as a localized patch usually
situated superficially in the cortex of the mastoid process. Partial
necrosis of the labyrinth, more especially of the vestibule and the
portions of the semicircular canals, is also met with occasionally. When
the necrosed area is superficial, such as the squamous portion of the
temporal bone or the cortex of the mastoid process, it should be
removed. If, however, it be situated more deeply, forcible removal
should not be attempted until the sequestrum becomes loose, the wound
cavity being meanwhile kept as aseptic as possible.

=Osteomyelitis.= In children, as the result of acute inflammation of the
mastoid process, the bone may be found riddled with small points of pus,
sometimes termed osteomyelitis. As a result of free opening of the
mastoid cavity recovery, as a rule, takes place in the ordinary manner.

Distinct from this is another condition in which thrombosis of the
diploic veins occurs. It is, fortunately, a rare complication of mastoid
disease. It may occur before operation or be the result of infection of
the bone as a result of operation. The infection tends to spread in
every direction, more especially upwards along the parietal region and
towards the occiput. With this, localized areas of necrosis or abscesses
may occur, giving rise to painful swellings on the head, and usually are
accompanied by cellulitis of the scalp, pyrexia, and intense headaches.

The only chance of recovery is to expose the affected area freely, and
thoroughly remove all the diseased bone. To do this it may be necessary
to lay bare the dura mater over a considerable area. If, however, the
disease be not quickly eradicated, death will eventually occur as a
result of extension of the septic infection to the larger veins, or from
some other intracranial complication.




CHAPTER VI

THE COMPLETE MASTOID OPERATION


Before considering the question of the radical operation, it is assumed
that conservative treatment has been attempted and has failed, and that
the middle-ear suppuration has existed for a considerable period.

=Indications.= (i) As a prophylactic measure. If there be merely a
perforation of the tympanic membrane and no evidence of disease of the
ossicles nor the walls of the tympanic cavity, the probability is that
the continuance of the suppuration is due to an affection of the mucous
membrane rather than of the underlying bone; for example, to a chronic
empyema of a large antrum cavity which, owing to its anatomical
structure, will not drain freely.

In such cases the complete mastoid operation is only indicated if the
deafness is extreme, the bone conduction diminished, and the high
tuning-forks not well heard, or if the ossicles are bound down by
adhesions to the inner wall of the tympanic cavity, as it is then
obvious that the hearing power cannot be restored completely.

It must, however, be remembered that in many cases a slight discharge
may exist for years without giving rise to any complications. If the
patient be made aware of the slight danger which exists in every case of
middle-ear suppuration, and be in a position to obtain medical attention
if retention of pus occurs, then operative measures may be deferred
indefinitely. If, on the other hand, the patient intends going to some
remote country where medical attendance is impossible, then it is
probably wiser to submit to the complete operation rather than risk
future trouble.

(ii) If there be recurrent attacks of giddiness, nausea, or headaches
radiating up the affected side which are not arrested by the ordinary
methods of treatment. These symptoms of retention of pus within the
antrum and mastoid process should be considered as danger signals. In
this case also it is assumed that the hearing cannot be restored, and in
consequence there is no object in performing Schwartze’s operation.

(iii) If there be recurrence of polypi and granulations within the
tympanic cavity in spite of curetting, especially if the operation of
ossiculectomy has already been performed.

(iv) If there be symptoms of retention of pus due to want of free
drainage in the case of stenosis of the external meatus, whether due to
fibrous contraction of its soft parts, or from the presence of
exostoses.

(v) If cholesteatomatous formation be present. Even if there be no
symptoms necessitating immediate interference, operation is usually
indicated owing to the fact that cholesteatoma is the commonest
predisposing cause of intracranial suppuration and septic thrombosis of
the lateral sinus.

(vi) If there be a fistula of the bony wall of the mastoid process,
whether it extends anteriorly into the auditory canal or externally
through the skin over the region of the mastoid process. It must not be
forgotten, however, that simple opening of the antrum and mastoid cells
will be quite sufficient if the condition is the result of a recent and
acute inflammation of the mastoid process.

(vii) If there be facial paralysis occurring in the course of a chronic
middle-ear suppuration. This may mean either that there is bone disease
involving the facial canal, or that the inflammatory process has spread
through the Fallopian canal towards the inner ear. In either case
operation is indicated.

(viii) As a preliminary step in intracranial suppurative lesions of
otitic origin.

(ix) In tuberculosis of the middle ear. If the patient’s general
condition permits of it, and if the pulmonary disease be slight or
arrested, the complete operation should always be done. The difficulty
is to remove all the diseased bone. If this can be done the wound will
heal quite well.

(x) In acute inflammation of the mastoid process occurring in the course
of chronic middle-ear suppuration, the complete mastoid operation should
be performed, as in these cases the attic, aditus, and antrum are always
involved.

(xi) Amongst the rarer conditions for which the complete operation may
be necessary are removal of a foreign body which has been pushed
inadvertently into the region of the attic and aditus and cannot
otherwise be removed; and actinomycosis of the temporal bone.


METHODS OF OPERATION

The actual method of carrying out this operation varies. For those who
have not had great experience the best method is first to open the
antrum, as in Schwartze’s operation, and then to remove the ‘bridge’ of
bone between it and the tympanic cavity (Küster-Bergmann operation,
sometimes called the Schwartze-Stacke operation). Instead of doing this,
the upper posterior part of the auditory canal may be chiselled away
simultaneously during the act of exposing the antrum (Wolf’s operation).
On the other hand, the mastoid and antrum may be exposed from within
outwards by removing the outer attic wall and working backwards
(Stacke’s operation).

=The Küster-Bergmann (or Schwartze-Stacke) operation.= The preliminary
preparation, the position of the patient, and the instruments required
are the same as in opening the antrum.

[Illustration: FIG. 221. THE ‘RADICAL’ MASTOID OPERATION. To show
removal of the ‘bridge’ from above. The seeker, inserted into the
aditus, acts as a protector to the underlying external semicircular
canal and facial nerve.]

The =incision= is begun just above the upper insertion of the pinna, and
is carried downwards in a curved direction behind the auricle along the
margin of the skin and scalp. Some authorities prefer to make the
incision close behind or even along the post-auricular fold. In favour
of the incision being placed far back is the concealment of the scar by
the hair. Also, as it is situated on healthy bone somewhat posterior to
the actual wound cavity, it should heal by primary union and with no
after-displacement of the auricle. In addition, if it be necessary to
expose the lateral sinus, this can usually be done by simple retraction
of the soft parts.

The exposure of the field of operation is the same as in the simple
opening of the antrum, excepting that the soft tissues should be
separated a little further forwards and above the external bony meatus,
as in this operation the upper posterior wall has to be removed.

The antrum is opened as already described (see p. 382).

The fibrous portion of the external meatus is separated carefully from
the posterior wall of the bony meatus by means of a periosteal elevator,
and is pulled forward by a retractor. The external portion of the
posterior wall is now removed in a wedge-shaped fashion by alternate
strokes of the chisel from above downwards (Fig. 221) and from below
upwards. The upper level of the bone to be removed corresponds with the
zygomatic ridge. After a small portion has been removed, a pair of
forceps is passed into the auditory meatus and its point made to
project into the wound posteriorly through the end of the now detached
fibrous portion of the auditory canal. With the forceps a piece of gauze
is drawn through the auditory meatus in the form of a loop. By its means
the auricle and fibrous portion are pulled well forward, thus exposing
to view the tympanic cavity. Two openings are now seen: one, the
auditory canal and tympanic cavity, in front, and the other, the antrum
and mastoid cavity, behind. Between them is the ‘bridge’; that is, the
innermost portion of the posterior wall of the auditory canal.

[Illustration: FIG. 222. STACKE’S PROTECTOR.]

Any granulations present are curetted away gently from the tympanic
cavity. The seeker is next passed into the tympanic cavity, and its
point directed upwards and backwards into the aditus, so that it rests
on the floor of the latter, or its point may be inserted into the aditus
through the mastoid wound. Beneath it lies the eminence of the external
semicircular canal and the facial nerve. This is a most important
landmark. Provided the seeker is kept in this position, all the bone
lying superficially to it can be removed without injury to the
semicircular canal or facial nerve.

In this connexion may be mentioned Stacke’s probe or ‘protector’ (Fig.
222). Although historically an instrument of importance, I do not make
use of it. It is so large and of such sharp outline that, unless used
with extreme care, it is itself very liable to injure the facial nerve.
For this reason I prefer the seeker, a much finer and more delicate
instrument, which will serve the purpose without the same risk (Fig.
219).

The ‘bridge’ is now carefully removed by the gouge or chisel, frequent
use being made of the seeker meanwhile. As the roof of the antrum,
aditus, and attic is a continuous one, the bone to be removed is
necessarily at a higher level than the roof of the bony meatus. This is
a point which must not be forgotten, as the great fault of the beginner
is to remove the bone too low down.

As the aditus is approached, the strokes of the chisel must be very
gentle. If too much force be used, the chisel, on breaking through the
innermost portion of the ‘bridge’, may injure the deeper-lying parts,
more especially the facial nerve.

Some authorities advocate removal of the ‘bridge’ by means of bone
forceps. This, however, is not so sure a method as by the chisel or
gouge.

After removal of the bridge, the tympanic cavity, antrum, and mastoid
will form a continuous cavity. As a rule the outline of the external
semicircular canal appears as a well-marked white eminence, and
projecting beyond it are the remains of the posterior wall of the
auditory canal. In removing this ridge good illumination is essential.
The bone is removed in layers with the chisel, beginning at the tip of
the mastoid process, and working parallel to the auditory canal and the
underlying facial canal. If necessary the seeker may be used as a guide,
its point being allowed to rest on the floor of the aditus, superficial
to the semicircular canal (Fig. 223).

The amount of bone removed should be such that at the end of the
operation the auditory canal is only separated from the main cavity of
the mastoid antrum by a slight eminence, the remainder of the posterior
wall, which is continuous with that of the external semicircular canal.

[Illustration: FIG. 223. THE ‘RADICAL’ MASTOID OPERATION. Showing
removal of the remains of posterior wall of the auditory canal; the
seeker acting as a protector.]

Occasionally the facial canal and the stylo-mastoid canal are abnormally
superficial. Provided the bone be removed in the manner just described,
the facial nerve should not be injured, even though it may be exposed
inadvertently. A warning of this occurrence is given by bleeding from
the vessels within the canal (see p. 374).

If the malleus and incus be still _in situ_, they can now be seen and
can usually be removed by the curette. No force must be used. Removal of
the incus is a matter of no difficulty. In the case of the malleus there
may be some resistance owing to the attachment of the tendon of the
tensor tympani muscle. If so, the malleus should be grasped by a fine
pair of forceps and the tendon severed by means of Schwartze’s tenotomy
knife.

The overhanging edge of the outer wall of the attic can now be felt by
means of the seeker. It is best removed by gentle taps of the chisel or
small gouge. Especial care must be taken not to drive the gouge too far
inwards. If this be done inadvertently, the transverse portion of the
facial nerve passing along the inner wall of the tympanic cavity may be
injured. As a safeguard some surgeons use an attic punch-forceps or a
burr, others a Stacke’s protector which should be inserted into the
attic before chiselling away its outer wall.

After the outer attic wall has been removed, the roof of the auditory
canal and the attic should be continuous. This is verified by inserting
the seeker, with its point turned upwards, within the attic, and then
withdrawing it; no ridge of bone should now prevent its withdrawal.

[Illustration: FIG. 224. PFAU’S CURETTE FOR THE EUSTACHIAN TUBE.]

Granulations or the epithelial lining of cholesteatomata should be
removed from the recesses of the tympanic cavity with a small curette.
Care must be taken not to injure the surface of the promontory, or the
region of the fenestra ovalis and fenestra rotunda. It is especially
important to curette away the mucous membrane from the orifice of the
Eustachian tube in order that scar tissue may obliterate its lumen and
so prevent reinfection of the middle ear from the naso-pharynx. For this
purpose a narrow curette is necessary (Fig. 224).

Removal of the innermost portion of the floor of the auditory canal is
not always necessary. Sometimes, however, the ‘hypotympanum’ is well
marked, and in order to ensure a good result it is wiser to remove this
projecting piece of bone. If the ridge of bone be removed piecemeal, and
if the gouge or chisel be kept parallel to the floor of the canal, there
should be no danger of wounding the bulb of the jugular vein. Cases,
however, have been recorded in which this has occurred.

The final step is to see that no pockets nor overhanging ledges or
ridges of bone remain, and that all the diseased area has been removed.
The cavity, although irregular in outline, should be a continuous one
with a smooth surface (Fig. 225).

=Wolf’s operation.= This slight modification of the Küster-Bergmann
operation requires merely a note of description. The position of the
patient and the preliminary steps of the operation are the same as in
the former operation.

In this operation, instead of first exposing the antrum cavity and
afterwards removing the posterior wall of the external meatus, this
procedure is performed in one step.

The chisel or gouge is first brought into contact with the bone just
behind the upper posterior margin of the auditory canal. The bone is
removed in layers by chiselling it away in a forward direction and in
such a manner that each stroke of the chisel is carried directly into
the auditory canal (Fig. 226). With each successive stroke, begun a
little more posterior and inferior to the one preceding it, more bone is
removed until at length the antrum is exposed. There should be no risk
of injuring the external semicircular canal nor the facial nerve, owing
to the fact that the outer wall of the antrum lies superficial to the
tympanic cavity and aditus.

[Illustration: FIG. 225. THE ‘RADICAL’ MASTOID OPERATION COMPLETED. A,
Attic and antrum; B, External semicircular canal; C, Promontory and
inner wall of tympanic cavity; D, Remains of posterior wall of auditory
canal; E, Facial nerve canal; F, Floor of auditory canal.]

After the antrum has been exposed, the technique of the operation is the
same as that already described in the Schwartze and Küster-Bergmann
operation.

=Advantages.= 1. If the surgeon be experienced it saves much time, as
the preliminary steps of the operation can be carried out very rapidly.

2. If the mastoid be sclerosed and there are no landmarks, the antrum,
however small, is bound to be reached by making use of this method, by
keeping high up, and, if necessary, exposing the dura mater. To verify
the depth to which the bone may be removed and also the position of the
antrum, the seeker should be inserted occasionally through the tympanic
cavity into the aditus.

=Disadvantages.= If the surgeon be not experienced, it is not so safe a
method as that of first exposing the antrum.

=Stacke’s operation.= After exposure of the field of operation, as in
the Küster-Bergmann operation, the fibrous portion of the auditory canal
is separated posteriorly from the bony portion.

[Illustration: FIG. 226. WOLF’S OPERATION.]

Any granulations, together with the malleus and incus, are removed from
the tympanic cavity (see p. 353). Under a good illumination, using a
head-lamp if necessary, the surgeon passes a seeker along the auditory
canal, its point being made to project into the attic in order to define
its limits and that of the aditus. The innermost portion of the upper
posterior wall of the auditory canal, that is, the outer wall of the
attic, is now removed piecemeal by means of a small gouge (Fig. 227). By
working backwards the aditus is approached, the bone being removed
carefully in small fragments. The seeker is inserted repeatedly into the
entrance of the aditus so as to rest on the external semicircular canal,
in order that the position of the latter and the underlying facial nerve
may be kept constantly in mind. More bone above and external to this
point is removed in small fragments, until at length the upper and
innermost portion of the antral wall is removed and its cavity thus
exposed. The cavity is gradually enlarged by removing still more bone in
a backward and outward direction, until finally it resembles that left
after the complete operation. Stacke originally devised this method in
those cases in which he considered that the disease was limited to the
ossicles, the walls of the attic, aditus, and innermost portion of the
antrum. It was, indeed, merely a more radical method of performing
ossiculectomy.

=Advantages.= Although this operation has practically been abandoned as
a method of performing ossiculectomy, yet under the following conditions
it may be adopted during the performance of the complete operation:--

1. If the mastoid be very sclerosed and if the antrum cannot be
exposed, although the bone has been removed to a depth corresponding to
its usual position.

2. If there be difficulty in exposing the antrum in the performance of
the radical operation owing to the lateral sinus projecting far forwards
and the middle intracranial fossa overlapping it externally.

=Disadvantages.= The chief disadvantage is that it is more difficult and
tedious to begin the operation within the depth of the wound, and if the
meatus is very deep and narrow it may be almost impossible to carry out.

=Preservation of the ossicles and tympanic membrane after performing the
complete mastoid operation.=

This method of operation is well known and has been performed for some
years, especially by Jansen of Berlin, and in America.

[Illustration: FIG. 227. STACKE’S OPERATION.]

The only indication for this modification of the complete mastoid
operation is disease involving the antrum and mastoid process so
extensively as to require complete removal of the posterior wall of the
auditory canal, without there being any coexisting bone disease of the
walls of the attic or of the ossicles.

As the complete mastoid operation is only performed for some condition
due to chronic middle-ear suppuration, it is difficult to imagine that
the ossicles and attic region could remain unaffected when the extent of
the disease necessitates the complete operation.

In my opinion, if it be necessary to remove the ‘bridge’ it is also
necessary to remove the outer wall of the attic and with this the
malleus and incus. If, on the other hand, there be no bone disease of
the attic region or of the ossicles, Schwartze’s operation, or some
modification of it, should be sufficient. The majority of aurists agree
that, excepting in those cases in which the continuance of the
suppuration is due to an empyema of the antral cavity, the ossicles are
almost invariably carious to a greater or lesser extent in chronic
middle-ear suppuration. This view is supported by Grunert’s researches
(_Archiv für Ohrenheilkunde_, Band 40), who found that the ossicles were
only normal in five cases in a series of 113 cases in which the complete
operation had been performed.

[Illustration: FIG. 228. POST-MEATAL SKIN FLAPS (_Author’s method_).
Bistoury incising the posterior fibrous portion of the auditory canal.
The dotted line shows the line of incision. A is the Y-shaped flap
afterwards sutured to the skin behind the auricle.]

Although removal of the ‘bridge’ may eradicate the disease within the
mastoid process and antrum, yet, if the ossicles are left,
post-suppurative adhesions will almost certainly afterwards bind them
down and so cause a greater deafness than if they had been removed
originally. Still, a few isolated cases have been reported in which
hearing to the extent of 20 feet or more has been obtained as the result
of this operation. The same results, however, frequently occur after the
performance of the complete operation with removal of the malleus and
incus. Until we have a large and consecutive series, recording the
results of this particular operation in detail, together with
information regarding the duration of the symptoms, the previous
treatment, and the condition of the ear before operation, it is
impossible to judge the value of this method.


THE FORMATION OF POST-MEATAL SKIN FLAPS

This is done for two reasons: firstly, to prevent stenosis of the
auditory canal; and secondly, to aid the growth of the epithelium over
the wound surface, so that the latter will heal as rapidly as possible.

These flaps may be formed in several different ways. The following is
the technique I adopt: A long, narrow, curved bistoury is passed down
the auditory meatus so that it projects through the detached end of the
fibrous portion, its point being directed backwards. The auricle is held
well forward and the fibrous portion of the meatus cut through
posteriorly, from within outwards, for a short distance (Fig. 228). The
edge of the bistoury is then directed in a slanting direction upwards
and outwards, and the incision continued as far as the cartilaginous
portion of the meatus, care being taken not to cut into the concha. The
bistoury is then withdrawn and reinserted at the point at which it was
first made to turn upwards. It is now directed downwards and outwards
and, in a similar manner, the incision is made in a slanting direction
towards the inferior margin of the cartilaginous meatus. In carrying out
these manipulations care must be taken that the outer portion of the
bistoury does not injure the tragus or other portion of the auricle, a
mistake which can easily occur. The fibrous portion of the meatus is
thus divided by a Y-shaped incision into three small flaps; namely, a
posterior or external V-shaped flap, and a superior and an inferior flap
(Fig. 229).

[Illustration: FIG. 229. POST-MEATAL SKIN FLAPS (_Author’s method_).
Flaps cut: A, Y-shaped flap sutured to the skin; _b_, Superior flap;
_c_, Inferior flap.]

The outer flap is fixed to the skin behind the auricle by means of a
catgut suture (Fig. 230), and the auricle is then pulled back into its
normal position. By inserting the tip of a finger into the meatus, the
upper and lower flaps are pressed upwards and downwards against the roof
and floor of the mastoid cavity, and can be kept in position afterwards
by suturing the flaps to the subcutaneous tissue or by packing the
cavity through the meatus with a strip of ribbon gauze.

Amongst other methods the following may be mentioned:--

=Körner’s method= (Fig. 231). Two parallel incisions are made in a
longitudinal direction through the fibrous portion of the posterior wall
of the meatus and are prolonged outwards as far as the concha. On the
auricle being restored to its normal position, this posterior flap is
pressed backwards and so covers a large area of the posterior wound
surface. The chief objection to it is that, owing to involvement of the
concha, there is considerable enlargement of the meatal opening and
therefore subsequent disfigurement.

[Illustration: FIG. 230. CLOSURE OF WOUND AFTER ‘RADICAL’ MASTOID
OPERATION. A is the point at which the Y-shaped meatal flap is sutured
to the skin.]

=Panse’s method= (Fig. 232). A transverse incision is carried through
the posterior margin of the meatus, at the junction of the concha and
auditory canal posteriorly. With a pair of scissors or knife, the
posterior wall of the fibrous portion of the canal is now split by a
longitudinal incision. In this way two flaps are formed, a superior and
inferior one. They are fixed into position by catgut sutures through the
subcutaneous tissues at the upper and lower angles of the wound.

=Stacke’s method= (Fig. 233). This consists of a large inferior flap,
formed by making a longitudinal incision along the posterior upper
border of the fibrous portion of the auditory canal and a transverse
incision meeting it at right angles, the latter cutting through the
fibrous portion of the meatus at its junction with the concha.

In order that these flaps may be thinner and more adaptable, the
subcutaneous tissue should be cut away. Of these flaps the Y-shaped one
is the most practicable, as it is suitable whether the posterior wound
is closed or left open.

[Illustration: FIG. 231. KÖRNER’S POST-MEATAL FLAP.]

[Illustration: FIG. 232. PANSE’S POST-MEATAL FLAP.]

[Illustration: FIG. 233. STACKE’S POST-MEATAL FLAP.]

Körner’s method has the objection that there is subsequent disfigurement
owing to the large meatal opening formed by cutting into the concha. It
has the advantage, however, that the large posterior flap will cover
the posterior surface of the wound cavity to a considerable extent, and
also that it will permit a good view of the surface.

Panse’s flap is only of service if the posterior wound is left open and
if there is not sufficient tissue left to make a posterior flap owing to
previous destruction of the posterior wall of the auditory canal.

Stacke’s method is good if skin-grafting is afterwards employed.


CLOSURE OF THE WOUND

Excepting under the conditions mentioned below, the posterior wound is
closed by bringing together the edges of the skin incision with fine
silkworm-gut sutures (Fig. 230). Before this is done, the wound cavity
should be irrigated with a weak solution of biniodide of mercury, dried,
and the deeper parts of the wound plugged with a strip of gauze inserted
through the external meatus. This will not only arrest the hæmorrhage
and keep the inner part of the wound dry, but at the same time will keep
the skin flaps in position. After the wound has been closed, firm
pressure should be applied in front and behind the ear to press out any
blood from the cavity.

As a final step the gauze which has been inserted into the meatus is
removed, and the cavity again packed evenly and lightly from the bottom
of the wound with a fresh strip. The ear and surrounding parts are
protected with a pad of sterilized gauze covered with cotton-wool and
kept in position with a bandage.

_The posterior wound should be left open under the following
circumstances_:--

1. If there be an abscess over the mastoid process. Although it may be
possible to excise the whole of the lining membrane of the abscess
cavity, it is wiser to leave the wound open for the first few days. The
innermost portion of the wound cavity is packed through the external
meatus, only the superficial part being packed through the posterior
wound incision. As healthy granulations appear, the posterior packing is
diminished, so that the edges of the incision gradually come together.
If necessary, the edges of the wound can also be freshened and brought
together by silkworm-gut sutures under cocaine anæsthesia.

2. If there be extensive disease of the bone, especially if the dura
mater and lateral sinus are covered with septic granulations.

3. If there be bone disease of the anterior and inferior parts of the
tympanic cavity. The after-treatment of packing or the curetting away of
granulations can be carried out more easily through the posterior wound
than through the external meatus, as it gives a better view of these
regions.

4. In young children it is frequently advisable to leave the posterior
wound open owing to the difficulty of packing the wound cavity through
the small external meatus.


SKIN-GRAFTING AFTER THE MASTOID OPERATION

In order to shorten the duration of healing, a large Thiersch’s skin
graft may be transplanted into the wound cavity. If this procedure be
adopted it may be carried out in several ways. The skin may be
transplanted in one large piece or in several small portions, and it may
be introduced into the wound cavity either immediately after the
completion of the mastoid operation or from seven to ten days later.

There is considerable diversity of opinion as to whether skin-grafting
should be employed or not, and also when it should be done.

This may be partially accounted for by the fact that although,
theoretically, the application of skin grafts is easy, yet, practically,
the technique is difficult. Those who favour skin-grafting point to the
fact that healing of the wound may take place within five weeks,
whereas, if grafting be not undertaken, cicatrization of the cavity,
even under favourable conditions, can hardly be expected to occur before
eight to twelve weeks.

The skin-grafting operation as suggested by Charles Ballance is
generally performed as a second stage, some ten or more days after the
primary operation. This, from the patient’s point of view, is a serious
matter; and the disappointment caused by the grafting not being always
successful has induced many to give it up and to be content with what
seems to be a more certain, though more prolonged, after-treatment.

More recently, however, it has been shown that in suitable cases skin
grafts, if applied at the time of the completion of the primary
operation, will take just as well as at a later date. This altogether
alters the aspect of the case. If at the end of the primary operation it
be certain that all the diseased bone has been removed and the cavity
has been rendered aseptic, there can be no objection to the immediate
application of skin grafts. If the result be successful, the period of
after-treatment is considerably curtailed. If, on the other hand, it be
not successful, the patient, beyond having a raw surface on his arm or
leg for a few days, is no worse off than if the graft had not been
applied.

Skin-grafting, however, cannot be done in every case. Two conditions are
necessary for its success: firstly, that all the diseased bone has been
removed; and secondly, that the wound cavity is aseptic.

Immediate skin-grafting, therefore, should not be employed if, in
addition to the chronic disease, there be acute inflammation of the
mastoid process, or of the subcutaneous tissues covering it; nor should
it be done if it has been necessary to expose the dura mater over a
large area, nor if there be any possibility of some subsequent
intracranial complication. In such cases it may be justifiable to do
skin-grafting after the acute symptoms have subsided. If, however, the
case be progressing satisfactorily, the advisability of submitting the
patient to a second operation should be a matter of careful
consideration.

Disease of the inner wall of the tympanic cavity, or around the orifice
of the Eustachian tube, is also a contra-indication against grafting, as
the graft, if applied, will not take over these areas. The author’s
opinion with regard to skin-grafting is that, if it can be applied
immediately after the completion of the primary operation (and the
conditions justifying this are limited), it may be done. If, however,
the conditions be such that they will not permit of this, it should not
be done at all.

=Technique.= _When the grafting is done at the completion of the mastoid
operation._ The first step is to see that the mastoid wound cavity is
rendered thoroughly aseptic and dry. All bleeding points in the soft
tissues are arrested by means of pressure forceps. The mastoid cavity is
then filled with hydrogen peroxide lotion, which is afterwards syringed
out with a warm saline solution, the cavity being dried with sterilized
strips of gauze, and finally packed from the bottom with a fresh strip.

The size of the graft, which is usually taken from the thigh, should be
at least 2 inches in width and 4 inches in length. The skin is cleansed
by washing it with soap and water, then with ether, and finally with
normal saline solution, the part being afterwards dried with a
sterilized towel. It does not matter what type of razor is used to
remove the graft, so long as it is sharp. The chief point to observe, in
order to secure success, is to see that the skin is kept uniformly
stretched--the tighter the better. The technique of removal of grafts is
described elsewhere (see Vol. I, p. 670). The graft taken from the leg
is transferred to a large spatula and smoothed out over its surface. The
auricle is now pulled forward, and the gauze strip is removed from the
mastoid cavity. The spatula is laid across the surface of the cavity so
that it rests on the anterior margin of the wound surface (Fig. 234).
With a sharp probe the edge of the graft, which just overlaps the
spatula, is held in position at this point, the spatula being gently
retracted so as to leave the graft stretched across the surface of the
wound cavity. With a ‘stopper’ (Fig. 235), the graft is now pushed
inwards towards the tympanic cavity.

A glass pipette (Fig. 236), having a curved beak, is then passed inwards
beneath the graft until its point, directed downwards, lies within the
tympanic cavity (Fig. 237). Any blood which has accumulated between the
bone and the graft is now sucked out, and in doing this the graft
becomes closely applied to the bone surface (Fig. 238). After removing
the pipette, any part of the graft which is not adherent to the bone is
smoothed out over its surface. The tympanic cavity and the innermost
portion of the mastoid cavity are then plugged with sterilized pellets
of cotton-wool wrapped in gauze and dusted with aristol powder. The
outer portion of the cavity is filled up with a strip of gauze, its end
being brought out through the external auditory meatus.

[Illustration: FIG. 234. SKIN-GRAFTING OF MASTOID WOUND CAVITY AFTER
OPERATION. Skin graft being transferred from the spatula to the mastoid
cavity.]

The posterior part of the graft, still projecting beyond the posterior
margin of the wound, is now turned forwards so as to form a covering
over the gauze filling up the wound cavity (Fig. 239). On the auricle
being restored to its normal position, this portion of the graft is
brought into contact with the subcutaneous tissues of the skin forming
the post-aural flap, which now forms the outer wall of the mastoid
cavity. The posterior incision is closed with sutures and a dry dressing
and bandage are applied to the ear.

[Illustration: FIG. 235. BALLANCE’S ‘STOPPER’ FOR PUSHING IN THE GRAFT.]

_If skin-grafting be performed a week or more after the primary
operation._ The post-aural wound, now healed, has to be reopened. In
doing so there may be considerable bleeding, which must be arrested. The
mastoid cavity is usually found to be covered with a fine layer of
granulations. They are curetted away carefully, special attention being
paid to the region of the Eustachian tube and the floor of the tympanic
cavity. After removal of the granulations, the bone should appear
uniformly smooth though somewhat vascular. If any points of carious bone
be found they should be removed freely with the gouge or burr.
Considerable time may have to be spent in arresting the oozing from the
surface of the bone cavity. This is best done by washing out the cavity
with hydrogen peroxide solution and then plugging it tightly for a few
moments with adrenalin solution. The gauze is withdrawn in a few
moments. If there be still oozing, the pressure will have to be repeated
until it ceases. The method of applying the graft is the same as already
described.

[Illustration: FIG. 236. PIPETTE FOR SUCKING AIR AND FLUID FROM BENEATH
THE GRAFT.]

[Illustration: FIG. 237. SKIN-GRAFTING OF MASTOID WOUND CAVITY AFTER
OPERATION. Skin graft in the act of being sucked into position by the
pipette.]

=After-treatment.= The outer dressing may be changed every second day,
but the wound itself is not interfered with until the eighth day. If
asepsis has been obtained, the posterior wound has usually completely
healed, so that the stitches can be removed at the first dressing. Owing
to the secretion from within the cavity there may be a certain amount of
odour, and as a rule some purulent discharge from the meatus. Under good
illumination the strip of gauze is gently removed through the meatus
and afterwards the small pellets of cotton-wool. In order to make
certain that all are removed, a note should be made at the time of
transplanting the graft as to how many were inserted in the wound
cavity. The ear is now syringed out gently with a weak solution of
hydrogen peroxide and afterwards dried by mopping it out with small
wicks of cotton-wool.

A speculum is next inserted into the meatus and the cavity thoroughly
examined. Any portions of the graft not in absolute contact with the
bone or which overlap the skin of the meatus will have died, and can be
removed by forceps. Care, however, must be taken not to pull off these
portions too forcibly, as in doing so other pieces of the graft may be
torn away. The external meatus is then plugged with a tiny piece of
gauze and a dry dressing applied. If the graft has not taken and has
died, it will be expelled at the first dressing on syringing.

[Illustration: FIG. 238. SKIN-GRAFTING OF MASTOID WOUND CAVITY AFTER
OPERATION. Skin graft in position.]

[Illustration: FIG. 239. POSTERIOR PORTION OF SKIN GRAFT COVERING OUTER
SURFACE OF WOUND CAVITY.]

Further treatment consists in syringing and afterwards drying the cavity
daily. From day to day the outer layer of the graft will gradually come
away piecemeal. At the end of the second week the patient can usually go
home and carry out the treatment for himself, but he should be seen by
the surgeon at least once a week until complete healing has taken place.
If the graft has not taken uniformly over the surface of the bone, small
patches of granulations may be seen covering these areas. Under cocaine
anæsthesia these patches should be curetted. If the granulations recur
repeatedly, it means that there is some underlying carious bone, and
that healing will not take place until the tiny fragment is eventually
exfoliated.

=Results.= Statistics vary. There is no doubt that the results are
better according to the experience of the surgeon with regard to
grafting. If it be only applied in those cases in which it is certain
that all the diseased bone has been eradicated at the primary operation,
then the percentage of success with relation to failure is very high.
If, however, skin-grafting be adopted as a matter of routine, the
ultimate result is probably not so good as in a similar series of cases
in which grafting has not been done.

=Skin-grafting through the external meatus.= This has been advised
chiefly in order to avoid a second operation.

The technique of applying the graft is practically the same as that for
transplanting a large graft. The same care must be taken to get the
interior of the mastoid cavity aseptic and dry. To avoid a general
anæsthetic, the small grafts may be removed from the arm or leg under
local anæsthesia produced by a subcutaneous injection of Schleich’s
solution. The graft is transferred from a small spatula to the edge of
the meatus and then coaxed into position within the cavity by means of
probes. The grafts are kept in position by small pellets of cotton-wool
covered with gauze. If successful, the grafting may shorten the duration
of the after-treatment. It is not, however, so satisfactory a procedure
as applying a large graft directly through the post-aural wound.

In order to keep the grafts in position, Drew has suggested laying the
graft on sterilized gold-beater’s skin, and in this way applying it to
the interior of the mastoid cavity.

More recently, Stoddart Barr of Glasgow has introduced an ingenious
method of getting the grafts into position. The graft is manipulated
over the end of a suitably-bent glass tube, having attached to the other
end a piece of rubber tubing with a glass mouthpiece or small rubber
bag. The graft at the end of the tube is passed through a wide speculum
to the inner wall of the tympanum, when, by blowing air through the
tube, the graft is spread out over the inner surface, including the
tympanic walls, aditus, and antrum.


AFTER-TREATMENT OF THE CASE

_If the posterior wound has been closed._ Provided the temperature keeps
normal and there be no pain and no head symptoms, the first dressing
need not take place until the fifth or sixth day. By this time the edges
of the skin incision have usually united, so that the stitches can be
removed, although occasionally the wound may have to be opened up to
permit of drainage on account of septic infection. The withdrawal of the
gauze from the auditory canal may cause considerable pain, which,
however, can be prevented by continuous irrigation of the ear before and
during its removal (see p. 315).

After the gauze has been removed, the ear is mopped out with pledgets
of cotton-wool. To relieve the pain a few drops of a sterilized 1%
solution of cocaine may be instilled and left within the ear for a few
minutes.

Under good illumination, the largest possible speculum is inserted into
the meatal orifice. The cocaine solution is mopped out, and the cavity
dried, in order that careful inspection of the deeper parts may be made.
The chief point is to see that the flaps are in position. There may be
slight oozing from the surface of the wound, but as a rule the bone
appears almost white, owing to the fact that granulations have not yet
begun to form. The wound is then packed gently and evenly with gauze and
the ear protected again with an external dressing and bandage.

Until the first dressing has taken place, the patient should be kept in
bed. After this, provided the condition be satisfactory, he may be
allowed to get up for a few hours every day, the period being gradually
increased; by the tenth day or so he is practically well. In an
uncomplicated case there is seldom any shock or discomfort after the
operation, so that frequently the patient is anxious to be up and about
even before the first dressing has been performed. It is wiser, however,
to insist on rest for the first few days.

The subsequent dressings should be done every second or third day,
depending on the condition found. If the wound cavity be clean, and if
there be no odour, it is sufficient to irrigate it with a simple saline
or boric lotion. Granulations begin to cover the bone about the tenth
day, when there may be some purulent discharge necessitating daily
dressings. To keep the parts sweet, an ear-bath of hydrogen peroxide (10
vols. %) may be given, the ear being subsequently irrigated with a 1 in
5,000 solution of biniodide of mercury.

Provided the patient be doing well there should be no temperature, pain,
nor headaches. If any of these symptoms occur, or if the patient feels
ill, or has attacks of sickness and becomes drowsy, the surgeon should
at once be suspicious of some impending intracranial complication.

If the case be progressing favourably and all the diseased area of bone
has been completely removed, granulations do not become exuberant, but
form a fine smooth layer over the wound surface, the last portion to
become covered being the region of the external semicircular canal and
the ridge forming the remains of the posterior wall of the bony meatus.
Exuberant granulation tissue is significant of underlying bone disease.
If patches be observed, a 10% or stronger solution of cocaine should be
applied to the part, which should afterwards be curetted. This process
may have to be repeated on several occasions until, perhaps, a small
spicule of bone is removed, after which granulations usually cease. As a
rule the bone is completely covered with granulations by the fifth or
sixth week. Meanwhile, owing to the growth of epithelium from the edges
of the flaps, the raw surface within the wound cavity gradually becomes
smaller, and with this there is diminished secretion.

The gauze packing can usually be discontinued about this period, or
considerably earlier, perhaps even by the third week. In its stead an
aqueous solution containing 50% of rectified spirit with 10 grains of
boric acid to the ounce may be instilled into the wound cavity after it
has been cleansed and dried.

Complete cicatrization of the cavity should take place within two or
three months, depending on the size of the cavity.

_If the posterior wound has been left open_, the first dressing should
be done on the second or third day.

The subsequent treatment depends on each individual case. If the wound
has been left open on account of its septic condition, or owing to the
dura mater having been exposed and found covered with granulations, its
edges may be brought together by sutures after a period of ten days or
so, when the wound cavity looks clean, and the packing carried out
through the meatus.

On the other hand, if the wound has been left open on account of bone
disease involving the inner wall of the tympanic cavity or region of the
Eustachian tube, the packing should be continued through the posterior
opening until the patches of carious or necrosed bone heal or are
exfoliated. In these cases the granulation tissue tends to become
fibrous in character in consequence of the necessary curettings, and
eventually to form a thickened pad covering the inner wall.

After complete healing has taken place, the patient, before being
dismissed, should be warned to visit the surgeon at least once in three
months. Owing to the large cavity being lined with epithelium,
desquamation takes place to a greater or lesser extent, so that the
wound cavity may gradually become filled with masses of epithelial
débris or cerumen. In consequence the cavity may become septic, and on
removal of the epithelial débris underlying ulceration may be found.
This can usually be cured by aseptic treatment, but if granulations have
already occurred, curetting and the application of trichloracetic and
chromic acid may be necessary.


DIFFICULTIES AND DANGERS OF THE OPERATION

_Anatomical difficulties._ The chief difficulties are due to a middle
fossa overlapping the antral cavity, a lateral sinus projecting far
forwards and lying superficially, and a sclerosed mastoid having no
landmarks to indicate the way into the antrum. Unfortunately these
conditions are frequently associated.

Formerly it was advised that it was wiser not to proceed further if the
antral cavity could not be discovered after chiselling to a depth of
three-quarters of an inch. This advice, however, is no longer reliable,
as by the combination of the Stacke, Wolf, or Küster-Bergmann method any
anatomical difficulties should certainly be overcome.

An inexperienced operator may mistake a large mastoid cell for the
antrum and in this way may get into difficulties. The opening into the
antrum, however, can always be identified by passing a bent malleable
silver probe in an inward and forward direction into the aditus. If only
a large cell has been opened, the probe will show that it is a limited
cavity.

_Hæmorrhage._ In the majority of cases this is more of an inconvenience
than a danger, being chiefly due to a general oozing from the soft
tissues. It is, however, very necessary that the surgeon should have a
clear view of the deeper parts whilst operating. If he works blindly in
a pool of blood he courts disaster.

The hæmorrhage is best prevented by first curetting away any granulation
tissue and then packing the cavity firmly with a strip of gauze. If this
be not sufficient, it may be again packed with gauze containing
adrenalin solution. It will repay the surgeon to have a good assistant
to keep the field of operation dry. Troublesome bleeding, coming from a
small vessel in the bone, may be arrested by the local application of a
small fragment of Horsley’s sterilized wax (see Vol. I, p. 437).

_Wound of the lateral sinus._ This is a serious matter for two reasons:
firstly, it may prevent completion of the operation; and secondly, it
may lead to infection of the sinus.

If the sinus has already been exposed before the accident occurs, the
surgeon promptly arrests the hæmorrhage by placing the forefinger of his
left hand directly over the wound in its wall and exerts sufficient
pressure to completely obliterate the sinus at this point. With his
finger kept in this position, the wound cavity is carefully dried, and,
if there be sufficient room, a piece of sterilized gauze is then packed
between the bone and the outer wall of the sinus, both above and below
the site of the injury. If there be not enough room to do this, then the
surgeon with his right hand, or the assistant, should punch away more
bone by means of bone forceps. After the lumen of the sinus has been
obliterated above and below the injured area, the finger may be removed.
If the packing has been successful, there will be no bleeding; if there
be still slight bleeding, it can be controlled by further pressure. If
possible, this method should always be carried out, as it practically
excludes any chance of after-infection of the sinus.

If the injury takes place before the sinus has been sufficiently
exposed to permit of direct pressure with the finger, then the only
thing to do is to press in a small strip of gauze and plug the opening.
As to what should be done next is a matter of opinion. Some surgeons are
content to leave the gauze _in situ_. The author prefers to expose the
sinus further, as in the former case, and to make certain that it is
obliterated above and below the injured area. No doubt, if the injury be
slight, the pressure of the strip of gauze covering the puncture will be
sufficient to control the hæmorrhage, and the patency of the sinus may
be maintained on healing. At the same time infection of the sinus has
been known to take place, although the symptoms of this may not occur
for ten days or two weeks after the operation.

If the sinus projects far forwards the gauze plugs may so inconvenience
the operator as to prevent him completing the operation, which therefore
may have to be delayed for at least a week. If, however, the sinus be
injured at an early stage of the operation and the symptoms for which it
is being performed are urgent, then, in spite of all difficulties, the
antrum, at any rate, must be opened to permit of drainage, the operation
being completed at a later date.

_Injury to the facial nerve._ The nerve may be injured in any part of
its course within the tympanic cavity, or in its vertical course through
the stylo-mastoid canal. To avoid this injury, curetting of the tympanic
cavity should always be performed gently, and care should be taken not
to chisel too low down,--the usual fault of the inexperienced.

Twitching of the face means that the nerve has been touched. If the
patient be under deep anæsthesia, it is difficult to say whether the
nerve has been injured or divided. In a case of doubt, it is wiser to
discontinue the anæsthetic until the conjunctival reflex returns, when
it can easily be demonstrated whether the facial nerve is affected or
not.

If the injury be the result of curetting, it is wiser to do nothing.
Recovery almost invariably takes place, owing to the fact that the
paralysis has been caused by slight injury of the nerve. If, however,
the nerve has been chiselled through, and the injury has occurred in its
lower portion, it should be freely exposed over this area. The severed
ends of the nerve should then be approximated and left _in situ_. In
this case permanent paralysis is possible.

The after-treatment consists in avoidance of pressure in packing, the
giving of strychnine internally, and faradism or galvanism to keep up
the tone of the facial nerve and the muscles it supplies. Careful
testing of the electrical reaction will show whether nerve regeneration
is taking place or not. If the paralysis has existed for six months, and
if in addition there be a definite reaction of degeneration, then the
question of anastomosing the peripheral portion of the facial nerve to
the spinal accessory, or what is more advisable, to the hypoglossal
nerve, may be considered (see Vol. I, p. 452).

_Injury to the labyrinth._ Of the semicircular canals the external is
the more liable to injury. The cochlea may also be injured from violent
curetting of the promontory, or infected from dislodgment of the stapes;
or it may even happen that a careless operator may inadvertently chisel
through the promontory itself. In consequence of these accidents,
vertigo, vomiting, and nystagmus may persist for several days, but as a
rule they gradually diminish and disappear.

The treatment is expectant. As a result of pyogenic infection,
suppuration of the labyrinth may occur. Even if this does not take
place, complete deafness may result.

_Injury to the dura mater._ The subsequent danger is meningitis,
fortunately a rare occurrence. The immediate treatment is to irrigate
the part with weak biniodide of mercury solution, and then to remove
more bone over the site of the injury. The intracranial pressure will
keep the dura mater in close contact with the bone, so that if
subsequent infection occurs there will be free drainage. The site of
injury should be carefully isolated from the general mastoid wound
cavity by covering it with sterilized gauze. If signs of meningeal
irritation occur, the wound should be inspected, and if there be any
evidence of localized meningitis, it should at once be surgically
treated.


RESULTS OF THE OPERATION

=With regard to life.= If, at the time of the operation, the disease be
limited to the mastoid cavity, there should be no immediate danger to
life.

=With regard to recovery.= (i) _The operation is successful._ Roughly
speaking this occurs in at least 80% of the cases, complete healing
taking place within eight to twelve weeks. If skin-grafting has been
successfully performed the duration of healing may be considerably
shorter. If the bone disease has been eradicated with complete healing
of the cavity, the possibility of intracranial complications in the
future can be excluded. On this account the patient may be considered as
a healthy individual from an insurance point of view.

(ii) _The after-treatment may be prolonged._ The chief causes of delay
in healing and continuance of the suppuration are sepsis and caries of
some part of the bony wall, usually the promontory or floor of the
tympanic cavity, or around the orifice of the Eustachian tube. In the
former case the use of ear-baths of hydrogen peroxide or of rectified
spirit, or frequent syringing of the cavity with a weak biniodide of
mercury solution, and afterwards drying it and protecting it with gauze,
may be sufficient to effect a cure. In the latter case the local
condition must be treated.

Another condition delaying cure is reinfection from the throat through a
patent Eustachian tube. In this case, although the mastoid cavity
becomes lined with epithelium, mucous membrane may still cover not only
the region around the Eustachian orifice, but the main portion of the
tympanic cavity. The chief object in these cases is to close the orifice
of the Eustachian tube. Sometimes this can be done by curetting under
cocaine; in other cases by actual cauterization. After closure has been
obtained, the cavity should be dried and gently packed with gauze
impregnated with boric acid or aristol powder.

Again, cholesteatomatous formation may be the immediate cause of
relapses. In these cases it is very difficult to remove all the diseased
tissue. Even although the patient may apparently be cured, yet, unless
kept under close observation, recurrence of cholesteatomatous masses
take place, and frequently cause further caries of the underlying bone.

Finally, delay in healing may be due to careless after-treatment: if the
cavity has not been properly packed, granulations spring up in the
region of the aditus and gradually form a partition between the mastoid
and tympanic cavities. If this takes place, further disease of the bone
may occur owing to the retention of the secretion.

(iii) _Symptoms may occur pointing to some intracranial complication_,
and further operation may become necessary.

=With regard to hearing.= The hearing power depends not only on the
condition before operation, but also on the result of the
after-treatment. The average hearing power after the removal of the
malleus and incus is about 12 feet off for ordinary conversation. The
same result should be obtained after the complete mastoid operation,
provided there be no internal-ear deafness and provided the stapes be
not already ankylosed within the fenestra ovalis. If the patient before
operation hears conversation at a greater distance than 12 feet he
should be told that the hearing power may be reduced to this amount. If,
however, there be considerable deafness, due to polypi or granulations
blocking up the tympanic cavity and auditory canal, the hearing power
may be improved by the operation. The ultimate hearing depends on the
condition of the stapes within the fenestra ovalis: if it remains freely
movable, the hearing power may be extremely good. The great object,
therefore, of the after-treatment is to prevent the inner wall of the
tympanic cavity becoming covered with granulations which may become
organized later into a fibrous pad covering the inner wall of the
tympanic cavity, and thus prevent movement of the stapes and, in
consequence, marked deafness. The prevalent idea that the hearing power
is destroyed irrevocably, as a result of the complete operation, is
quite wrong: equally so is the harmful statement that, as a result of
this operation, complete restoration of the hearing can be obtained.




CHAPTER VII

OPERATIONS UPON THE LABYRINTH


GENERAL CONSIDERATIONS

Labyrinthine suppuration usually occurs in the course of a chronic
middle-ear suppuration; more rarely, as the result of tuberculous
disease of the temporal bone, or in consequence of an acute middle-ear
suppuration. In the latter case, however, it is a matter of experience
that, although symptoms of labyrinthine suppuration may be present, they
almost invariably subside as a result of drainage of the middle ear and
mastoid. This is an important point which should be remembered, as
otherwise the labyrinth may be explored unnecessarily at a considerable
risk to the patient’s life.

The most frequent paths of extension of the pyogenic infection from the
middle ear to the internal ear are through the external semicircular
canal, the promontory, and the fenestra ovalis, the result of
cholesteatomatous erosion, caries, or necrosis. Hinsburg, in 198 cases
of labyrinthine suppuration, traced the infection in 61 cases. In 27
cases the infection had entered through the external semicircular canal,
in 17 through the fenestra ovalis, in 7 through a fistula of the
promontory, in 5 through the fenestra rotunda and ovalis, and in 5
through a fistula in the posterior or superior semicircular canal
(_Archives of Otology_, 1902, vol. xxxi, p. 116).

Although operations on the labyrinth are practically limited to
suppurative disease, yet under certain conditions they are justifiable
when no suppuration is present.

These operations may consist in partial or complete opening of the
semicircular canals, or of the vestibule, or in removal of the cochlea,
or complete extirpation of the labyrinth.


INDICATIONS FOR OPERATION

(i) =In non-suppurative labyrinthitis.=

(_a_) _To relieve vertigo._ This operation is only justifiable if the
condition cannot be cured by other methods, and is so distressing as to
render the patient’s life unendurable.

In such cases it is first essential to make certain that the attacks of
vertigo originate from some lesion within the semicircular canals. For
this reason the other forms of vertigo must be excluded, and, in
addition, there should be evidence of definite involvement of the
labyrinth, such as falling over of the patient to the affected side,
internal-ear deafness, or post-suppurative changes within the middle
ear, suggestive that the internal ear has also become affected. It must,
however, be remembered that it is possible, though extremely rare, for a
lesion, limited to the semicircular canals, to produce marked vertigo
without any deafness being present, in which case the operation will be
limited to extirpation of the semicircular canals.

(_b_) _To relieve tinnitus._ If the tinnitus be unbearable and all other
measures have failed to cure it, the question of extirpation of the
cochlea, in order to destroy the nerve-terminals, may be discussed. This
operation, so far, has not been completely successful, and therefore it
cannot be recommended.

In this connexion it may be mentioned that, instead of attacking the
cochlea, it has been proposed to divide the auditory nerve before it
enters the internal meatus. Charles Ballance has recently described such
a case.

The difficulty of this latter operation and the very slight chance of
cure which it offers, owing to the tinnitus probably being central, are
sufficient to raise the question as to whether such an operation is
really justifiable.

(ii) =In suppurative labyrinthitis.= The object of the operation is to
remove the infective focus and, by permitting drainage, to prevent
further complications, such as meningitis or intracranial suppuration.

Before deciding the question of operation every means available should
be used to determine: (1) whether the symptoms are merely the result of
disturbance of the labyrinthine function in consequence of suppuration
still limited to the tympanic and mastoid cavities; (2) whether the
labyrinthine lesion is localized or general; (3) whether the
labyrinthine suppuration is associated with some intracranial
complication, more especially meningitis or cerebellar abscess.

Suggestive of labyrinthine suppuration are vertigo, vomiting,
spontaneous nystagmus, and disturbances of the equilibrium. In the more
acute cases there may be loud tinnitus, pyrexia, rapid onset of deafness
(with inability to hear high tuning-forks and loss of bone conduction),
facial paralysis, and deep-seated pain.

In addition much information may be gained by determining the character
of the _spontaneous nystagmus_, if present, or whether nystagmus can be
elicited by _Bárány’s caloric tests_.

(_a_) If the ear be normal, there is no spontaneous nystagmus.

If, however, the ear be syringed with water above or below the body
temperature, a rotatory nystagmus will be obtained if the patient’s
head is kept in the erect position, or a horizontal nystagmus if the
patient is lying in the horizontal position with the face upwards.

Syringing with hot water causes a nystagmus directed _towards_ the ear
syringed; syringing with cold water, _away from_ the ear.

(_b_) If there be a localized labyrinthine lesion, and the function of
the labyrinth is still maintained, the same results will be obtained on
syringing. Care, however, must be taken that the syringing is not
forcible, otherwise the caloric tests will be unreliable, as in these
cases nystagmus may be produced on even slight increase of pressure
within the external auditory canal, and with this there may be a
sensation of giddiness and nausea.

Spontaneous nystagmus, however, will probably be present, and will be
directed towards the affected side. This spontaneous nystagmus is
greatly modified by the caloric tests, being strongly exaggerated on
syringing with hot water, and weakened or arrested on syringing with
cold water.

(_c_) If the function of the labyrinth be destroyed, as in suppurative
labyrinthitis, nystagmus will not be produced as a result of the caloric
tests, but the spontaneous nystagmus, if present, will be directed
towards the opposite, the normal side.

These various tests must be taken in combination with the symptoms, and
frequently are of extreme value in deciding whether operation is
indicated or not.

The chief difficulty is to exclude the possible existence of a
cerebellar abscess (see p. 460). In favour of labyrinthine inflammation
is complete internal-ear deafness, although this in itself does not
exclude an accompanying intracranial lesion.

1. _Immediate exploration of the labyrinth is indicated_ (provided there
is internal-ear deafness):--

(_a_) If symptoms of _acute_ labyrinthine suppuration occur in the
course of a middle-ear suppuration, even although at the time of opening
of the mastoid no definite fistula of the labyrinthine wall can be
discovered.

(_b_) If symptoms of involvement of the labyrinth be present and a
definite fistula is found on operation.

(_c_) If symptoms of a cerebellar abscess or of meningeal irritation be
present in addition to those suggestive of a labyrinthine affection.

2. _Opening of the labyrinth should be delayed_ if Bárány’s and other
tests show that the labyrinth is not yet destroyed:--

(_a_) If, in spite of clinical symptoms pointing to involvement of the
labyrinth, pus be found under tension within the tympanic cavity or the
mastoid process.

(_b_) If the symptoms before operation consist only of attacks of
vertigo and nystagmus, and on operation merely an erosion of the outer
wall of the labyrinth (usually the external semicircular canal) is
discovered.

In the above cases, if the symptoms be due to irritation of the
labyrinth, a rapid recovery is to be expected as a result of the mastoid
operation. If, however, they continue or become progressively worse,
then the wound cavity must be reopened and the labyrinthine wall
carefully examined and further operation undertaken.

The reader may again be reminded that although exploration of the
labyrinth is indicated when it is certain that a suppurative lesion
exists, yet it is a very serious mistake to open up a labyrinth not yet
infected.

Although a great advance has been made in the last few years with regard
to operations on the labyrinth, yet there is still much to be learnt,
not only with regard to the indications for operation but the result
obtained by operation. Now that operations on the labyrinth have become
universal, the general tendency is to operate on the immediate
occurrence of symptoms of labyrinthine irritation without waiting to see
whether simple opening of the mastoid process will not be sufficient--a
matter much to be regretted.

=Surgical Anatomy.= The facial canal, it will be remembered, extends
horizontally backwards above the promontory, and passes downwards
superficially to the inferior portion of the vestibule which lies
between the fenestra ovalis below and ampullary ends of the external and
superior semicircular canals above. The nerve then extends directly
downwards towards the stylo-mastoid foramen, being situated deeply
within the posterior meatal wall.

Of the semicircular canals the external is the most prominent, and the
only one visible during the performance of the ordinary mastoid
operation; its outer border forms the inner and lower boundary of the
aditus, and can usually be recognized as a white eminence. The superior
semicircular canal can only be seen on careful removal of the overlying
bone; its ampullary end is found lying just above that of the external
canal. It forms the highest point of the labyrinth, becoming fused with
the innermost portion of the tegmen tympani, and is in such close
relationship with the upper surface of the petrous bone as to cause a
smooth elevation on its surface. It is at this point in the operation of
removal of the semicircular canal that the greatest risk is encountered
of breaking through the petrous bone and of injuring the dura mater.

The posterior semicircular canal lies at right angles to the external
canal, and is best exposed by careful removal of bone just posterior to
the latter (see Fig. 240).

The outer half of the first whorl of the cochlea is formed by the
promontory. Anteriorly it is in close relationship with the carotid
canal, whilst below it lies the dome of the jugular fossa. Medially the
modiolus is only separated from the internal auditory meatus by a very
fine rim of brittle bone, which can easily be broken; a mishap which may
permit of escape of the cerebro-spinal fluid, and also of possible
infection of the meninges through the internal meatus.


METHODS OF OPERATING

These operations may be divided into: (1) simple curetting away of a
localized lesion of the labyrinthine wall; (2) opening up of the
vestibule with removal of the semicircular canals; (3) opening of the
cochlea; (4) a combination of these methods--extirpation of the
labyrinth.

=Curetting away of a localized lesion of the labyrinthine wall.= It has
been already stated that, provided the labyrinth be not yet destroyed,
it is not justifiable to explore it on the mere discovery of an erosion
of the semicircular canal. At the same time, if a definite fistula from
which granulations protrude is present, a small fragment of bone may be
chipped away, the granulations being afterwards removed by the curette.
Unless pus is found to exude from the labyrinth, it is not necessary to
do anything further at the present moment. If, however, at a later
period, symptoms of labyrinthine infection occur, then it is necessary
to further explore the semicircular canal and vestibule, the extent of
the operation depending on what is discovered at the time of the
operation.

Sometimes an examination of the tympanic cavity may be prevented before
operation owing to the auditory canal being filled with polypi or
granulations. On performing the complete mastoid operation and curetting
away these granulations and polypi, a fistula may be found in the
promontory, and carious bone may be felt on probing. Not infrequently
these cases are tuberculous in origin and are accompanied by facial
paralysis. Provided there be no labyrinthine symptoms, it is sufficient
to curette out the granulations, but only gently. Violent curetting may
break through the barrier between the infected area and the internal
meatus and so lead to meningitis. It is wiser to curette too little than
too much.

A further condition which may be met with is necrosis of a portion of
the promontory, or of the walls of the vestibule, or of the semicircular
canals. If the sequestrum be not quite loose at the time of operation,
it should be left _in situ_, provided there be no intracranial symptoms.
In fact, there is less danger in leaving the sequestrum than in
attempting to remove it. After the operation, the wound cavity is kept
open, so that the sequestrum can be removed at a later date after it has
separated from the living bone.

=Opening the vestibule= (with partial or complete removal of the
semicircular canals). This may be performed by one of the following
methods:--

_Above and behind the facial nerve through the semicircular canals._ The
complete mastoid operation is performed first. The chief difficulty is
to expose the field of operation so as to obtain sufficient room for the
necessary manipulations. To do this the following steps should be
carried out: The tip of the mastoid process and the remains of the
posterior wall of the auditory canal are removed to their extreme limit
without injury to the underlying facial nerve. The floor of the auditory
canal is also chiselled away until the lower level of the tympanic
cavity is brought freely into view, the amount of bone removed depending
on the anatomical condition found. To expose the anterior portion of the
tympanic cavity, the skin incision is extended slightly forwards, but
not far enough to wound the temporal artery, the soft tissues being then
separated from the bone and the auricle pulled still further forwards
and downwards.

Skin meatal flaps are now fashioned--either the Y-shaped flap or
Stacke’s flap (see p. 403)--and are afterwards kept in position by means
of sutures. Good illumination is necessary, and for this reason a
head-light should be used. One assistant is employed to retract the soft
tissues from the wound, another to keep it as dry as possible.

The exposed portion of the external semicircular canal is first
identified. If the bone be soft, the arches of the semicircular canal
should be defined (Fig. 240). The posterior canal will be discovered by
gouging away the bone just posterior to the arch of the external
semicircular canal, and the superior, by working inwards and upwards
towards the roof of the attic. If the outline of the canals can be made
out, the further steps of the operation are rendered very much easier.
Unfortunately, the bone is sclerosed in the majority of cases, rendering
anatomical exposure of the canals an impossibility.

The next step is to remove the eminence of the horizontal semicircular
canal. This is best done by means of a small gouge and mallet. Some
prefer a burr, specially constructed to cut vertically; others a chisel.
I prefer a fine gouge. As the facial canal runs along the lower anterior
portion of the external semicircular canal, the gouge should be directed
in a backward direction in removal of the outer wall of the latter, so
as to cut away from the facial canal.

The surgeon should be content to remove the bone piecemeal, as, owing to
its brittleness, it is very apt to splinter, or the point of the gouge
itself may slip and so injure the facial nerve.

After an opening has been made into the canal, it should be enlarged by
following the canal forward until its ampulla is reached. After this has
been done, a fine probe, bent at a right angle (Schwartze’s seeker will
do very well), is passed into the opening, and the limits of the
vestibule made out as far as possible. The bone is then removed in an
upward direction until the ampulla of the superior canal is reached. The
opening may then be extended backwards so as to remove the outer wall of
the vestibule, that is, the portion of bone which lies between the
ampullæ of the superior and external canals.

If the bone be sclerosed, so that it is impossible to find the superior
and posterior canals, then, after opening the exposed portion of the
external semicircular canal, the bone should be chiselled away at the
area marked out in Fig. 240. By this means the vestibule will certainly
be reached, and from this point its opening can be extended in any given
direction. A sufficient opening should be made so that the inner portion
of the vestibule can be seen (Fig. 241). During each step of the
operation a clear view must be obtained.

[Illustration: FIG. 240. DIAGRAM TO SHOW EXPOSURE OF THE SEMICIRCULAR
CANALS. The ‘black ring’ shows the area at which the semicircular canals
and vestibule may be opened.]

Not infrequently the facial nerve is exposed or pressed upon in chipping
away the outer wall of the external semicircular canal, as will be shown
by sudden twitchings of the face. If the surgeon be careful, and works
in a direction away from the nerve, it should not be injured. If
possible, the outer margin of the horizontal semicircular canal,
together with the Fallopian canal, should be left intact as a bridge
crossing the vestibule. If necessary, the external and superior canals
can be removed in their entirety. A fine probe is inserted into the
lumen of the canal so as to tell its direction, and its outer wall is
then burred away. For this particular purpose a burr should be used as
soon as the surgeon has got beyond the region of the facial nerve. After
a view of the interior of the vestibule has been obtained, the ampullary
nerves may be destroyed by means of the curette or with pure carbolic
acid at the end of a probe. Removal of the posterior canal is best
effected by opening it just behind the external semicircular canal and
following it out in an upward direction until it meets the superior, and
then downwards until it enters the vestibule. This extensive operation
is one of extreme difficulty and seldom necessary.

_Posterior to the semicircular canals: Neumann’s method._ Neumann enters
the vestibule posteriorly. The bone forming the inner wall of the antrum
is removed by means of bone forceps or gouge and mallet until the
posterior semicircular canal is opened. By this means the posterior
surface of the petrous bone can be exposed as far inwards as the
internal auditory meatus.

_Below and anterior to the facial nerve through the promontory._ The
preliminary steps of the operation having been performed and the field
of operation freely exposed, the stapes, if still present, is extracted
by means of a small hook passed between its crura. The bridge of bone
between the fenestra ovalis and fenestra rotunda is then cut through by
light taps on a very fine gouge. The bone is removed by attacking the
lower limit of the fenestra ovalis, and working downwards until the
fenestra rotunda is reached. With a fine curette or scoop the loosened
fragments of bone are removed. Care must be taken not to work above the
region of the fenestra ovalis or the facial nerve will probably be
injured. After a sufficient opening has been made, a bent probe can be
passed through the opening in the promontory in an upward and backward
direction behind the facial nerve into the inferior and anterior portion
of the vestibule (Fig. 241).

[Illustration: FIG. 241. OPERATION UPON THE LABYRINTH. To show the
opening into the vestibule above the facial nerve with partial or
complete removal of the semicircular canals. The arrow passes behind the
facial canal between the vestibule and the fenestra ovalis.]

=Removal of the cochlea.= If necessary, the first turn of the cochlea
can now be removed by gouging away the promontory from behind forwards.
If the anterior wall of the external auditory canal interferes with this
being done, it may be partially removed by means of the gouge and
mallet. After the first half-turn of the cochlea has been opened, its
contents may be curetted out, care, however, being taken to avoid the
carotid canal, which lies in close relationship with its anterior
inferior portion. If the bone be carious only gentle curetting is
necessary. If, however, this be not the case, simple curetting may not
be sufficient, and the gouge and mallet may have to be used. To destroy
the cochlear nerve, the whole of the cochlea should be removed. This is
sometimes a difficult matter to determine. If the operation be done for
the relief of tinnitus, then, after as much as possible of the cochlea
has been removed, the interior may be swabbed out with strong carbolic
acid solution, which should set up sufficient inflammatory reaction to
destroy the nerve-terminals.

[Illustration: FIG. 242. EXTIRPATION OF THE LABYRINTH. The vestibule is
freely opened and the greater portion of the semicircular canals and
cochlea is removed.]

=Extirpation of the labyrinth.= This consists in the removal of the
semicircular canals, and opening of the vestibule and cochlea, the steps
of which have already been described in the above operations.

Before the operation is completed, the inner wall of the vestibule and
the cochlea should be carefully examined for fistulæ, and in order to
see if any pus enters these cavities from within. If this be the case it
means that, in addition to labyrinthine suppuration, there is presumably
an extra-dural abscess of the posterior intracranial fossa, drainage of
which is essential in order to obtain a recovery.

After the operation has been completed, the cavity should be filled with
hydrogen peroxide, then gently syringed out with weak biniodide
solution, and finally dried and lightly packed with sterilized gauze.

Even although the operation may have been performed in a
non-suppurative case, it is wiser to leave the posterior wound open for
the first few days in order to permit of free drainage.

=After-treatment.= If the suppuration has been limited to the internal
ear, a successful result may be expected if the symptoms subside rapidly
as a result of the operation. If there be complete destruction of the
labyrinth before operation its performance should give rise to no
symptoms of shock nor further disturbance of equilibrium.

In the majority of cases, however, owing to the nerve-terminals being
still in a state of activity, the irritation set up as a result of the
operation may cause increased attacks of nystagmus, vertigo, and
vomiting. The vomiting is the first symptom to disappear, and then the
nystagmus; but complete recovery of equilibrium may not occur for a
considerable period, during which time the patient, though otherwise
well, may still have a slightly staggering gait.

If the operation has been limited to the external semicircular canal,
and the hearing power still exists, the after-treatment should be
carried out as already described in the complete mastoid operation. If,
on the other hand, the cochlea has been interfered with, or if it be
certain that there is no longer any hearing power, then there is no
object in trying to preserve the patency of the tympanic cavity, which
in this case may be allowed to granulate up from its depth like an
ordinary surgical wound.

The immediate anxiety of the surgeon after the operation is the possible
onset of meningitis or the presence of a cerebellar abscess, which will
necessitate further operation unless otherwise contra-indicated (see p.
460).

=Comparison of the operations.= Opening of the vestibule above the
facial nerve is limited to those cases in which the lesion is situated
within the semicircular canals and to the posterior portion of the
vestibule; that is, either in non-suppurative cases in which the
operation is performed in the hope of curing vertigo, or in suppurative
cases in which the function of hearing still exists.

Opening of the vestibule below the facial nerve is to be preferred as a
rule, especially if the function of hearing is already destroyed,
because it permits of drainage from the inferior part of the vestibule;
in addition, by working forwards, the outer wall of the cochlea can be
removed and any disease within it can be tracked out to its limits.

If there be suppuration within the cochlea, sufficient drainage will not
be obtained by merely opening the vestibule through the semicircular
canals, but the cochlea itself must be opened. Again, if the lower
portion of the vestibule and cochlea be first explored and found filled
with purulent secretion, it is wiser to complete the operation by also
opening the vestibule from above,--that is, to completely extirpate the
labyrinth, which is now functionally useless and almost certain to be
infected throughout its whole extent.

=Intracranial complications.= If, in addition to the labyrinthine
suppuration, intracranial suppuration be suspected, the labyrinth should
be explored first; but when possible the operation should be arrested at
this point to see if the symptoms subside. If they continue, the
exploration of the intracranial cavity can then take place through the
internal ear, after a delay of twenty-four hours or more.

Of the intracranial complications, meningitis is most frequent, and next
in order cerebellar abscess. In addition, thrombosis of the bulb of the
jugular vein may take place from infection through one of the smaller
tributary veins; or a localized extra-dural abscess may be found
situated along the posterior portion of the petrous bone in consequence
of direct extension of the infection through the internal auditory
meatus, or as a result of empyema of the endolymphatic sac. This latter
condition is almost impossible to diagnose, but may be discovered
accidentally if the vestibule is opened by the posterior route according
to Neumann’s method.

=Difficulties.= The chief difficulties are anatomical, and the inability
to obtain a clear view owing to general oozing of blood.

The first is generally due to insufficient removal of bone; the second
can usually be controlled by means of good assistants and the frequent
employment of hydrogen peroxide or of adrenalin solution.

=Dangers.= _Injury to the facial nerve._ This, as might be expected, is
not infrequent. If a burr be used, the nerve may be completely torn
across and permanent paralysis may result. If, however, the gouge and
mallet be employed, complete recovery usually takes place, as the injury
seldom consists in complete destruction of the nerve.

_Opening up of the internal meatus._ This may be accompanied by a gush
of cerebro-spinal fluid. There is nothing to be done except to try and
keep the part as clean as possible and see that there is free drainage.
Undoubtedly, as a result of this mishap, death has afterwards occurred
in consequence of septic meningitis.

_Injury to the internal carotid or bulb of the jugular vein._ These are
possibilities which, however, should not occur if ordinary care is
taken.

=Prognosis.= The prognosis of labyrinthine suppuration is always grave,
owing to the frequency of intracranial complications.

The most favourable cases are those in which the disease is localized
and is of chronic duration. The most unfavourable are those in which
acute suppurative labyrinthitis is accompanied by extensive bone
disease.

According to statistics, the mortality is about 50% in cases not
operated upon. As a result of operation, this has been reduced to less
than 20%, and in the majority of these cases the ultimate fatal result
cannot be put down to the operation itself. The patient is frequently
seen too late, that is, after intracranial complications have already
occurred. There is no doubt that the death-rate will diminish
proportionately according as the necessity of operating early becomes
more and more recognized.

With regard to hearing, extensive operations upon the labyrinth lead to
complete deafness; nor, indeed, can recovery of hearing be expected
except in those cases in which the disease and operations have been
limited to the semicircular canals and to the posterior portion of the
vestibule, and even then recovery of hearing is exceptional.




CHAPTER VIII

OPERATIONS FOR EXTRA-DURAL ABSCESS AND MENINGITIS OF OTITIC ORIGIN


ON INTRACRANIAL COMPLICATIONS IN GENERAL

As the intracranial complications of otitic origin are due to direct
extension of the pyogenic infection through the temporal bone to the
cranial cavity, it follows that they will depend on the extent of the
disease within the temporal bone, the direction in which it has spread,
and the virulence of the infection. For this reason, also, the site of
the intracranial lesion is always in close relationship with the area of
the diseased bone. Thus, if the infection spreads upwards through the
attic and tegmen tympani, it may lead to extra-dural abscess or to
meningitis of the middle fossa, or to a temporo-sphenoidal abscess.
Similarly, disease of the mastoid cells posteriorly may give rise to a
perisinuous abscess, to meningitis of the outer surface of the posterior
fossa, to lateral sinus thrombosis, or to a cerebellar abscess situated
superficially and involving the outer portion of its lateral lobe just
behind the lateral sinus; or caries of the floor of the tympanic cavity
may give rise to thrombosis of the jugular bulb; or internal-ear
suppuration to an extra-dural abscess occupying the posterior surface of
the petrous bone, to meningitis of the posterior fossa, or to an abscess
of the cerebellum deeply placed in its anterior inferior angle.

Operation is always imperative unless the patient is seen too late and
it is obvious that the condition is hopeless.

Before operation is decided on the following points must be carefully
considered: (1) Is it possible that the symptoms simulating the
intracranial lesion are due to suppuration still limited to the temporal
bone? (2) What is the character of the lesion? and (3) What is its
situation?

As a rule, so long as the suppurative process is limited to the middle
ear and to the mastoid region, the symptoms are those of a local septic
infection. At the same time it must be remembered that in infants and in
young children it is not uncommon for retention of pus within the middle
ear to produce a clinical picture closely simulating an intracranial
suppurative lesion. The ear, therefore, should always be inspected in
every case. Sometimes a bulging membrane is discovered or the existing
perforation is found to be insufficient for drainage. In such cases the
symptoms may subside on free drainage being obtained by the simple act
of paracentesis of the tympanic membrane.

If, however, free drainage already exists, the mastoid operation should
be performed at once.

If the intracranial symptoms be still somewhat indefinite, and there is
no apparent urgency, the intracranial cavity should not be explored
immediately unless this is found to be imperative at the time of
operation. This can be done later, if the symptoms do not subside.

Although exploration of the intracranial cavity is always urgent when it
is certain that an intracranial suppurative lesion is present, yet to
explore with a negative result is a grave misfortune, owing to the
possibility of infecting the intracranial cavity.

Although the surgeon may be certain that an intracranial lesion is
present, yet it may be very difficult to determine its character or
whether several lesions coexist. The surgeon must therefore be prepared
to act according to what he finds at the time of operation.

Thus, if exploration of the temporo-sphenoidal lobe be negative, and yet
the cardinal symptoms point to an intracranial abscess, the cerebellum
must also be explored. Again, if the diagnosis of intracranial abscess
be doubtful before operation, and if, during the operation, lateral
sinus thrombosis be discovered, it is wiser to limit the operation to
tying of the jugular vein and removal of the septic thrombus. The bone,
however, should be removed above and behind the sinus so as to expose
the dura mater covering the temporo-sphenoidal lobe and the cerebellum.

In such cases, if the symptoms of intracranial suppuration still
continue, it is an easy matter to explore the temporo-sphenoidal lobe or
cerebellum at a subsequent operation.

Although under exceptional circumstances (see p. 461) it may be
justifiable to open an intracranial abscess by directly trephining the
skull over it, yet free opening of the mastoid process should be the
first step in the operation, as the primary focus of the disease exists
within the temporal bone. In addition, much information may thus be
gained in a doubtful case with regard to the situation of the
intracranial lesion.


OPERATIONS FOR EXTRA-DURAL ABSCESS

This is far more common as a sequel of acute than of chronic disease of
the mastoid process.

=Indications.= Operative interference is indicated in order to permit of
drainage. An extra-dural abscess is frequently discovered accidentally,
especially if the surgeon follows out the golden rule to trace any patch
of carious bone to its limit. In doing so he may suddenly meet with a
gush of purulent discharge coming through an opening in the bone in the
region of the tegmen tympani or sigmoid sulcus.

Although an extra-dural abscess may give rise to no special symptoms,
the following are suggestive:--

1. If, in spite of opening up the mastoid cells and antrum, pyrexia and
headache persist, especially if the headache be localized to the
affected side and accompanied by tenderness on pressure above the ear or
behind the mastoid process.

2. If, before operation, there be a very profuse discharge from the ear,
apparently too copious to come from the tympanic cavity or mastoid
antrum.

3. In children an extra-dural abscess may give rise to symptoms of
cerebral irritation or compression if it extends upwards from the tegmen
tympani along the parietal region; or, if situated in the posterior
fossa, to retraction and stiffness of the neck.

Although such symptoms may be also associated with an intracranial
abscess or meningitis, yet, if on exploration of the intracranial cavity
a large extra-dural abscess be discovered, further operation may be
postponed (unless its extension is obviously necessary) until time is
given to see whether the symptoms will subside or not.

=Operation.= If the mastoid process has not been opened already, the
simple or the complete operation is performed, according to whether the
suppuration is recent and acute, or is of long standing.

If, however, this has been done, the wound is reopened, all granulations
are curetted away, and the cavity is cleansed and dried.

The antrum and mastoid cavity are then thoroughly examined. If a fistula
in the bone already communicates with the abscess, pus may be seen to
ooze through it. If not, careful search is made for any carious tract of
bone, which is now followed up until the dura mater is reached.

After the pus has drained away more bone is removed so as to expose the
dura mater fully over the infected area, which is usually vascular or
covered with granulations. The latter, however, should be left severely
alone. If the abscess be situated in the middle fossa above the tegmen
tympani, the bone is best removed by chiselling upwards until the lower
margin of the squamous portion of the temporal bone is reached. Then,
with a pair of bone forceps, more bone can be punched away quickly until
a sufficient opening is obtained (Fig. 243).

Exploring with the probe and curetting away of granulations should be
avoided as far as possible for fear of injuring the sinus. If its wall
be already inflamed, it may be torn through, and the resulting
hæmorrhage may render the further steps of the operation a matter of
extreme difficulty.

Before completion of the operation, a blunt-pointed seeker should be
passed round the edge of the opening in the bone to see that its margin
is smooth and even, and all sharp edges of bone bordering on the dura
mater should be removed. If this precaution be neglected, a splinter may
get pressed inwards and injure the dura mater, and thus set up
meningitis.

If possible the bone should be removed until the healthy dura mater is
reached. If the extent of the abscess prohibits this, its limits,
however, should be ascertained. This can be done by pressing the dura
mater inwards with a spatula so as to separate it from the overlying
bone.

The final step is to irrigate the cavity with warm boric or saline
solution and to insert drains of gauze or of fine india-rubber tubing
between the dura mater and bone. The wound cavity is then lightly packed
with gauze and a simple dry dressing applied.

=After-treatment.= Provided there be no other intracranial symptoms,
recovery should be as rapid as in the case of simple inflammation of the
mastoid process. In the after-dressings, however, special care should be
taken not to press in the gauze roughly or tightly against the still
inflamed dura mater, in case of injuring its surface and causing further
extension of the pyogenic infection to the meninges or lateral sinus.
The dressings should be changed daily. It is sufficient to irrigate the
wound with some mild aseptic lotion and afterwards to repack it lightly.
If Schwartze’s operation has been performed, the after-treatment is
similar to that already described (see p. 387). In the case of the
complete operation, after the purulent discharge has practically ceased
and the surface of the wound appears healthy, the packing of the cavity
may be carried out through the meatus, instead of through the posterior
wound, the latter being then allowed to close.

=Intracranial complications.= Infection of the lateral sinus is the most
frequent complication, but meningitis, ulceration of the surface of the
brain, or intracranial abscess may also occur.

One or more of these complications may already exist at the time of
operation, but may not be sufficiently marked to warrant further
exploration of the intracranial cavity. It is wiser, therefore, to give
a guarded prognosis during the first few days after the operation, not
only with regard to recovery, but also to the possibility of further
operative procedures becoming necessary.


OPERATIONS FOR MENINGITIS OF OTITIC ORIGIN

Formerly the onset of symptoms of meningitis was a distinct
contra-indication to operation. More recently, however, this view has
become modified, especially as it has been shown definitely by Macewen,
Jansen, Brieger, and others that recovery is possible if operation is
undertaken sufficiently early before the inflammation of the cerebral
membrane has become diffuse.

In this connexion must be mentioned--(1) Serous meningitis: a name given
to an increase of the cerebro-spinal fluid within the subdural or
subarachnoid space, or the ventricles, the hypersecretion being probably
caused, as Merkens suggests (_Deutsche Zeitsch. für Chir._, vol. lix),
by the toxic infection induced by the suppurative focus in contact with
the external surface of the dura mater. The symptoms of serous
meningitis may closely simulate an intracranial abscess or a purulent
meningitis, except that frequently there is no pyrexia. (2) Purulent
meningitis, which may be diffuse or localized. (3) Pseudo-meningitis:
that is, a condition simulating meningitis but in reality due to
irritation of the meninges as a result of suppuration still confined
within the temporal bone--for example, the result of acute middle-ear
suppuration in infants.

Clinically it is often difficult to determine before operation which
variety is present.

=Indications.= Operation is indicated as soon as the onset of meningitis
has been diagnosed and should be performed without delay. Waiting for
all the cardinal symptoms of meningitis to occur will never save life.
The only possibility of doing so is to operate while the inflammatory
process is still localized. At the same time it must be recognized that
whenever symptoms of meningitis occur the prognosis is most serious.

Lumbar puncture should always be performed as an aid to diagnosis. If
the cerebro-spinal fluid be clear and sterile, diffuse meningitis can
usually be excluded, although at the same time it must be remembered
that it does not negative a localized meningitis without increased
intracranial pressure. Increased flow of cerebro-spinal fluid indicates
increased intracranial pressure, perhaps the result of serous
meningitis. Slight turbidity suggests early purulent meningitis,
especially if bacteria are present, but not necessarily that the case is
hopeless. If the fluid be definitely purulent, operation may be
considered out of the question; a case, however, has been recorded in
which recovery took place.

The value of cytological examination of the fluid is still doubtful.
Marked increase of polynuclear cells is said to point to acute and
intense inflammation, whereas an abatement of the polynucleosis may be
taken as a sign of diminution of the meningeal irritation. With this,
increased leucocytosis, increasing as recovery progresses, may be looked
upon as a hopeful sign.

If it be obvious that the patient is dying, not only from the local
infection but also on account of general septic absorption, operation,
of course, is excluded. Similarly, at the present time, post-basic
meningitis of infants is rightly deemed inoperable.

=Operation.= Although no set operation can be described, the principles
of the operation are to expose the infected area widely so as to allow
of free drainage and, at the same time, to relieve intracranial
pressure. The extent of the operation will therefore depend largely on
what is found during the course of the operation itself.

1. In an infant or young child, if the symptoms develop in the course of
an acute otitis media, the tympanic membrane should first be inspected
to see if there is sufficient drainage. If not, it should be freely
incised, and opening of the antrum and mastoid may be delayed for at
least twelve hours.

2. In an adult, immediate exploration of the mastoid and antrum is
indicated on the onset of meningeal symptoms, even although they occur
during the course of an _acute_ middle-ear suppuration.

If the symptoms of meningitis in these cases be as yet indefinite, and
if pus be found under tension within the mastoid cavity, or if an
extra-dural abscess exists, the dura mater should not be incised at
once, but a delay of twenty-four hours should be advised; in many cases
complete recovery will take place. If, however, the symptoms continue,
intracranial exploration will be necessary.

3. In chronic middle-ear suppuration, meningitis is usually secondary
to, or accompanies, other intracranial complications or internal-ear
suppuration, the symptoms of which it may mask.

After performing the mastoid operation any tract of carious bone is
followed out to its limits.

According to what he finds, the surgeon may first expose the dura mater
covering the lower portion of the middle fossa (Fig. 243), or of the
posterior fossa behind and in front of the lateral sinus; these are the
usual sites of infection. The removal of bone must be free, in order to
get well beyond the limits of the infected area, if possible. The dura
mater is incised to the limits of its exposure either crucially or by
cutting it through in the form of a large flap.

The dura mater is usually congested, but if an extra-dural abscess or
lateral sinus thrombosis be present, it may be thickened and of a
leathery appearance; or in the latter case almost gangrenous.

The further steps depend on the conditions met with on incision of the
dura mater.

[Illustration: FIG. 243. METHOD OF REMOVAL OF BONE BY THE FORCEPS. In
this instance the bone is being removed above the tegmen tympani in
order to expose the lower portion of the middle fossa.]

1. _In serous meningitis_ a certain amount of clear fluid may escape and
the brain surface may be only slightly congested. After removal of the
bone and of the dura mater over the infected area the surface of the
brain should be scarified in various directions to make certain that the
pia-arachnoid has been incised, and fine drainage tubes should be
inserted between the latter and the dura mater. In these cases a hernia
seldom occurs, although the brain surface may bulge slightly into the
wound.

2. _In purulent meningitis_ the surface of the brain is usually covered
with turbid fluid or purulent lymph, which may be localized to the site
of the diseased bone, or may have spread from this point to a varying
extent over its surface.

If the limit of the infection cannot be reached, in spite of removal of
a considerable extent of bone and dura mater, all that can be done is to
irrigate the exposed area with warm saline solution and to insert fine
drainage tubes between the brain and dura mater, at the same time (as
in the case of serous meningitis) incising the meninges in various
directions.

3. _Purulent lepto-meningitis_ is usually accompanied by encephalitis.
If localized by adhesions an accumulation of pus may occur, forming an
abscess on the surface of the brain, which also may be superficially
ulcerated or necrosed. If there be intracranial pressure from
encephalitis, the brain tissue usually protrudes as a dark, hæmorrhagic
friable mass, in which shreds of necrotic brain tissue will be seen. In
other cases, if there be no increased intracranial pressure and if the
condition be quite localized, no hernia may occur, but the surface of
the brain may be rough or eroded.

Any purulent secretion should be removed by irrigation, care being taken
not to disturb the brain more than is necessary, so as to diminish the
risk of breaking down the surrounding adhesions. A hernia may or may not
form immediately. If no hernia takes place, it is wiser to do nothing
further; that is, provided sufficient bone and dura mater have been
removed to reach the limits of the infected area. Some authorities,
however, consider that the necrosed portion of the brain should be
curetted out. Although in other parts of the body the removal of
necrosed tissue is a proper procedure, yet in the case of the brain
there is considerable risk of setting up further œdema or septic
cerebritis, the progress of which may have become arrested at the time
of the operation.

If the inflamed brain tissue protrudes to an excessive degree during the
operation itself, the opening in the skull should be enlarged, if it be
not already of considerable magnitude, and the dura mater incised to the
full limits of the opening. The protruding mass may then be cleanly
excised by means of a scalpel. If, however, the brain tissue continues
to prolapse, the wound cavity should be simply cleansed and protected by
a dressing of sterilized gauze. If the encephalitis subsides, the hernia
will not increase in size, and if the wound cavity be kept aseptic, it
may gradually shrink.

=After-treatment.= This consists in covering the wound surface lightly
with gauze so as to permit of free drainage, and changing the dressing
as often as may be necessary.

In serous meningitis a large quantity of cerebro-spinal fluid may
escape, and the dressings must be changed frequently. If recovery be
going to take place, the temperature gradually becomes normal and the
symptoms of meningitis disappear. In involvement of the posterior fossa,
the head retraction gradually diminishes and after a few days free
movement is noticed. Adhesions form rapidly, binding together the
surface of the brain, meninges, and the overlying bone. For this reason
the drainage tubes, already inserted between the dura mater and brain,
can be removed within a day or two. The exposed dura mater usually
becomes covered with granulations from which a certain amount of
purulent discharge may be secreted. The duration of the after-treatment
depends on the extent of the operation and the size of the wound.
Eventually the skin flaps grow together and cover the brain, which
afterwards may be felt pulsating through the scar. In these cases it is
usually necessary to provide the patient with some protection, such as
an aluminium plate.

If, however, a hernia forms and gradually increases in size, the brain
should be explored again to see if another abscess can be discovered; or
the lateral ventricle itself may be tapped in case of it being distended
with fluid. Both these operations, however, must be looked upon as
extreme measures.

If the patient otherwise recovers and a hernia still persists, the
question arises what to do. Conservative treatment should first be
employed, aseptic dressings being maintained, and slight pressure
applied with compresses soaked in rectified spirits. If these measures
fail, then the projecting portion of the hernia may be excised (see Vol.
III).

=Other methods.= In addition, the following methods of treatment have
been suggested. Although many failures have occurred in proportion to
the few successful cases published, yet they show the possibility that
something can be done by operative measures, and that considerable
advance has been made in recent years in this direction.

(i) =Repeated lumbar puncture.= In a few cases of serous meningitis this
has proved successful in that it has relieved intracranial pressure. It
is, however, only of value if free communication still exists between
the spinal theca and subarachnoid space.

(ii) =Continuous drainage from the spinal canal.= Friedrich, of Kiel,
has suggested a counter-opening in the spinal canal by means of
laminectomy in order to permit of drainage of the entire dural sac.

(iii) =Puncture of the lateral ventricle.= The temporo-sphenoidal lobe
is pierced with a trocar, just above the zygomatic ridge, until the
ventricle is reached; this has been performed frequently in order to
relieve intracranial pressure. I know of only one recorded instance in
which recovery has taken place in spite of there being pyogenic
infection of the lateral ventricle; a fact which was proved by tapping
the ventricle and removing from it a drachm and a half of purulent fluid
(_Archives of Otology_, vol. xxxv, p. 535).

(iv) =Drainage through the internal ear.= West and Scott have recently
described a case of meningitis which occurred after having curetted the
inner wall of the tympanic cavity. They then opened up the labyrinth and
inserted a wire drain through the internal auditory meatus, at the same
time making a counter-opening in the lumbar region, through which they
drained the spinal canal. The patient, a child, ultimately recovered.

=Prognosis and after-results.= Unless saved by operation, meningitis is
almost uniformly fatal. Even if the patient recovers, whether as the
result of operation or not, deaf-mutism or mental deficiency frequently
occurs. In a few cases, however, complete recovery has taken place.




CHAPTER IX

OPERATIONS FOR LATERAL SINUS THROMBOSIS OF OTITIC ORIGIN


GENERAL CONSIDERATIONS

The sigmoid portion of the lateral sinus is the part usually infected.
Thrombosis, however, may occur primarily in the region of the jugular
bulb from direct extension of the pyogenic infection through the floor
of the tympanic cavity; this, though less frequent than involvement of
the sigmoid sinus, is not so rare as has hitherto been supposed.

Operative treatment is imperative as soon as septic thrombosis of the
sinus has been diagnosed. This, however, is not always an easy matter.
Sometimes, indeed, there are no clinical symptoms, the condition perhaps
only being discovered whilst performing the complete mastoid operation
as a prophylactic measure. The sinus is generally exposed accidentally
whilst following out a tract of carious bone, and, to the surprise of
the surgeon, pus or granulations may be seen to exude or protrude from
an opening in its outer wall. On further exposure of the sinus on each
side of the thrombus, the dura mater may appear to be of a dark colour
for a short distance, but beyond this to be of normal appearance.

Seeing that there are no symptoms, the presumption is that the sinus is
occluded on each side of the septic thrombus by a non-infective clot. It
is, therefore, sufficient in such cases to simply excise the sinus wall
over the septic area. If the case be so treated, it is essential that
the sinus should only be curetted gently over the exposed opening, but
otherwise left undisturbed. Also this limited operation should only be
performed if the surgeon is satisfied that the septic focus is
surrounded on each side by an organized normal clot--the condition in
fact being treated as a simple abscess.

To secure free drainage, only the depth of the mastoid wound should be
packed with gauze, the surface being protected by a simple dry dressing.
The after-treatment is the same as that already described for the
complete mastoid operation in which the posterior wound has been left
open.

In other cases, if there be an acute inflammation of the mastoid process
and if only one rigor has occurred, it may not necessarily mean that
thrombosis of the sinus has taken place, as the rigor may be due simply
to septic absorption. In such cases it is justifiable to delay opening
the sinus if it is found to be exposed within the wound cavity and to be
covered with granulations.

The bone, however, should be freely removed until the normal dura mater
is reached, and the cavity afterwards rendered as aseptic as possible by
syringing it out with hydrogen peroxide lotion. In a large proportion of
cases a favourable result occurs, the pyrexia and head symptoms
disappearing and an uneventful recovery taking place. On the other hand,
gradually increasing pyrexia or a sudden rigor may occur, perhaps not
until ten days or so after the primary operation, showing that the sinus
has become infected after all. It should then be opened at once, but
before doing so the jugular vein should be tied (see p. 448).

In a typical case, however, there is a history of repeated rigors, and
in addition there may be attacks of vomiting and headache localized to
the affected side, with pain and tenderness on pressure behind the
mastoid process, and optic neuritis. In the more severe cases there may
also be evidence of thrombosis of the jugular vein or cavernous sinus.
It must, however, be remembered that a high and intermittent pyrexia,
especially in children, may take the place of rigors. The principles of
surgical treatment are to expose the sinus and remove the infective clot
completely.

In connexion with this operation two points cannot be impressed too
forcibly on the reader:--

1. The operation must be performed at once. The greater the experience
of the surgeon the more he realizes that expectant treatment is nearly
always fatal, and that a successful result depends largely on early and
complete operative measures.

2. Before the sinus is interfered with in any way it is essential to
obliterate its lumen below the thrombus in order to prevent any portion
of it being swept into the circulation during its removal.


EXPOSURE OF THE LATERAL SINUS

=Indications.= (i) In doubtful cases to decide whether thrombosis exists
or not.

(ii) As a preliminary to opening the sinus with or without ligature of
the jugular vein.

=Operation.= The first step is to perform the complete mastoid
operation, except in the case of acute inflammation of the mastoid
process, when Schwartze’s operation will be sufficient.

To expose the field of operation more freely, an incision an inch or
more in length is made horizontally backwards, beginning at the
mid-point of the posterior margin of the primary incision (Fig. 216),
the soft parts being reflected upwards and downwards from the bone, and
the flaps so formed being then retracted. Above, the bone should be
exposed beyond the level of Reid’s base-line, which roughly corresponds
to the line of the transverse sinus; below, the tip of the mastoid
should be cleared until the mastoid vein is reached. If it be thrombosed
it may be assumed that the lower part of the lateral sinus is also
thrombosed. Bleeding from the bone at this point may be arrested by
temporarily plugging the foramen with a fragment of sterilized wax.

The condition found on opening the mastoid process varies considerably.
If the result of acute inflammation of the mastoid process, the mastoid
cells surrounding the sigmoid sinus usually contain pus or granulations,
on removal of which a fistula may be seen to communicate with the outer
wall of the sinus; or the bone around the sigmoid groove may already be
destroyed, with free exposure of the sinus within the wound. With this
there is frequently an extra-dural abscess. In other cases, if the
infective process has been very virulent, evil-smelling pus, sometimes
intermixed with bubbles of gas, may escape on chiselling through the
mastoid cortex. This is a sure sign of extensive disease, the sinus wall
often being gangrenous and the bone surrounding it necrosed and
discoloured.

If occurring in the course of a chronic middle-ear suppuration, very
little disease of the mastoid process may be found except along the path
by which the infection has spread.

After the sinus wall has been reached, sufficient bone should be removed
to expose its outer surface for at least half an inch above and below
the supposed infected area.

The decision as to whether thrombosis exists or not may have to be made
during the operation itself, and is based partly on the appearance of
the sinus wall and partly on the symptoms, the relative value of each
varying in each individual case.

Normally the sinus pulsates and is of a bluish-grey colour. If
thrombosed, the wall of the sinus may be of a yellow or dark colour and
may not pulsate, but neither discoloration nor the absence of pulsation
is an absolutely reliable sign of thrombosis. Again, if the sinus be
covered with granulations or purulent lymph, it is sometimes impossible
to say whether it is thrombosed or not, especially if the clot is
limited and parietal. Further, the thrombus may be situated low down
towards the jugular bulb, so that if it has not extended very far
upwards the exposed portion of the lateral sinus may still be normal in
appearance. Palpation of the sinus with the finger or aspiration with a
hollow needle is sometimes advised as an aid to diagnosis. These
procedures, however, are extremely unwise, owing to the risk of
dislodging a small fragment of the infected clot, which may easily occur
if the latter does not obliterate the sinus completely. As a means of
diagnosis the withdrawal of blood by the aspirating needle is of no
value, as it does not negative the presence of a parietal thrombus,
owing to the possibility of the needle passing through it into the free
lumen of the sinus.


OPENING OF THE LATERAL SINUS

=Indications.= The sinus should always be opened as soon as it is
certain that septic thrombosis has occurred.

=Contra-indications.= The only contra-indication for opening the sinus
and removing the thrombus is the certainty that either the patient’s
general condition will not permit of the operation being performed, or
that the septic thrombosis has spread beyond the region from which it is
possible to remove it.

For this reason, operation is unjustifiable if the patient is already
suffering from septic pneumonia, pericarditis, or acute septicæmia; or,
on the other hand, if there are symptoms of cavernous sinus thrombosis
on both sides, or general meningitis. If, however, the patient’s general
condition be good, operation may be attempted as a last resource even
although a pulmonary empyema or a one-sided cavernous sinus thrombosis
already exists.

=Operation.= After exposure of the lateral sinus, the next point to
determine is the site and extent of the infected area (Fig. 244). On
this will depend whether it will be necessary or not to tie the jugular
vein in the neck.

The sinus is first exposed towards the jugular fossa until its surface
appears normal for at least half an inch. It is wiser, however, always
to expose the sinus as low down as possible. A strip of sterilized gauze
is then pressed in between the bone and the outer wall of the sinus so
as to obliterate its lumen at this spot. Instead of removing the bone
from above downwards, the sinus may be exposed first at its lowest limit
by chiselling directly through the tip of the mastoid process. In this
way it can be obliterated by a strip of gauze before attacking the area
of infection. The overlying bone is afterwards removed from below
upwards until the thrombosed area is reached.

In removal of the bone from above downwards there is a certain risk of
small particles of clot being dislodged into the circulation, or, if the
sinus wall is injured, of hæmorrhage taking place if the thrombus at
this particular point does not completely occlude the sinus. If,
however, the sinus be first exposed and obliterated at its lowest limit,
these risks are greatly minimized. There is no special technique in
removing the bone beyond that already given in the description of the
complete mastoid operation.

The next step is to expose the lateral sinus behind the infected area
and follow it backwards until the dura mater appears normal for at least
three-quarters of an inch. If necessary, the skin incision must be
prolonged still farther backwards, in order to permit of removal of the
bone overlying the transverse sinus, which may, perhaps, have to be
exposed even to the torcular Herophili.

[Illustration: FIG. 244. DIAGRAM TO SHOW THE USUAL POINTS AT WHICH THE
LATERAL SINUS IS PRIMARILY INFECTED. A, High up; from the posterior
mastoid cells. In this case it may not be necessary to tie the jugular
vein. B, Low down; involving the jugular bulb. This necessitates
ligature of the vein.]

In removing the bone overlying the infected thrombus, the gouge and
chisel should be used rather than the bone forceps or burr. With the
latter there is greater risk of dislodging particles of clot into the
circulation, owing to pressure of the instrument on the sinus wall.

After the sinus has been exposed well beyond the region of the thrombus,
the bone forceps may safely be used, especially in exposure of the
transverse sinus; and this is a much more rapid method than removing the
bone by means of the gouge and mallet. To prevent the inner blade of the
forceps from nipping the sinus wall between it and the bone, the dura
mater forming the outer wall of the sinus should be separated from the
overlying bone by means of a dura mater separator. In the region of the
infected area the sinus wall may be adherent to the bony wall as a
result of the inflammatory adhesions, and, in addition, may be extremely
friable and so easily torn through.

In exposure of the sinus two points should be remembered: firstly, that
it is sometimes difficult to differentiate it from the dura mater
covering the temporo-sphenoidal lobe above and the cerebellum below; and
secondly, that the transverse sinus is a very much broader vessel than
is imagined, being even half an inch in width. Not much force is
required to obliterate its lumen, but care must be taken to pack the
gauze evenly across its whole width.

After the sinus has been occluded above and below the area of infection,
it should be incised with a small knife along its whole length between
the obstructing plugs of gauze (Fig. 245). If there be bleeding, it may
be due to the sinus being obliterated incompletely, or it may come from
the superior petrosal sinus. To find out where the bleeding comes from,
the finger should be pressed upon the sinus at its upper and lower
limits, close to the obstructing plugs of gauze. If the bleeding stops,
it shows that the sinus has not been obliterated completely; this can
now be done by further plugging with gauze. If, in spite of this,
bleeding still continues, it presumably comes from the petrosal sinus.

All clot and granulations are now rapidly curetted out and the lateral
sinus plugged with gauze. After a moment the gauze is withdrawn and
another small piece is pressed into the lateral sinus at the point of
entrance of the petrosal sinus. After the bleeding has been arrested,
the outer wall of the lateral sinus is excised by cutting it away with
blunt-pointed scissors. The interior of the sinus is then inspected,
special attention being given to the lower portion to see if its lining
is normal. If this be not the case, even if there be no signs of
thrombosis, it means that the surgeon has failed to get well below the
infected area, and therefore the internal jugular vein must be
ligatured. If, however, it be normal, the gauze plug already placed
between the sinus wall and the overlying bone is left undisturbed.

If there be no bleeding from the sinus (excepting a slight amount from
the blood contained within the isolated portion), the thrombus is
curetted out and the inner surface of the sinus inspected. After
excising the outer wall, search is made for the superior petrosal sinus,
which presumably is thrombosed, although perhaps only by normal clot. To
expose this tributary, which enters the lateral sinus at the point at
which it turns downwards to form the sigmoid sinus, bone must be removed
in front of the lateral sinus along the angle forming the roof and inner
wall of the mastoid and antrum; that is, along the superior margin of
the petrosal bone. If the inner surface of the lateral sinus in its
neighbourhood be normal, nothing need be done. If, however, the sinus
wall be infected, the petrosal sinus should be followed out, if
possible, its outer wall being incised and the clot removed, bleeding
being afterwards arrested by pressure.

[Illustration: FIG. 245. THE LATERAL SINUS EXPOSED AND OPENED. The lumen
of the sinus is obliterated above and below the region of the infected
thrombus by plugs of ribbon gauze pressed in between the sinus wall and
the overlying bone. In this case it is not necessary to tie the jugular
vein.]

As a final step, the gauze plugging which still obliterates the lumen of
the sinus in its upper part is removed. If the sinus be normal at this
point, free hæmorrhage will occur; this is arrested at once by again
introducing a strip of gauze between the sinus and the bone. Although
during the earlier stages of the operation the inner lining of the
posterior portion of the sinus may have seemed to be normal, yet it
occasionally happens that hæmorrhage does not at once occur on removing
the plug of gauze; but after a moment or two a long smooth clot,
gradually tapering at its end, may be shot out from the opening within
the sinus, being followed by a gush of blood. The terminal portion of
this clot is non-infective and of recent formation. Its appearance is
always a matter of satisfaction, as it means that the sinus has been
freely exposed and opened behind the infected area.

If on exposure of the sinus it be found that the clot extends so low
down that it will be impossible to obliterate the sinus well below the
infected area, the jugular vein should be ligatured at once before
interfering further with the sinus from the mastoid wound.

Attempts to remove the clot from the jugular bulb by curetting out the
sinus from above are only referred to to be condemned. The surgeon who
believes in this method hopes that all the infected portion of the clot
will be swept out by the flow of blood. It is not, however, always
possible to introduce a curette into the jugular fossa, and if the clot
extends beyond this region it cannot be curetted away completely. The
result of the operation does not depend so much on the skill of the
surgeon as on whether the terminal portion of the clot be infected or
not. Recovery is most likely to take place if a non-infective clot
already extends beyond the region of the curette and so obliterates by
natural means the lumen of the vein below the point reached by the
surgeon. If, on the other hand, free hæmorrhage occurs as a result of
the curetting, it means that the lumen of the vein has been restored,
but there is no guarantee that all the clot has been completely removed.
If any infective portion remains, a fatal result will almost certainly
occur eventually as the result of pyæmia.


LIGATURE OF THE JUGULAR VEIN

=Indications.= Unfortunately, opinion is not unanimous with regard to
this matter. The chief arguments raised against ligature of the jugular
vein are: (1) That it favours extension of the thrombus along the veins
communicating with it, especially along the inferior petrosal and
condyloid veins, which enter the jugular bulb. (2) That it in no way
prevents the spread of infection along other paths, owing to the freedom
with which its tributaries communicate with one another. (3) As a result
of obstruction in the circulation, acute inflammation of the cerebellum
may take place.

Since the jugular vein should only be ligatured if the symptoms point to
the onset of a general infection of the circulation and if it be found
impossible at the time of operation to obliterate the sinus below the
infected thrombus, and since this vein is the chief route by which this
infection takes place, it seems a matter of common sense that it should
be ligatured. At the same time, as many as possible of its tributaries
above the point of ligature should also be ligatured well beyond the
point at which they may be thrombosed.

Although extension of the infection may take place along other veins
after ligature of the jugular vein, it is impossible to say whether the
result is _post_ or _propter hoc_. Against ligature, statistics have
been quoted to show that in a series of cases in which the jugular vein
has not been tied the percentage of recoveries is just as high as in
those in which it had been ligatured. This argument is not quite sound,
because there is no doubt that in the cases in which ligature of the
jugular vein is justified the chances of recovery, owing to the
extension of the thrombus downwards, must be less than in the less
serious cases in which it is admittedly unnecessary to tie the vein. It
is also impossible to say how many cases would otherwise have ended
fatally if ligature had not been performed.

In the majority of cases the vein is ligatured after exploration of the
lateral sinus. In a few cases, however, the symptoms warrant it being
performed as a primary step of the operation, even before the mastoid
process has been opened.

=After exposure of the lateral sinus.= (i) If the clot extends so low
down that it is impossible to obliterate the lumen of the sinus below
its lower limit.

(ii) If there be thrombosis of the bulb of the jugular vein. This
condition is sometimes difficult to diagnose. There may be no symptoms
excepting, perhaps, rigors occurring during the course of chronic
middle-ear suppuration, as even the lower portion of the sinus may be
quite normal in appearance owing to the clot being limited entirely to
the jugular bulb. The probability of the diagnosis being correct is
strengthened by the presence of granulations or carious bone on the
floor of the tympanic cavity. It is better to risk tying a normal vein
than to fail to tie one already infected.

(iii) If the sinus was obliterated above the jugular bulb at the primary
operation and rigors occur subsequently, showing that the sinus is
infected still lower down.

=Before exposure of the lateral sinus.= (i) If there be thrombosis of
the jugular vein. In addition to the ordinary signs of lateral sinus
thrombosis, there may also be infiltration of the tissues, or tenderness
along the anterior border of the sterno-mastoid muscle. The prevalent
idea that a thrombosed jugular vein can be felt on palpation as a hard
cord extending down the neck is erroneous. If anything be felt it is
probably some enlarged cervical glands lying along the line of the vein.
In any case it is bad practice to palpate the internal jugular, as by
doing so there is considerable risk of dislodging particles of the
septic clot.

(ii) If, as a result of septic infection, the general condition of the
patient be so serious that a prolonged operation seems unjustifiable. In
such cases, the lateral sinus is rapidly exposed and incised after tying
the internal jugular, its contents are curetted out and the wound cavity
lightly plugged; the completion of the operation, consisting of the
opening up of the mastoid cells and antrum, and possibly also
exploration of the intracranial cavity, may be performed next day or
later.

(iii) If it be doubtful whether septic thrombosis of the sinus has
already occurred, it is justifiable in certain cases merely to expose
the sinus freely and not to open it (see p. 440). If rigors subsequently
occur in these cases and it becomes evident that the sinus has become
infected after all, then it is wiser to tie the jugular vein as a
primary step of the operation before opening up the sinus itself.

The writer’s reason for doing so is, that at the second operation he has
always found the clot to be extensive, or, at any rate, to be situated
so low down as to prevent the sinus being obliterated below the infected
area.

[Illustration: FIG. 246. INCISION FOR EXPOSURE OF THE INTERNAL JUGULAR
VEIN. The illustration shows the superficial structures. A, Common
facial vein; B, Fascia covering the hyoid bone; C, Anterior border of
the sterno-mastoid muscle; D, Omo-hyoid muscle.]

=Operation.= Formerly it was considered sufficient to divide the vein
between two ligatures and to leave it _in situ_. Now, however, the upper
portion of the vein is brought out through the wound in the neck after
this has been done.

The patient lies in the recumbent position with the affected side close
to the edge of the table. The head and shoulders should rest on a hard
pillow in such a fashion that the neck is slightly extended, the chin
being drawn upwards and the head turned a little to the opposite side so
that the anterior border of the sterno-mastoid muscle can be clearly
defined throughout its whole length. The surgeon stands at the side to
be operated on. The neck is carefully cleansed, but in doing so care
should be taken not to rub the neck too violently, nor should any
attempt be made to palpate the line of the jugular vein in the hope of
feeling it. There is no object in doing so, and if it is thrombosed a
portion of the clot may be dislodged.

An incision, at least three inches in length, is made along the anterior
border of the sterno-mastoid muscle, the mid-point of the incision
corresponding to about the level of the cricoid cartilage. On cutting
through the skin and platysma some small veins may be met with: they
should be clamped with forceps and divided. If, however, the anterior
jugular vein be exposed, it should be drawn to one side, if possible,
and not divided. The anterior border of the sterno-mastoid muscle is
clearly defined, until the upper border of the omo-hyoid muscle is
reached (Fig. 246). Its edge is then drawn slightly outwards by means of
a retractor and separated from the underlying deep fascia. Beneath this
fascia is the carotid sheath, which encloses not only the carotid artery
but the internal jugular vein and the vagus nerve. The vein is external
and somewhat superficial to the artery, and the vagus nerve lies behind.
A vein of varying size will be seen crossing obliquely downwards and
outwards to pierce the deep fascia at a level corresponding to the
cornua of the hyoid bone; this is the common facial vein about to enter
the internal jugular (Fig. 247). If the surgeon has not had much
experience and has difficulty in finding the jugular vein, a certain
method of doing so is to find the facial vein and then follow it down
until it enters the jugular. The carotid sheath should be opened about
this point, and the position of the vein ascertained by feeling the
pulsations of the carotid artery. The sheath of fascia covering the
jugular vein is picked up with a pair of fine forceps and cut through
with a sharp scalpel, which should be inclined obliquely outwards so
that the flat of the knife is held towards the vessel. Any enlarged
lymphatic glands lying over the vein must be removed.

[Illustration: FIG. 247. EXPOSURE OF THE INTERNAL JUGULAR VEIN HIGH UP.
A, Common facial vein; B, Sterno-hyoid muscle; C, Omo-hyoid muscle; D,
Anterior border of the sterno-mastoid muscle retracted outwards. A
ligature is placed around the jugular vein just above the common facial
vein. When the jugular is ligatured at this spot it is not necessary to
tie the facial vein. In actual practice the vein, of course, would be
tied and cut between two ligatures, the upper portion of the vein being
brought out into the neck.]

When the vein has been identified, a blunt dissector is passed between
its outer wall and the sheath, so as to separate the two. The sheath is
incised upwards and downwards until the vein is freely exposed. If the
vein be patent, it will be of a bluish colour, expanding and diminishing
in volume with each act of respiration. If it be thrombosed, there is
usually accompanying periphlebitis which may make the separation of the
sheath from the vein and the surrounding tissues difficult. If there be
no periphlebitis, the thrombosed portion may be purplish, or, if the
clot be of long standing and breaking down, more of a yellowish colour;
the vein stands out as a cord and does not pulsate. If the thrombus be
limited to the portion above the entrance of the common facial vein, the
upper portion of the jugular may be small and collapsed, only becoming
full and pulsating below the point at which the facial joins it.

The next step in the operation is to get well below the point at which
the jugular is thrombosed. If the thrombus be practically limited to the
jugular fossa the vein may be ligatured above the common facial; if not,
as low down the neck as possible. In ligaturing the vein low down in the
neck, the skin incision must be extended downwards, and as the lower
portion of the neck is reached, the omo-hyoid will have to be pulled
aside. The probe should be passed all round the vein so as to make
certain that it is freed from its sheath, and especially that it is
separated from the vagus nerve which lies behind it.

An aneurysm needle threaded with silk is now passed around the vein from
within outwards. The loop of silk is cut so as to form two ligatures,
and the aneurysm needle then withdrawn; the lower ligature is first
tied, its ends being cut short. The upper ligature is then tied a short
distance above it, but in this case the ends are left long. The vein is
raised from its bed by slight traction on this ligature and is cut
across between the two, the lower portion being allowed to sink back
into the wound. The upper portion is then carefully separated for some
distance upwards. Lying behind the vein may be seen the vagus nerve
(Fig. 248). Any tributaries are clamped between two forceps, cut across,
and ligatured, the upper end of the vein being brought out into the
upper angle of the wound. Care must be taken that enough of the vein is
dissected out to allow of this being done, especially if the ligature is
applied above the level of the common facial; in this case the facial
need not be tied.

If there be no periphlebitis, inflammation of the soft tissues, or
thrombosis of the vein itself in the neck, the wound may be closed by
means of silkworm-gut sutures, excepting at its upper angle through
which the open end of the jugular vein projects. If, however, the vein
be thrombosed, and especially if there be periphlebitis, the wound
should be left open, except perhaps at its lower angle, and should be
lightly packed with gauze, as in these cases cellulitis of the neck may
afterwards occur.

After completion of the operation in the neck the surgeon turns to the
mastoid process. If the ligature of the vein has been the primary step,
the mastoid operation is now performed and the lateral sinus is freely
exposed for a considerable distance behind the thrombus. If, however,
the mastoid operation has been the first stage, and the jugular has been
tied as soon as exposure of the sinus showed it to be thrombosed, the
operation on the mastoid is now completed and the sinus opened as
already described (see p. 444). The next step is to incise the sinus
freely from above downwards towards the jugular fossa and curette out
the thrombus.

If there be considerable hæmorrhage, it means that the thrombus is
probably parietal and situated within the jugular bulb, the bleeding
presumably coming from the inferior petrosal sinus or other tributaries
which enter the bulb or upper portion of the jugular vein. If the
bleeding be excessive, the sinus is plugged after a moment or two, by
inserting a piece of gauze into its lumen towards the jugular bulb.

[Illustration: FIG. 248. LIGATURE OF THE INTERNAL JUGULAR VEIN LOW DOWN
IN THE NECK. The upper portion of the vein is dissected out and brought
into the neck. A, A', Cut ends of the ligatured facial vein; E,
Descendens noni nerve; F, Carotid sheath and internal carotid artery; G,
Vagus nerve; H, Gland; J, Lower end of the internal jugular vein. The
hook pulls aside the omo-hyoid muscle.]

In this case the portion of the vein brought into the neck is usually
also filled with blood. After isolating it from the deeper tissues by
packing strips of gauze round it, the vein is deliberately opened just
above the ligature. The bleeding usually stops after a moment or two,
but if it cannot be controlled, the lumen of the vein must again be
closed by a ligature, the end of the vein being allowed to project on to
the neck.

If there be no bleeding from the lower portion of the lateral sinus and
jugular bulb, it means that the vessel is completely thrombosed at this
point. The clot should now be removed by curetting through the sinus
from above downwards towards the jugular bulb, and also from below
upwards through the open end of the jugular vein.

[Illustration: FIG. 249. FREE EXPOSURE OF THE LATERAL SINUS, WHICH HAS
BEEN INCISED, WITH LIGATURE OF THE INTERNAL JUGULAR VEIN. The lateral
sinus is obliterated posteriorly by a plug of gauze pressed in between
its outer wall and the underlying bone. The sinus is freely exposed
almost down to the jugular fossa. The vein has been ligatured and its
upper portion sutured to the skin wound in the neck. The arrow shows the
direction along which the sinus and vein are syringed.]

The venous channel is afterwards syringed through from above downwards.
To do this, a piece of rubber tubing is inserted into the opening in the
lateral sinus and some warm saline solution is injected through it with
a syringe. If the clot be not firmly adherent it can usually be washed
out through the opening in the vein. No force should be used. If gentle
syringing be not sufficient to expel the clot, the attempt must be given
up. The chief objection against syringing is the possibility of
particles of the septic thrombus being forced into the veins
communicating with the jugular bulb. A small drainage tube is inserted
within the sinus.

In order to keep the lumen of the vein in the neck open, it should be
stitched to the edge of the wound surface by several catgut sutures
(Fig. 250). If the bleeding necessitated plugging of the lower end of
the sinus and retention of a ligature on the vein in the first instance,
syringing should be postponed until the first dressing; the portion of
the vein left protruding through the skin wound in the neck is then cut
across, and the edge of the vein sutured to the margin of the wound
under cocaine.

The mastoid cavity is lightly plugged with gauze and a dry dressing
applied. The wound in the neck is similarly treated.

=After-treatment and progress of the case.= There is frequently
considerable shock after the operation, especially if exposure of the
jugular bulb has been undertaken, partly owing to the duration of the
operation and to hæmorrhage. If the patient be very collapsed, a
continuous saline injection, to which some brandy may be added, may be
given per rectum according to Moynihan’s method. After the primary shock
has passed off, the immediate result is usually satisfactory.

_If the jugular vein has not been ligatured_, the first dressing should
be performed within forty-eight hours, the gauze packing being removed,
the wound syringed out, and afterwards repacked. The plugs of gauze,
which were pressed in between the outer wall of the sinus and the
overlying bone in order to obliterate the lumen of the latter, should
not be interfered with for at least six days. If the case progresses
favourably, the temperature becomes normal within a day or two, the
patient feels well, and the wound assumes a healthy appearance. If, on
removal of the gauze plugging, hæmorrhage takes place, then the plugging
must be renewed and not touched again for three or four days. After it
is possible to remove these plugs, the wound is treated as has already
been described in Schwartze’s operation or in the complete operation in
which the posterior wound was left open.

_If the jugular vein has been ligatured_, the sinus and vein should be
syringed through daily, and this should only be stopped after all
secretion has ceased, usually a matter of a week or ten days.

_When the sinus, jugular bulb, and vein have been exposed throughout
their length_ the wound is treated as an ordinary surgical one, being
packed until it granulates up from the bottom (_vide infra_).

[Illustration: FIG. 250. METHOD OF SUTURING THE OPEN END OF THE INTERNAL
JUGULAR VEIN IN THE NECK.]

Apart from intracranial and pyæmic complications, the progress of the
case may be delayed owing to the enfeebled and septic condition of the
patient, and also from the occurrence of abscesses in the neck, or
region of the mastoid itself. These abscesses are the result of septic
thrombosis occurring in some tiny vessel. The first sign of their
occurrence is an attack of pyrexia, shortly followed by a painful
swelling at the affected spot. Any collection of pus should be drained
at once. Although it is quite good practice to close the incision in the
neck in a clean case, yet there must be no hesitation to open it up on
the slightest sign of it becoming septic.

The case may appear to progress favourably for the first week or ten
days, and then an intermittent and increasing pyrexia may occur for no
obvious reason. This is usually due to extension of the infection along
the petrosal sinuses, or perhaps along the transverse sinus.

Symptoms of involvement of the cavernous sinus may arise, perhaps even
with formation of a peri-orbital abscess; or, on the other hand, the
patient may gradually sink in consequence of septic toxæmia; or the end
may come more suddenly with the onset of basal meningitis.
Unfortunately, these cases are almost hopeless from the first, as very
little can be done from a surgical point of view owing to the fact that
they are not seen soon enough.

_In thrombosis of the cavernous sinus_ the only hope of recovery lies in
its exposure and incision of its wall. The sinus may be approached by
tracking forwards the superior petrosal sinus--a matter of considerable
difficulty, and seldom justifiable. Recently Charles Ballance has
suggested the adoption of the Hartley-Krause route for extirpation of
the Gasserian ganglion, and says he has found the operation easy and
effectual. If pus be evacuated from the sinus he considers it advisable
to adopt the recommendation of Voss, who cuts away the zygoma and
removes more bone from the basal aspect of the skull so as to get direct
drainage (Allbutt and Rolleston’s _System of Medicine_, 1908, vol. iv,
Part ii, p. 495).


EXPOSURE OF THE JUGULAR BULB

This may be performed either by following the sinus downwards or through
the floor of the auditory canal and tympanic cavity. The former method
was first described by Grunert (_Archiv für Ohrenheilkunde_, 1902, vol.
liii, p. 287); the latter by Piffl (_Archiv für Ohrenheilkunde_, 1903,
vol. lviii, p. 76).

=Indications.= The object of the operation is to remove the septic clot
situated within the jugular bulb in the hope of preventing extension of
the infection along the veins leading into it, more especially the
inferior petrosal sinus. This indeed has been known to occur even after
the lateral sinus has been curetted out, the jugular vein ligatured, and
the venous channel syringed through.

=Grunert’s operation.= After free opening of the mastoid process and
exposure of the outer wall of the lateral sinus, the skin incision is
extended downwards beyond the tip of the mastoid. The soft tissues are
then separated from the bone forwards and backwards so as to expose
completely not only the mastoid process, but also the digastric fossa
and base of the skull immediately behind it, up to the outer bony margin
of the jugular foramen. Unless care is taken, the forcible traction
forwards of the soft tissues necessary to expose the field of operation
may injure or tear the facial nerve as it emerges from the stylo-mastoid
foramen.

The tip of the mastoid process is removed first. The lateral sinus is
then freely exposed to its lowest possible limit by removing the
overlying bone. In doing this it must be remembered that the sinus
becomes horizontal just before it ends in the jugular fossa, so that at
this point the skull forms its floor instead of its outer wall.

After having exposed the sinus as freely as possible, the ‘bridge’ of
bone separating it from the outer wall of the jugular foramen is removed
in small pieces by nipping it away with narrow biting forceps until the
jugular bulb is exposed from its outer surface. The facial nerve should
not be injured, as it lies in front and external to the portion of the
bone to be removed.

In performing the later stages of the operation, the patient’s head
should be turned well over to the opposite side in order to get a good
view of the parts lying behind and beneath the mastoid process; and in
tracking the sinus downwards, the probe should be used carefully in
order to try and define the exact position of the jugular fossa.

=Piffl’s operation.= Owing to the anatomical difficulty of reaching the
jugular bulb by following the sigmoid sinus downwards, especially in
those cases in which the sinus lies far forwards and in which, at the
same time, there is a very well-developed jugular fossa, Piffl
recommends exposure of the jugular bulb from above through the auditory
canal. The object of this method is to prevent injury to the facial
nerve, which he states is almost certain to occur in Grunert’s
operation, if carried out in cases such as those just mentioned.

After the complete mastoid operation has been performed, the skin
incision is extended downwards and forwards in order that the soft
tissues may be freed from the floor and anterior surface of the bony
portion of the auditory canal as far forward as the Glaserian fissure.
The soft tissues are pulled forward with a blunt hook to give sufficient
room. The lower portion of the tip of the mastoid is removed by means of
the gouge, as far as can be done without injuring the facial nerve,
which in this operation is pulled backwards with the soft tissues at the
posterior inferior margin of the wound. The lower bony margin of the
auditory canal, now freely exposed, is removed by means of a pair of
fine biting forceps until the floor of the tympanic cavity is reached.
If there be not sufficient room, the bone may be clipped away as far as
the styloid process, which also may be removed by bone-forceps after the
muscles attached to it have been dissected off.

In freeing the styloid process, its posterior surface must be approached
with caution for fear of injuring the facial nerve, which here lies in
close connexion with it. In the front of the wound the capsule of the
temporo-maxillary joint may be exposed, but must not be interfered with.

After removal of the styloid process, the uppermost portion of the
external jugular vein should be seen emerging from the jugular fossa.
This is followed upwards by careful removal of the bone between it and
the floor of the auditory canal and tympanic cavity, until the jugular
bulb is brought into view. This part of the operation must be proceeded
with very cautiously, the bone being nibbled away in small fragments
with gouge forceps which are of sufficient strength to nip through the
bone without having to wrench it away. The amount of bone to be removed
and the difficulty of the operation depend largely on the anatomical
condition found.

Whether Grunert’s or Piffl’s operation has been employed, the operation
may be completed either by incising the outer wall of the sinus and
jugular bulb, then curetting out the thrombus, and finally washing
through the lower portion of the vein from above downwards, or by the
more radical method of also exposing the upper portion of the jugular
vein throughout its whole length. To do this the post-aural incision is
continued downwards until it joins the one previously made in the neck.
To obtain room, the neck must be somewhat extended and the jaw pulled
well forward and the sterno-mastoid muscle backwards. The jugular vein
is then dissected upwards towards the bulb.

The nearer the jugular fossa is approached the deeper and more difficult
becomes the exposure of the vein. Passing in front of it may be found
the stylo-pharyngeal, stylo-hyoid, and digastric muscles. In Grunert’s
operation they need not be cut through as the vein will lie posterior to
them. In Piffl’s operation these muscles probably have been already
reflected forward, after removal of the styloid process.

Particular care must be taken not to injure the nerve trunks, which are
in such close relationship with the vein. Lying immediately behind the
vein is the vagus nerve; the spinal accessory passes downwards and
outwards behind it, and the glosso-pharyngeal and hypoglossal nerves
forwards between the vein and the internal carotid artery.

After the vein, the jugular bulb, and the sigmoid sinus have been
exposed throughout their course, their outer wall is cut through with a
pair of blunt-pointed scissors along its whole length, so as to convert
the venous canal into an open gutter. The thrombus is then curetted out
and the dissected portion of the jugular vein cut off as high up as
possible. Any bleeding from the inferior petrosal sinus or condyloid
veins, which may not be thrombosed, should be arrested by direct
pressure of a strip of gauze over the bleeding points. The wound cavity
is then washed out with a weak biniodide solution and dried.

The lower portion of the incision in the neck may be closed with sutures
and a small drainage tube inserted at its lower angle. The upper portion
of the wound, now directly continuous with that of the mastoid cavity,
is left open and packed lightly with gauze, which is inserted into the
remains of the venous channel.

=Comparison of operations for lateral sinus thrombosis.= Except when the
thrombus is limited to the upper part of the sigmoid sinus, it is
undoubtedly wiser to tie the jugular vein than to be content with
curetting out the clot after obstructing the sinus above and below by
means of gauze plugs. Exposure of the jugular bulb is so difficult an
operation and requires so much time, especially if the whole length of
the upper portion of the jugular vein is also dissected out, that it is
seldom advisable to perform it; nor will it often be justifiable owing
to the condition of the patient, who is seldom strong enough to undergo
such a prolonged operation. The records of this particular operation are
so few that it is impossible as yet to determine its value.

If the sinus be exposed as low down as possible, and the jugular vein
dissected out and brought out into the neck, and the venous channel
afterwards syringed through, the chances of recovery should be almost as
good as in the case of free exposure of the jugular bulb.

If the inferior petrosal sinus be already infected before the operation,
it does not matter whether the operation performed is that of syringing
through the jugular bulb or freely exposing it, as in either case the
inferior petrosal sinus cannot be followed out.

Curetting of the lower portion of the sinus without previous ligature of
the jugular vein should never be done.

=Difficulties and dangers of the operation.= The chief difficulty in
these operations is anatomical; the chief danger is hæmorrhage.

If the hæmorrhage be due to accidental tearing of the wall of the sinus
in the earlier part of the operation, and if it be impossible to
obliterate the sinus below this point by pressing in gauze between its
wall and the underlying bone, then the jugular vein should be tied
before anything else is done.

Extreme vascularity of the bone is not unusual after ligature of the
jugular vein. In these cases the surgeon must rely on the cleverness of
the assistants in keeping the field of operation clear by careful
swabbing.

In exposure of the jugular vein there may be difficulty in finding the
vessel, especially if the cervical glands are enlarged, or if there be
matting together of the tissues in consequence of periphlebitis or
cellulitis. In these cases the best plan is to identify the common
facial vein and then trace it down to its entrance into the jugular
vein.

With regard to the sinus, the chief danger is injury of its inner wall
whilst curetting out its contents: this may afterwards give rise to
meningitis or a cerebellar abscess. Accidental pricking of a
non-thrombosed jugular vein may allow of entry of air into the vein and
so cause death: this is a catastrophe I have not yet met with. Also, if
the operator be careless or inexperienced, he may injure the carotid
artery or vagus nerve; in the former case the only thing to do is to
ligature the artery above and below the wound.

=Complications.= The chief intracranial complications are meningitis and
cerebellar abscess; the former usually from extension of the septic
thrombosis along the petrosal sinuses. If, at the time of operation, it
be doubtful whether intracranial suppuration already exists or not, the
surgeon should content himself with removing the septic thrombus from
the sinus and await further symptoms. At the time of the operation,
however, sufficient bone should be removed to expose the dura mater over
the cerebellum. If, in addition to the clinical symptoms, the appearance
of the dura mater, the increased intracranial tension, and the absence
of palpation suggest the presence of an abscess, the cerebellum should
then be exposed and explored (see p. 467). Before doing this, the wound
should be made as aseptic as possible and a fresh set of sterilized
instruments used.

The complications resulting from general septic infection are pyæmia and
septicæmia.

=Prognosis.= The prognosis depends entirely on whether the septic focus
can be completely removed or not. Failure to do this is frequently due
to the operation not having been sufficiently extensive. It is a matter
of experience that if a second operation has to be performed recovery
seldom takes place. For this reason the first operation must be
thorough.

If such cases could be operated on in the earliest stage whilst the
infective thrombus was still limited, without doubt a higher percentage
of recoveries would be obtained. Unfortunately, the surgeon may not be
summoned until too late, owing to the seriousness of the condition not
having been realized.

In any individual case it is impossible to tell for the first few days
after the operation what the ultimate result will be. Without operation
a fatal termination is practically certain. As a result of operation
about one-third of the cases may be expected to recover.




CHAPTER X

OPERATIONS FOR INTRACRANIAL ABSCESS OF OTITIC ORIGIN


An intracranial abscess, the result of disease of the temporal bone, is
usually situated close to the surface of the brain, and is in close
relationship with the diseased area of bone through which the infection
has taken place. The actual track of the infection can frequently be
traced through the bone to the dura mater and brain substance itself;
sometimes, indeed, a fistula is found to pass through the bone and to
communicate with the intracranial abscess. On the other hand, though
rarely, the surface of the bone to all appearances is normal and there
are no adhesions between it and the dura mater and underlying brain
substance, and the abscess may be situated deeply within the brain.

With regard to the comparative frequency of temporo-sphenoidal and
cerebellar abscess, in 100 cases collected from the records of the
London Hospital the writer found that in children under ten years of age
temporo-sphenoidal abscess occurred in 87% and cerebellar only in 13%,
whereas in adults cerebral abscess occurred in 65% and cerebellar in
35%; and that a cerebral and cerebellar abscess occurred together only
in 5% of the cases.

These statistics are practically the same as Körner’s (_Die otitischen
Erkrankungen des Hirns, der Hirnhäute und der Blutleiter_). Ballance, on
the other hand, considers cerebellar abscess a more frequent occurrence
than temporo-sphenoidal.

Multiple abscesses may be met with, usually the result of pyæmia.

=Indications.= An intracranial abscess must always be opened and
drained.

Indications pointing to such a condition are persistent headache,
purposeless vomiting, a slow pulse, a subnormal temperature, and optic
neuritis. With this there is usually some change in the mental
condition, especially in the case of a temporo-sphenoidal abscess. In
the early stages there may be attacks of simple forgetfulness or mental
aberration, or, on the other hand, that of extreme mental excitement.
Owing to the intracranial pressure caused by the increase in size of the
abscess, the mental state becomes impaired and the condition known as
slow cerebration or the ‘dream state’ may be observed.

It must, however, not be forgotten that the same clinical picture may be
produced by other conditions, such as an intracranial tumour: in the
case of a middle-ear suppuration, however, an intracranial abscess may
be diagnosed unless this can otherwise be excluded.

Before operation is decided on, the site of the lesion must be
determined. This can only be done if certain localizing symptoms are
present.

_In a temporo-sphenoidal abscess_, if the cortical region be affected,
there may be paralysis or paresis of the opposite side, beginning with
the face and then spreading to the arm and leg; or in the opposite order
if the internal capsule be involved.

If the left temporo-sphenoidal lobe be the site of the lesion, aphasia
may be met with, and if the abscess extends backwards, word-blindness
may occur. If the centre of hearing be affected there may be complete
deafness of the opposite side owing to its destruction; or tinnitus or
hyperacusis if the centre be only irritated by the proximity of the
abscess; or if the anterior extremity be involved anosmia or parosmia
may be noticed. Another important sign, occurring in conjunction with
the above symptoms, is a fixed pupil on the affected side.

_In a cerebellar abscess_ the symptoms are less marked, or may even be
absent, so that the abscess may remain undiagnosed during life and only
be discovered at the autopsy, which may perhaps have been performed on
account of the sudden and unexpected death of the patient from rupture
of the abscess itself. In walking, in addition to a peculiar staggering
gait, there is a tendency for the patient to direct his course gradually
towards the affected side. Lateral nystagmus, if present, is usually
directed towards the affected side and has to be differentiated from
that due to internal-ear disease. If a cerebellar abscess be associated
with a labyrinthine suppuration and the latter is explored by operation,
the nystagmus will still remain directed to the affected side. If,
however, no cerebellar abscess be present the labyrinthine operation
will be followed by nystagmus strongly directed to the opposite side.
Optic neuritis and vomiting usually are more severe than in
temporo-sphenoidal abscess. Headache, if present, may be referred to the
occipital region, and there may also be slight retraction of the neck or
pain behind the mastoid region as a result of localized and early
meningitis of the posterior fossa. If the abscess be very large, there
may be paresis or paralysis of the facial nerve and perhaps also of the
upper extremity. The deep reflexes may also be altered, the knee-jerk
being frequently absent on the affected side. The patient in the late
stage usually lies curled up in bed on the side opposite to the lesion,
with the knees flexed.

=Methods of operation.= Two methods may be employed:--

1. Trephining directly over the area of the abscess (rarely necessary).

2. First performing the mastoid operation and then following out the
route of infection (usual method).

In the case of middle-ear suppuration, trephining has practically been
abandoned, and rightly so, since it has become recognized that the
intracranial abscess is due to direct extension of the pyogenic
infection from the middle-ear and mastoid cavities.

The only circumstances in which trephining may be advised are--(1) If
the diagnosis be certain and the operator has no experience of aural
surgery. In a case of emergency he is wiser, perhaps, to trephine and
drain the abscess, leaving the mastoid to be dealt with afterwards by
someone competent to do so. (2) If, after performing the mastoid
operation, the situation of the abscess be doubtful. In order to
diminish the risk of infection of the brain by an exploratory puncture
which may prove negative, the bone may be trephined a little beyond the
mastoid wound, either above or behind, according as a temporo-sphenoidal
or cerebellar abscess is suspected. If, however, it be considered
advisable to make a fresh opening in the bone beyond the septic wound
cavity, the aural surgeon will probably prefer to do so by means of the
gouge and bone-forceps, to which he is more accustomed.

Trephining has also been advised if the patient is so ill that a
prolonged operation is impossible; or if there is cessation of
respiration during the operation itself, which may occur in a cerebellar
abscess as a result of pressure on the medullary respiratory centres. To
those accustomed to perform the mastoid operation, the opening of this
cavity and the necessary removal of bone can be done more rapidly by the
gouge or bone-forceps than by the trephine.

For whatever reason trephining is done, it is afterwards essential to
perform the mastoid operation and to remove the primary focus of the
disease, otherwise one of the fundamental principles of surgery will be
neglected.

=Operation.= The preliminary preparation of the patient is the same as
for the mastoid operation, only the head should be shaved over a wider
area. The exposure of the field of operation is the same whether the
brain is explored through a trephine opening or from an extension of the
mastoid operation.

In the case of the temporo-sphenoidal lobe, it is necessary to extend
the incision behind the auricle vertically upwards for an inch or more
(Fig. 252); whereas if the cerebellum has to be explored, an incision is
carried backwards at right angles to the post-aural incision, just below
its mid-point (Fig. 253). In the former case, on reflecting the soft
tissues from the underlying bone, the squamous portion of the temporal
bone, immediately above the zygomatic ridge, will be exposed; in the
latter, the base of the skull behind and below the mastoid process and
lateral sinus will be laid bare.

1. =Trephining.= The trephine used should be three-quarters of an inch
to one inch in diameter according as the patient is a child or an adult.
Either the hand trephine or Macewen’s improved pattern mounted with a
guard may be used. If available, the trephine may be worked by a motor,
but in this case it should be remembered that the bone will be pierced
more quickly than by the hand instrument.

_Trephining for a temporo-sphenoidal abscess._ The object of the
operation is to expose the lowest portion of the middle fossa just above
the roof of the antrum and tympanic cavity. The trephine, therefore,
should be placed so that it is situated just above the suprameatal
spine, its lowest margin being slightly above the zygomatic ridge (Fig.
251). After the disk of bone has been removed the exploration of the
abscess is then carried out.

[Illustration: FIG. 251. TOPOGRAPHY OF THE AUDITORY REGION OF THE SKULL.
A, Point of trephining for a temporo-sphenoidal abscess; B, For a
cerebellar abscess; C, Dotted line marking a portion of the lateral
sinus.]

_Trephining for a cerebellar abscess._ The point at which the bone is
trephined must be behind and below the curve formed by the transverse
and sigmoid portion of the lateral sinus; that is, behind the mastoid
process and below Reid’s base-line.

If the mastoid operation has not been performed, the centre pin of the
trephine should be placed at a point 1-1/4 to 1-1/2 inches behind the
centre of the external auditory meatus, and an inch below Reid’s
base-line (Fig. 251). If, however, the mastoid has already been opened
and the lateral sinus exposed, the trephine should be placed so that its
anterior border is just behind the sinus and its upper border well below
Reid’s base-line.

2. =After performing the mastoid operation.= If this has been done
already, the wound is reopened, and cleansed by filling it with
hydrogen peroxide. After gently curetting away any granulations the
wound cavity is irrigated and then packed in order to dry it. Under good
illumination, careful inspection is made to see if a fistula or a tract
of diseased bone extends in any direction. Whether the middle or
posterior fossa should first be explored depends not only on the
clinical symptoms but also on the condition found on opening the mastoid
cavity.

=Opening of a temporo-sphenoidal abscess.= A temporo-sphenoidal abscess
may be explored either through its lowest point, that is, through the
roof of the antrum and floor of the middle fossa, or through its outer
wall just above the zygomatic ridge. To obtain a view of the roof of the
antrum and mastoid cavities, the head of the patient should lie almost
flat on the operating table and be turned well over to the opposite
side. The bony roof of the antrum and mastoid is removed by means of the
gouge and mallet, and so expose the dura mater covering the floor of the
middle fossa (Fig. 252). If a fistula communicates with the antrum
cavity and the middle fossa, the bone surrounding it is first attacked.
In removing the bone, it must be remembered that the tegmen tympani is
exceedingly thin, and unless care is taken pieces of bone may be pressed
inwards on to the overlying dura mater. Sufficient bone should be
removed to determine whether the dura mater is normal or not. To do this
it may be necessary to chisel away the tegmen tympani outwards until the
squamous portion of the temporal bone is reached, after which a pair of
bone forceps may be used until a sufficient opening is obtained.

[Illustration: FIG. 252. EXPLORATION FOR A TEMPORO-SPHENOIDAL ABSCESS.
A, Above the tegmen tympani; B, Through the tegmen tympani. Occasionally
these methods are combined; the bone between the openings being also
removed.]

The condition found on examination of the dura mater varies. In many
cases it is congested or covered with granulations at the site of the
infection, and usually it is adherent to the underlying bone. At other
times it seems normal.

Increase of the intracranial pressure, as shown by the bulging outwards
of the dura mater, and absence of pulsation are suggestive of an
abscess. These signs, however, are not conclusive, as on the one hand
increased intracranial pressure may be due to other causes and on the
other it is quite possible to have pulsation if the abscess be small and
deeply placed.

If an extra-dural abscess be present, the intracranial cavity should not
be explored at once unless this is absolutely necessary, but this step
of the operation should be delayed for at least twenty-four hours. If,
however, immediate operation be necessary, special precautions must be
taken to render the part as aseptic as possible, and a fine layer of
gauze should be packed between the margin of the bone and the dura mater
in order to prevent further infection of the brain or meninges. In an
uncomplicated case only sufficient bone should be removed to permit of
the insertion of a large drainage tube; that is, the dura mater should
not be exposed over a larger area than the size of a shilling.

If there be disease of the tegmen tympani and the symptoms point to a
temporo-sphenoidal abscess, the brain should be explored through this
opening in the bone (Fig. 252), as the abscess is thus not only drained
through its most dependent part, but also through its stalk.

If, however, the diagnosis be doubtful, the temporo-sphenoidal lobe may
be explored through a fresh opening, just above the tegmen tympani. This
will diminish the risk of septic infection from the mastoid cavity.
After the dura mater has been exposed sufficiently a small incision is
made in it, taking care to avoid wounding any of the vessels. With a
pair of forceps the cut edge of the dura mater is drawn outwards and the
incision is prolonged in each direction with a pair of blunt-pointed
scissors. Similarly, the dura mater is cut through at right angles to
the primary incision, so that four small flaps are made and turned back
so as to expose the outer surface of the brain.

As a rule the dura mater, arachnoid, and pia mater are fused together by
inflammatory adhesions, so that from a practical point of view they need
hardly be considered as separate structures. Similarly, at the site of
infection, the point of the so-called stalk of the abscess, the cerebral
membranes are adherent to the underlying brain, especially if there has
been any localized meningitis. For this reason it is sometimes necessary
to peel away the dura mater from the brain, in order to expose the
latter.

As a rule, very little fluid escapes: if present in considerable
quantity, and if it escapes from between the dura mater and brain, it
is an unfavourable sign, as it generally signifies early meningitis.

If meningitis be present, purulent lymph or secretion may be seen on the
surface of the brain, either localized or spreading from the site of the
infection.

If the intracranial pressure be great, the brain will bulge through the
opening in the dura mater. If the abscess be very large and situated
superficially, the thin layer of brain substance forming its outer wall
may rupture as soon as an opening has been made in the dura mater.
Sometimes, indeed, the pus may be seen to ooze through an opening in the
dura mater, which may be found to communicate with the abscess cavity.

The next step is to open the abscess. Formerly a trocar and canula were
used. This method is no longer in favour for the following reasons:--If
the wall of the abscess cavity be very thick, it may not be pierced;
secondly, the trocar may pass through the abscess cavity and enter the
brain substance beyond without draining it; and thirdly, even if the
trocar enters the abscess cavity the pus may be so thick as to plug its
lumen. For these reasons a fine pair of Lister’s sinus-forceps or a
narrow-bladed bistoury is recommended. In the ordinary case Lister’s
forceps can be used.

The direction in which the brain is explored depends upon the point at
which this is done. Thus, if the procedure be carried out through the
tegmen tympani, the brain is explored in an upward direction. The
forceps are made to pierce the brain for about an inch; the blades are
then slightly dilated and the forceps partly withdrawn. If a large
abscess exists, the cavity is usually opened at once and pus flows out
along the track of the forceps. If the abscess be small and deeply
placed, its cavity may not be entered on the first thrust of the
forceps. In this case they are closed and withdrawn. The brain is then
explored by thrusting the forceps first upwards and forwards, then
upwards and backwards, and finally upwards and inwards; in the latter
case it is unwise to pierce the brain for more than an inch and a
quarter for fear of entering the lateral ventricle.

If the brain be explored through the outer wall of the
temporo-sphenoidal lobe, the first direction in which this is carried
out is directly inwards. If this be not successful, the brain is further
explored in a direction forwards, upwards, or backwards, the exploratory
instrument at the same time pointing slightly inwards.

If exploration proves negative, it may also be necessary to explore the
cerebellum. If, however, the surgeon be still convinced that a
temporo-sphenoidal abscess exists, he may next pierce the brain with the
bistoury, in case the forceps has failed to enter the abscess cavity,
perhaps owing to its walls being very thick. If all efforts fail to find
the abscess, the little finger may be inserted into the brain itself to
see if the resistant wall of an abscess can be felt. This procedure,
however, should be avoided if possible, as by doing so it causes
destruction of a certain amount of brain tissue.

If an abscess be opened a varying quantity of pus escapes, usually evil
smelling. In the more chronic cases it is thick and greenish; in the
acute cases it may contain shreds of necrosed brain tissue or be
intermixed with bubbles of gas. Sometimes there is also an escape of
turbid cerebro-spinal fluid, which if excessive is suggestive either
that the lateral ventricle has been opened inadvertently or that the
abscess has already burst into it. In these cases the patient is usually
comatose or in the state of muttering delirium at the time of the
operation.

After the abscess has been opened, the forceps or bistoury should be
retained in position until the pus has drained away. A large tube is
then pushed into the abscess cavity along the line of the forceps or
bistoury. It is only permissible to withdraw the instrument with which
the abscess has been opened after the end of the tube is well within the
cavity. The outer end of the tube should be flush with the surface of
the wound. To prevent it slipping too far into the brain, it may be
anchored to the edge of the skin wound by a silkworm-gut suture. If the
abscess be drained through the tegmen tympani, it will be difficult to
bring the tube out into the wound without kinking it. For this reason I
prefer to incise the brain substance slightly outwards after the abscess
cavity has been reached, so that a tube can be inserted obliquely
upwards and inwards at a point corresponding to the angle between the
tegmen tympani and the squamous portion of the temporal bone. If the
exploratory puncture has been made above the tegmen tympani and an
abscess discovered, the question arises whether another drainage tube
should not also be inserted into the brain through an opening in the
roof of the antrum so as to drain the abscess from below. This, however,
I do not think necessary.

In addition to the rubber tube, many varieties of drainage tubes have
been suggested, such as decalcified chicken bone, as originally used by
Macewen, and glass or silver tubes; the object of the latter being to
resist the pressure of the brain, which may compress a rubber tube. The
rubber tube is the simplest form of drainage, and if sufficiently thick
it should be employed. To make more certain of free drainage, some
surgeons use two tubes placed side by side. I think, however, one large
tube (half an inch in diameter) is better than two small ones.

Irrigation of the abscess cavity is still a matter of opinion. If the
abscess be small and circumscribed, the best method is to open it with
as little disturbance as possible to the surrounding parts, insert a
large drainage tube, and to do nothing further.

If, however, the abscess be large and irregular in shape, so that the
drainage is not free, and especially if it be very septic and contains
necrosed brain tissue, irrigation is justifiable if gently carried out.
The best method is to insert a fine tube along the lumen of the large
one and allow some warm saline solution to flow slowly along it into the
abscess cavity, the fluid returning along the larger tube. If two tubes
have already been inserted into the abscess cavity, the fluid injected
through one will escape by the other. Whatever method is employed, care
must be taken that there is free exit for the fluid, as otherwise the
abscess cavity may become over-distended, and in consequence rupture of
a portion of its wall may take place, especially the inner, which
perhaps only consists of a thin layer of brain tissue separating the
abscess from the lateral ventricle. During the act of irrigation there
is a risk of some of the fluid, now loaded with septic particles,
escaping between the surface of the brain and the dura mater and thus
setting up a secondary meningitis.

[Illustration: FIG. 253. EXPLORATION FOR A CEREBELLAR ABSCESS. A behind,
and C in front of the lateral sinus; B, Lateral sinus.]

=Opening of a cerebellar abscess.= The cerebellum may be explored from
two different points, either in front or behind the lateral sinus. The
posterior route is adopted if the abscess is superficial in the outer
portion of the lateral lobe, usually the result of lateral sinus
thrombosis or disease of the posterior mastoid cells. The anterior
route is indicated if it is thought that the abscess is deeply placed in
the anterior inferior portion of the cerebellum, that is, in those cases
in which it is apparently a complication of labyrinthine suppuration, or
the result of disease of the inner wall of the antrum and mastoid
cavities (Fig. 253).

(_a_) _Behind the lateral sinus._ After exposure of the lateral sinus
the bone is removed either by means of the gouge and mallet or by
bone-forceps, until a considerable area of the dura mater is exposed
behind and below the curve of the sinus (Fig. 253). The dura mater is
then incised as already described.

The cerebellum is explored by thrusting the instrument inward for about
an inch. As a rule the abscess is found at once. If it be not discovered
at the first attempt, the instrument should be directed forwards,
upwards, and inwards towards the posterior surface of the petrous bone.
Care, however, must be taken that it is not pushed in too far, otherwise
it may pierce the anterior upper margin of the cerebellum, and if an
abscess be present, the meninges may thus become infected. If the
surgeon has exposed the dura mater by trephining, it is necessary to
push the exploratory instrument at least two inches inwards and forwards
in order to reach an abscess situated in the anterior inferior portion
of the cerebellum. In such cases it is by no means difficult to miss a
small abscess, and further, drainage is frequently incomplete when an
abscess is discovered. For this reason, if the cerebellum be explored
first behind the lateral sinus and no abscess is discovered, it should
further be explored by the anterior route in front of the lateral sinus.
If the cerebellar abscess be secondary to lateral sinus thrombosis, and
if there be no doubt as to the diagnosis, the inner wall of the sinus
should be made as aseptic as possible, and the dura mater forming it
incised freely; the cerebellum being thus explored through the site of
infection.

(_b_) _In front of the lateral sinus._ The lateral sinus is first
exposed (Fig. 253). The triangular area of bone situated in front of it,
between it and the semicircular canals, and forming the inner boundary
of the antrum and mastoid cavities, is now removed with the gouge and
mallet or with a suitable pair of forceps. If it be certain that
internal-ear suppuration exists, or if the operation be secondary to
opening of the labyrinth, the posterior wall of the petrous bone may be
removed until the internal auditory meatus is almost reached. If,
however, the labyrinth be intact, care must be taken not to chisel away
too much bone for fear of encroaching on the posterior semicircular
canal. On exposure of the dura mater an extra-dural abscess may be met
with, usually the result of internal-ear suppuration. Even if no pus be
seen, it is always a wise precaution, if internal-ear suppuration
coexists, to separate the dura mater from the posterior wall of the
petrous bone by means of an elevator in order to prevent any deeply
situated extra-dural abscess being missed. After the dura mater has been
exposed sufficiently it is opened by a crucial incision. In this region
absence of increased tension within the brain and lack of bulging
outwards of the cerebellar tissue do not necessarily imply the absence
of an abscess; the cerebellum to all appearances may appear normal and
flaccid, although a small abscess may be present.

The cerebellum is explored in various directions to a distance of not
more than one inch. After the pus has been evacuated a tube is inserted
as described above. In the majority of cases this method is far superior
to opening the cerebellum behind the lateral sinus, especially as it is
now recognized that the chief cause of cerebellar abscess is
internal-ear suppuration.

=After-treatment.= This is similar to that of any ordinary abscess, but
care must be taken that free drainage is maintained. The main part of
the mastoid wound is lightly plugged with gauze, the tube inserted into
the brain abscess being brought flush with the surface of the skin. The
gauze filling the wound cavity should be arranged around the tube so
that it rests comfortably within the wound and is not kinked. If the
drainage tube be in its proper position, pus should be seen to ooze out
of it.

Although the mastoid cavity itself need not be dressed daily, if
necessary the outer dressings may be removed twice a day, in order to
see that drainage of the abscess is continuous. After the first two or
three days, the tube is gradually shortened. If the abscess be a recent
one and not encapsuled, it becomes rapidly obliterated by pressure of
the surrounding brain tissue, so that the tube may be forcibly ejected
within a few days. On the other hand, if the abscess has existed for a
considerable period and is bounded by a thick wall, which may be
extremely resistant, the purulent discharge may continue for many days
and necessitate the continuance of drainage. Generally speaking, the
tube may be shortened every second or third day, and can usually be
dispensed with by the end of the second week, if not before. It is,
however, very necessary that the tube should not be withdrawn until it
is certain that the abscess cavity has been obliterated completely.

The general treatment of the case in no way differs from that already
described for the mastoid operation in which the wound has been left
open posteriorly.

=Complications.= (i) On turning back the flaps of the dura mater, a
hernia, consisting of friable congested brain tissue, may occur at once.
This is extremely rare as a result of a simple abscess of the brain,
but is significant of encephalitis frequently associated with
meningitis (see p. 436). If an abscess be suspected, the brain should be
explored as already described. If, however, no abscess be discovered,
the treatment consists in removal of more bone and further incision of
the dura mater, in order to permit of free drainage and to relieve
tension.

(ii) Opening into the lateral ventricle. This may be due to rupture of
its wall owing to the sudden diminution of pressure from too rapid
drainage of the abscess cavity, or it may occur accidentally from
thrusting in the exploratory instrument or drainage tube too deeply. Its
occurrence is evidenced by the sudden gush of cerebro-spinal fluid. The
ultimate danger is subsequent infection of the cavity, which,
unfortunately, frequently occurs.

(iii) Cessation of breathing. This is more likely to occur in a
cerebellar abscess in consequence of direct pressure on the medullary
respiratory centres. The immediate treatment is to do artificial
respiration and to open the cerebellar abscess by the quickest method
possible. If this be successful, respiration probably will be restored.

=Prognosis and subsequent progress.= In an uncomplicated case a
favourable prognosis may be expected, provided the abscess is
successfully opened and drained without much disturbance of the
surrounding parts. Many factors, however, may lead to a fatal result.
With regard to recovery: in 100 cases taken from the records of the
London Hospital during the last ten years, recovery took place in 20%
operated on for cerebral and 10% for cerebellar abscess. Other
statistics give a much higher percentage of recovery, but it must be
remembered that in hospital patients a large number of the cases are
only seen by the surgeon at a very late stage, when the brain abscess is
complicated by other intracranial or suppurative lesions, and the
patient is in an almost moribund condition; so that the operation may
only be undertaken as a forlorn hope.

If the operation is going to be successful, the head symptoms quickly
disappear. Even if the patient was comatose before operation, the
recovery may be so rapid that his mental condition may be almost normal
within twenty-four hours. In many cases, if the abscess be a large one,
convalescence will be tedious or prolonged; sometimes, indeed, complete
restoration of the mental faculties, in spite of a most successful
operation, will not be obtained. The chief relief to the patient is the
cessation of the terrible headaches from which he has been suffering.

Unfavourable symptoms are the sudden onset of pyrexia accompanied by
delirium usually the result of diffuse meningitis, or of infection of
the lateral ventricles. In the latter case there is a rapid termination
in drowsiness, coma, and death.

Although the brain abscess may be draining freely, the patient for some
days may lie in a semi-comatose condition as a result of œdema or
inflammation of the surrounding brain tissue; in such cases prognosis is
difficult, but hope of recovery may be entertained if the pulse and
temperature keep practically normal.

=Recurrence of symptoms.= This may take place within the first few days
after the operation as a result of infective cerebritis, the presence of
another abscess, or faulty drainage; or at a much later period, owing to
the formation of another abscess or to a cyst within the brain at the
site of the former abscess.

1. If the recurrence of the symptoms appears immediately after the
operation, the wound should be inspected carefully, if necessary under
an anæsthetic. If drainage be not free, the tube should be removed and a
pair of forceps inserted along the track leading into the abscess, their
blades being then slightly opened and withdrawn. On doing this an
accumulation of pus may escape. The cavity may then be irrigated gently
with saline solution and a larger tube inserted.

If, however, this procedure does not give a satisfactory result, the
finger may be inserted into the brain to feel if the abscess is
loculated. By this means any existing septa may be broken through; or if
a feeling of resistance suggests the presence of another abscess, this
part of the brain can also be explored. It must also be remembered that
although a temporo-sphenoidal abscess has been opened successfully and
is draining well, the continuance of the symptoms may be due to a
coexisting abscess of the cerebellum, or _vice versa_; in other cases,
in spite of all care, the patient gradually sinks, partly from
exhaustion and partly from general toxæmia, the result of infective
cerebritis.

2. Recurrence of symptoms at a later period. The occurrence of a fresh
abscess is usually owing to the fact that the primary focus of the
disease has not been completely removed at the first operation; for
instance, if the surgeon only trephined and drained the abscess without
performing the mastoid operation.

A cyst is usually the result of the abscess having been encapsulated and
its wall not having been removed at the first operation. If a cyst be
discovered on exploring the brain in consequence of these symptoms, its
wall should be removed if possible.

Apart from symptoms of intracranial pressure, the patient may suffer
from attacks of Jacksonian epilepsy from time to time, presumably due to
the post-operative adhesions. If they continue in spite of conservative
treatment, it may become necessary to operate in order to remove this
source of irritation (see Vol. III).




                               SECTION IV

                     OPERATIONS UPON THE LARYNX AND
                                TRACHEA

                                   BY

           W. DOUGLAS HARMER, M.C. (Cantab.), F.R.C.S. (Eng.)

  Surgeon to the Throat and Nose Department, St. Bartholomew’s Hospital




CHAPTER I

ENDOLARYNGEAL OPERATIONS


=Indications.= (i) _Tumours._ Tumours of the larynx are more often
innocent than malignant. Sir F. Semon[5] collected 12,297 cases seen
between 1862 and 1888 by 107 laryngologists, and of these 10,747 (or
88%) were benign and 1,550 (or 12%) were malignant. Of the innocent
forms, papilloma, either simple or multiple, occurred in 39%; fibroma,
sessile or pedunculated, was next in frequency; cystic tumours were not
nearly so common; and other forms, including myxoma, angeioma, adenoma,
lipoma, and enchondroma, were rare. The period during which these
tumours are most common is between the ages of 20 and 40 years, but they
are also frequent during childhood.

[5] _Internat. Centralblatt für Laryngol._, Jahrgang v u. vi, 1888-9,
‘Die Frage des Ueberganges gutartiger Kehlkopfgeschwülste in bösartige,
speciell nach intralaryngealen Operationen.’

Malignant growths occur at a later age, mostly between the ages of 40
and 60, and attack males more than females. Carcinoma is far more common
than sarcoma, and is generally of the squamous-celled variety.
Endothelioma has not often been discovered.

The importance of distinguishing innocent from malignant tumours is
greater now than in former years, since it is agreed that endolaryngeal
operations are preferable for the eradication of the former, while the
latter are better treated by extra-laryngeal methods. Moreover, the
differential diagnosis has steadily improved, owing to the more general
use of the laryngoscope and the introduction of recent methods of
examination. Thus, by direct laryngoscopy it is possible to investigate
children as easily as adults. Microscopical examination of fragments
removed with laryngeal forceps is of great value in confirming the
clinical diagnosis; the sections can be made by freezing, or in
paraffin, the latter method requiring, with recent improvements, not
more than twenty-four hours. Semon, who has done more than any other man
to improve the early diagnosis of malignant disease of the larynx, is
strongly in favour of such examinations. It must be remembered, however,
that the result is sometimes inconclusive, for it is difficult to be
certain that the actual growth has been removed. In cases that are
thought to be malignant, it is better to open the thyreoid[6] cartilage
than to rely upon endolaryngeal operation, as there is a danger of
stimulating the growth to greater activity, especially by repeated
interference. When the thyreoid cartilage has been opened, the whole
disease can be explored thoroughly and a fragment selected from which to
make a frozen section. In the majority of cases a definite diagnosis can
thus be arrived at, and even when it is necessary to examine several
fragments the amount of time lost is small.

[6] [The spelling of this word has been adopted in conformity with the
Basle Anatomical Nomenclature.--Ed.]

As regards the value of skiagraphy, Walsham and myself have found that
photographs can be made of tumours of the larynx which in some instances
determine accurately the position and extent of the disease.

[Illustration: FIG. 254. SKIAGRAM SHOWING A TUMOUR OF THE LARYNX. A,
Tumour; B, Body of hyoid; C, Greater cornu of hyoid; D, Epiglottis; E,
Posterior plate of cricoid; F, Vocal cord; G, Trachea; H, Œsophagus.]

Fig. 254 is a photograph showing a cancer of the upper opening of the
larynx, lying above the vocal cords, the position of which was proved to
be accurate by later operation upon the patient. It is, however,
doubtful whether the method will eventually assist in the differential
diagnosis between innocent and malignant growths.

(ii) _Tuberculosis._ Endolaryngeal operations are successfully performed
for chronic conditions such as ulceration or tumour, and, rarely, in
acute forms such as abscess, necrosis, and the like. Removal of a
portion of the epiglottis occasionally gives great relief to a patient
who is suffering from dysphagia.

(iii) _Strictures_ resulting from trauma, from the ulcerations of
syphilis, diphtheria, and other inflammatory diseases, or caused by
congenital webs.

(iv) _Foreign bodies_ impacted in the larynx.

(v) _Œdema_ of the mucous membrane due to trauma or inflammation, local
abscess, necrosis, and other allied conditions, in which obstruction is
likely to supervene.

The operation may be performed either by indirect or by direct
laryngoscopy.


OPERATION BY INDIRECT LARYNGOSCOPY

It being essential that the patient should be tolerant, this method is
chiefly applicable in the case of adults. The operation may require a
course of instruction, but this presents no difficulty if given with
discretion. The employment of cocaine, novocaine, and adrenalin is of
the greatest importance to both surgeon and patient. Cocaine, which is
generally to be preferred, may be used in strong solutions--10 or even
20%--if applied to the mucosa by a small swab of wool; but, if used as a
spray, weaker solutions are employed (4%). With neurotic patients
cocaine must be applied cautiously, as a sense of suffocation is
sometimes produced. It is necessary first to treat the soft palate, the
uvula, base of the tongue, pharynx, and epiglottis; secondly, with the
help of a laryngeal mirror, the interior of the larynx must be
cocainized; this can be accomplished by expelling a few drops of the
solution from a laryngeal syringe or by means of a swab attached to a
suitable wool-carrier. Fifteen to twenty minutes must be allowed to gain
the full effect of anæsthesia. The patient must be instructed on no
account to swallow the saliva. The secret of successful intralaryngeal
operations lies in the thorough application of these principles, and in
not attempting the operation until the patient is able to tolerate the
presence of an instrument within the larynx. The surgeon must be
experienced in the use of laryngeal instruments, and must be provided
with a complete equipment, including forceps (Mackenzie’s, Whistler’s,
Grant’s, &c.), which must be of different lengths to suit the patient,
snares, galvano-cautery, curettes, probes, and other instruments for the
application of drugs. Proper illumination is also very important.

When removing an intralaryngeal growth, the surgeon sits facing the
patient. The mouth is opened to the fullest extent, and the tongue drawn
well forward and held by the patient’s right hand. The mirror is
introduced in such a way that the tumour is distinctly seen. If the
epiglottis overhangs, it can be drawn forward with the forceps; or, in
rare instances, a special instrument (Fig. 255) can be used for
transfixing its upper margin with a thread, the latter being grasped by
a pair of pressure forceps, which, being allowed to hang, will
automatically raise the obstruction.

The forceps, having been warmed, are taken in the right hand when the
tumour is on the right side of the larynx and in the left hand when the
tumour is on the left, thus allowing a clearer view than when the same
hand is employed irrespective of the position of the disease. It is
introduced as follows: firstly, the handle is directed towards the
patient’s left ear until the point of the forceps has passed beyond the
back of the tongue and lies behind the epiglottis; secondly, the
instrument is quickly rotated so that the handle lies below the chin;
thirdly, the hand is raised so that the point is directed forwards;
fourthly, the whole instrument is quietly lowered and the beak of the
forceps directed towards the growth. This manipulation is made more
difficult by the laryngeal image being reversed in an antero-posterior
direction.

[Illustration: FIG. 255. HORSFORD’S INSTRUMENT FOR TRANSFIXING THE
EPIGLOTTIS.]

When the point is seen to rest upon the growth, the instrument is
opened, and the tumour grasped and avulsed: with careful manipulation
there is little danger of wounding the normal mucosa, and hæmorrhage is
insignificant. When dealing with multiple growths the patient must
understand that it may be necessary to repeat the operation, either
immediately or after an interval. Given suitable instruments, sufficient
experience, and a tolerant patient, it is possible to remove, with the
help of cocaine, the majority of simple tumours. Operations upon cysts,
the scarification of mucous membrane with a guarded knife, the
curettement of tuberculous ulcers, and cauterization of the larynx, are
all conducted upon similar lines. Foreign bodies can generally be
removed with forceps; thus, F. A. Rose[7] reported a case in which part
of the breastbone of a chicken, measuring 1 inch in length and over 3/4
of an inch in width, was removed after having been impacted in the
larynx for nearly forty-eight hours. In rare instances such an operation
is not successful; _e.g._ with a foreign body firmly impacted, multiple
papillomata, or an intolerant patient, general anæsthesia may be
required, and removal may have to be effected through a tube-spatula or
by external incision.

[7] _Proc. Roy. Soc. Med. London_, vol. i, No. 2, Laryn. Sect., p. 5.

=After-treatment.= Intralaryngeal wounds generally heal well, but every
effort should be made to prevent infection of the parts, to allay any
inflammation that may arise, and to avoid catarrh and swelling of the
mucosa. It is advisable to order complete vocal rest until the redness
has subsided, and the patient should refrain from coughing; the sucking
of ice, or the inhalation of benzoin or other medicated steam, has a
sedative action upon the parts. If the larynx becomes septic or filled
with irritating discharge, the use of sprays or powders is indicated; in
such a case the patient may be given a parolein spray, with menthol,
eucalyptus, or other antiseptic, for constant use; or a powder such as
orthoform, the latter being sucked into the larynx through a warmed
glass tube (Leduc’s insufflator), or applied by the surgeon. In the
later stages the patient may be treated by the local application of
caustic fluids, or by galvano-cautery, as occasion requires. The success
of such operations depends largely upon the skill of the surgeon; if
attention be given to the after-treatment the results are very good, and
the voice is generally recovered. As Semon has shown conclusively, there
is no practical danger of the occurrence of malignant degeneration
through the influence of instrumentation.


OPERATION BY DIRECT LARYNGOSCOPY

=(Killian’s Method)=

=Indications.= (i) _Multiple papillomata._ These tumours occur most
commonly during the early years of life, and operations for their
removal present great difficulties, first, in their removal, and,
secondly, owing to their inveterate tendency to recurrence whatever
operation is performed; moreover, in some instances operation seems to
stimulate the growths to greater activity. The case reported by Stoker
is a well-known instance. He was consulted by a man thirty years of age
who had suffered from papilloma for twenty-three years, during which
period one surgeon had performed 100, and a second 120 operations.

(ii) _Benign tumours_ other than papillomata, which are not amenable to
operation by indirect laryngoscopy.

(iii) _Foreign bodies._ Direct laryngoscopy is advised for patients who
are intolerant (_e.g._ young children), or when the object is firmly
impacted, or when other methods of treatment have failed. Thus in one of
my cases a man presented himself with a long pin impacted transversely
above the vocal cords; it was found impossible to remove it by indirect
laryngoscopy without serious injury to the parts. An anæsthetic was
therefore given and a large tube-spatula passed into the larynx: with
strong forceps the pin was bent upwards and removed with ease.

(iv) _Granulations_, _ulcers_, _necrosis_, and other _inflammatory
conditions_ such as are caused by diphtheria, tubercle, syphilis, and
many other diseases.

(v) _For diagnostic purposes._ There can be little doubt that direct
laryngoscopy has a great future before it as a means of determining the
nature of doubtful laryngeal conditions. If the upper parts of the
larynx be swollen, if there be any stenosis such as follows ulceration,
or if the patient be intolerant, the air-passages cannot be thoroughly
examined with the laryngoscope alone. With the newer method many of
these difficulties have disappeared, and it is now possible for the
surgeon to diagnose with certainty many conditions which would otherwise
have remained doubtful.

_The apparatus required_ consists of:

(_a_) The _tube-spatulæ_. The tube originally suggested by Killian was
made of straight metal and circular in section, the distal end being cut
obliquely with the projecting portion fashioned like a spatula. A strong
handle, at right angles to the tube, was used for manipulation.
Different sizes were required for children and adults. Various
modifications of these tubes are now in use, notably those of Mosher and
Bruenings: the instrument recommended by the latter is easier to
manipulate and gives a better view than the earlier forms described.

[Illustration: FIG. 256. MULTIPLE PAPILLOMATA OF THE LARYNX. (_From
Specimen No. 1647 in the Museum of St. Bartholomew’s Hospital._)]

(_b_) The _lamp_ for illumination. Different forms of head-lamp
(Killian’s, Kirstein’s) and hand-lamp (Caspar’s) have been devised for
illumination from the outside, and Chevalier Jackson has invented a lamp
which is sufficiently small to pass to the distal end of the tube, where
it lies in a compartment of its own lest it should be broken and fall
into the trachea. Recently these electroscopes have been improved upon
by Bruenings, in whose instrument (Fig. 257) the lamp is more powerful
and is attached to the handle in such a manner that it can be easily
swung into position when required. A condensing lens has also been
added and the light can be focused to any desired distance. If
preferred, an ordinary forehead-mirror reflecting the light from a
powerful Nernst lamp (100 c.p.) can be employed.

(_c_) The _instruments_ for operation. Various forms of forceps for
removal of tumours have been devised by Killian, von Eicken, Bruenings,
Patterson, and others. In any form that is employed it is necessary, in
order to allow of clear vision, that the handle should be set at an
angle with the shaft. For foreign bodies, hooks of different shapes are
also useful. Other requirements include a gag for opening the mouth, a
tongue depressor, tongue forceps, suitable cotton-wool carriers, the
requisites for tracheotomy, and a darkened room.

[Illustration: FIG. 257. TUBE-SPATULÆ USED FOR LARYNGOSCOPY. A,
Killian’s. B, Bruenings’. A, Handle; B, Collar to allow rotation; C,
Fixation spring; D, Switch; E, Socket for lamp; F, Focus; G, Lamp; H,
Lens; I, Aperture for eye; K, Reflector.]

=Operation.= The operation can be performed with local or general
anæsthesia. With patients who are intolerant chloroform is more
reliable, and is preferable to other drugs, which tend to excite
secretion. Chloroform should always be employed for children. It should
be given slowly and in the smallest possible quantity, the head of the
patient being kept lower than the body to allow blood and mucus to drain
away from the trachea. To make the parts more tolerant, cocaine can also
be applied to the vocal cords, or a dose of morphine (codeine is advised
in children) can be given half an hour before the operation. The
importance of a skilled anæsthetist cannot be too strongly emphasized.
With chloroform, the patient should lie upon the back or right side,
with the head projecting beyond the end of the table, so that the neck
can be extended as required. With cocaine the upright position is often
preferred, and the patient should sit on a low stool facing the surgeon.
When the patient is recumbent, the surgeon should sit or kneel behind
the head (Fig. 258). He should observe the strictest antiseptic
precautions, and should introduce no instrument which has not been
properly sterilized; further, the tubes should be previously warmed to
prevent ‘fogging’, and oiled with sterilized liquid paraffin before
introduction. There should be two assistants, one (the chloroformist) to
support the head and watch the respiration and pulse, the other to help
with instruments.

In order to examine the larynx, the mouth is opened by a gag, and the
tube-spatula is passed to the upper border of the epiglottis; when this
has been inspected the spatula is pushed behind it, and the upper
portion of the cricoid plate is examined; the tongue is then pulled
forward and the tube tilted so that the larynx can be seen. The
examination should be methodical, and should include the vocal cords,
ventricular bands, and openings of the ventricles. The whole
manipulation can be performed with great delicacy, and is entirely
guided by the eye, so that there is little fear of injury even in young
children.

In this and the further technique the chief difficulties are caused by:
(_a_) _The prominence of the upper teeth._ This may seriously interfere
with the easy passage of a straight tube, even when the neck is fully
extended. The difficulty can be overcome by turning the head laterally,
so that the tube passes through the opposite angle of the mouth. (_b_)
_The mucus_, which collects in the tube and obstructs the vision. This
must be overcome by using a secretion aspirator, by frequent sponging,
or, as suggested by Ingals, by giving a previous dose of atropin[e].
(_c_) _Intolerance of the parts_, which can be counteracted by the
judicious use of cocaine (10%). It may be noted that this combination of
chloroform and cocaine is not dangerous, even in young children, so long
as the cocaine is prevented from running into the pharynx.

[Illustration: FIG. 258. REMOVAL OF MULTIPLE PAPILLOMATA BY DIRECT
LARYNGOSCOPY]

The condition of the larynx having been thoroughly examined, the
operation can proceed. The method of removing multiple papillomata will
first be described. In some cases it will be found that better exposure
of the tumours is obtained if the end of the tube is placed above the
epiglottis rather than in the larynx itself. The position of the growths
having been determined, a suitable forceps is selected and introduced
through the tube. The papillomata are seized and avulsed separately,
without injury to the normal tissues. To arrest the bleeding it may be
necessary to apply cocaine and adrenalin mixture, and to raise the foot
of the table so that the blood drains away from the field of operation.
As far as possible, all the growths should be removed; it may be
difficult to attack those which are situated in the anterior commissure
or subglottic region, but this difficulty may be overcome by the use of
specially devised instruments; thus, von Eicken has invented a tube
which is long enough to pass through the larynx and into the trachea,
the portion lying in the larynx being provided with a lateral window
which can be turned in any direction, so that a growth can be made to
project into the tube, where it can be easily removed.

At any moment during this operation the surgeon may be called upon to
perform tracheotomy.

=After-treatment.= This must be carried out upon the same lines as those
already suggested; everything must be done to relieve congestion and
irritation. Killian advises internal administration of arsenic for a
period of several months, and, if this fails, potassium iodide in large
doses. It should be remembered that in some instances syphilis seems to
play an important part in the causation of these conditions. Ingersole
suggests that X-rays prevent recurrence, and may even cause shrinkage of
existing growths.

Recurrence occurs in most cases in some degree, and requires further
operation; this may be carried out after an interval of a week or
longer, according to the case. At these secondary operations it may not
be necessary to use the forceps; local applications such as absolute
alcohol, salicylic acid in absolute alcohol (2-10%), solutions of silver
nitrate or chromic acid, and many other drugs, have been advised by
different surgeons. Wylie is strongly in favour of the galvano-cautery,
and is of opinion that the technique is more reliable and the liability
of local infectivity diminished. If the latter method be employed, very
little should be done at one sitting, otherwise great inflammatory
reaction may be set up, entailing tracheotomy. A tracheotomy tube may be
required for a short time while such treatment is being carried out;
some surgeons, with whom the author does not agree, always perform
preliminary tracheotomy, and claim that the papillomata are less likely
to recur if complete rest is thus given to the larynx.

=Results.= In discussing the value of the above method it is necessary
to refer to the results obtained by other operations, such as--

(i) _Tracheotomy_ (see p. 522). This operation has been advocated as a
method of curing papillomata. It has been noted that by giving rest to
the larynx the congestion is relieved, the papillomata decrease in size,
and in some cases completely disappear. Mackenzie[8] published seven
cases which he had had under observation for a minimum of two years,
with four recoveries, the canula having been worn for periods varying
from six to fifteen months. He also mentioned thirteen other cases in
which good results had been obtained by other surgeons, and was of
opinion that the method was most successful with ‘virgin’ cases. There
are, however, many objections to this form of treatment. For instance,
it is often necessary to retain the tube for a prolonged period, two
years or longer, and even then the result is doubtful; moreover, the
prolonged use of a canula is disastrous to the larynx, not only in
retarding development, but also in the production of stenosis; there is
also a danger of bronchitis, of broncho-pneumonia, and possibly of
tuberculosis. In regard to the last, G. A. Wright,[9] in reporting a
case in which tubercle supervened, argues that ‘presumably there is more
risk of this happening to the wearer of a tracheotomy tube than when
breathing in a normal way through the mouth or nose’. Further, the line
of treatment is difficult to enforce on account of the aversion shared
by most parents to the performance of tracheotomy.

[8] _Brit. Med. Journ._, 1901, vol. ii, p. 883.

[9] Ashby and Wright, _Dis. of Child._, 4th ed., p. 350.

(ii) _Laryngo-fissure_ (see p. 487). Under this head are included
thyrotomy, or complete division of the thyreoid cartilage; partial
thyrotomy, where a small portion of the upper or lower part of the
thyreoid cartilage is left intact (an operation which does not give a
good exposure of the larynx); infrathyreoid laryngotomy, which is only
applicable to adults; cricotomy, with division of the cricoid cartilage
and crico-thyreoid membrane; and subhyoid pharyngotomy. Of the above,
thyrotomy is the most satisfactory operation, because it gives the best
exposure of the parts and facilitates removal of the growths;
recurrence, however, is frequent, permanent injury to the voice is
common, and stenosis may result.

The results of these operations, especially during childhood, are by no
means satisfactory. In the statistics carried up to 1896, collected by
Rosenberg and von Bruns,[10] laryngotomy was performed 143 times on 109
children; 11 were operated upon twice, 3 children three times, and 1
child seventeen times. 52 of the children were under four years of age;
20 died, principally from suffocation with recurrent papillomata; 43
showed recurrences after repeated operation; 40 were cured (_i.e._ 36%),
and of these 10 showed disturbance of voice.

[10] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 231.

It must be admitted that operations for the treatment of papillomata do
not meet with any great measure of success. It seems probable, however,
that the results obtained by endolaryngeal removal are better than those
obtained by either tracheotomy or laryngo-fissure. To quote Killian[11]:
‘Formerly, and especially from the standpoint of the surgeon,
laryngotomy for laryngeal papillomata was very frequently done in little
children in whom removal was impossible by endolaryngeal methods. In my
judgment, direct laryngoscopy renders such a surgical procedure
unnecessary. We can in all cases, with the aid of a tube-spatula under
narcosis, remove papillomata, and the operation can be repeated as often
as seems necessary.’ These remarks express the general feeling of the
present day, and the most important factor in determining the success of
operative treatment is early diagnosis. Such diagnosis divides the cases
into two classes: those in which the growths are localized, and those in
which they are diffuse. The first class is easy to treat by
endolaryngeal methods, and, given careful after-treatment, the prognosis
is satisfactory. The second class is serious, and far more difficult to
treat; when Killian’s method fails the prognosis is very bad. Finally,
it must be borne in mind that, as recurrence may not occur for several
months, a guarded prognosis must be given in every case.

[11] _Trans. Amer. Laryng. Assoc._, 1907, p. 127. Discussion of paper by
C. G. Coakley on ‘Removal of papillomata of larynx by direct
instrumentation with the aid of Killian’s tubes.’

The removal of other benign tumours and of foreign bodies, and the
treatment of granulations, are conducted upon similar lines, and are
attended with excellent results.




CHAPTER II

EXTRA-LARYNGEAL OPERATIONS


THYROTOMY

=Indications.= This operation is performed for two purposes:

(i) To obtain access to the cavity of the larynx when the diagnosis is
uncertain, or as a preliminary to other operations.

(ii) As a method of eradicating certain diseases, of which the following
are important:--

1. _Malignant tumours_, both carcinoma and sarcoma, in which an early
diagnosis has been made, and so long as they remain intrinsic.

It is advisable to follow Krishaber in the separation of all forms of
laryngeal cancer into two classes, the _Intrinsic_ and the _Extrinsic_.
The term ‘intrinsic’ implies a growth springing from the vocal cords,
the ventricular bands, the ventricles, or the subglottic space, and the
growth must lie entirely within the laryngeal cavity. ‘Extrinsic’ is the
term used for a growth affecting the arytenoids, the posterior part of
the cricoid cartilage, the aryteno-epiglottidean fold, or the
epiglottis. Such a growth is not entirely limited to the larynx, but
also involves some part of the pharynx.

2. _Extrinsic localized malignant tumours_ which are attached to the
epiglottis, or to the aryteno-epiglottic fold.

3. _Innocent tumours_ which are too extensive for endolaryngeal
operation or of a doubtful character. In either of these cases it is
justifiable to perform an external operation, which may be thyrotomy, or
occasionally, an atypical operation: thus Semon[12] removed a large
fibromatous tumour of the larynx by submucous resection, without opening
the cavity of the larynx.

[12] _Brit. Med. Journ._, 1905, vol. i, p. 6.

4. _Stenosis_ following syphilis, trauma, acute exanthemata, scleroma,
and other rare diseases. C. Jackson has reported twenty-four cases
falling under this head, nineteen of which lived for more than a year
after the operation with useful voices. If the surgeon is satisfied that
the disease is quiescent, he should point out to the patient that it may
be possible to cure the obstruction by thyrotomy. It must, however, be
remembered that tertiary syphilitic lesions may again become active as
the result of operative interference. It is probable that slight cases
of stenosis can be treated better by intubation than by thyrotomy.
Thyrotomy has also been suggested to relieve stenosis caused by double
abductor paralysis of the vocal cords, but such cases are better treated
by tracheotomy or intubation.

5. _Foreign bodies._ Thyrotomy is rarely necessary, and should be
reserved for irregular or sharp-pointed bodies, such as tooth-plates or
bones, which are so firmly jammed that removal by other methods is
impracticable. If there has been much laceration of the soft parts, a
tracheotomy tube should be retained for a few days until the swelling
has subsided.

[Illustration: FIG. 259. INTRINSIC TUMOUR OF THE LARYNX. (_From Specimen
No. 1649 in the Museum of St. Bartholomew’s Hospital._)]

[Illustration: FIG. 260. EXTRINSIC TUMOUR OF THE LARYNX. (_From Specimen
No. 1653 in the Museum of St. Bartholomew’[s] Hospital._)]

6. _Tubercle._ Thyrotomy has been successfully performed in such cases,
mostly under the impression that the disease was malignant. The
differential diagnosis between tuberculous and malignant growths is
sometimes very difficult until the tumour has been explored. In cases
that are known to be tuberculous, the feeling prevails that thyrotomy
is not to be recommended. It should be remembered that the external
wound is liable to become tuberculous.

=Instruments.= Scalpel, curved scissors, dissecting forceps, pressure
forceps, aneurism needles, double hook retractors, bone shears
(Waggett’s) or bone scissors, tenaculum forceps, needles on handles,
catgut in various sizes, a Hahn’s tube, and tracheotomy equipment. A
head-light is required for illumination of the deeper parts during
removal of tumours.

=Operation.= In England, owing to the fact that the administration has
been in skilled hands, chloroform is not considered dangerous, and the
operation is well tolerated even for three or four hours (_e.g._ in
laryngectomy). On the Continent, however, Kocher, von Bruns, and others
advocate local anæsthesia with cocaine or novocaine. Jackson suggested
rectal etherization as an alternative, but this has many dangers. In my
opinion a general anæsthetic should be given, as it enables the
operation to be performed more thoroughly and is followed by less shock.
It must nevertheless be borne in mind that, if the growth is intrinsic
and of large size, it is difficult to administer chloroform, and the
patient is liable to suffer from urgent dyspnœa. In such a case i[t] is
advisable to perform preliminary tracheotomy with novocaine alone (see
p. 544).

As regards the operation, the important question arises whether
tracheotomy ought to be performed several days prior to the main
operation, in order to accustom the patient to the tube and the new
method of breathing. The following reasons are advanced in favour of
this: the main operation is shortened, and relief is given to the larynx
and lungs, so that congestion subsides and broncho-pneumonia is less
likely to supervene. The objections are also important, namely, that
there are two operations instead of one, and perhaps two anæsthetics
(though this can be avoided if local anæsthesia is used for the
tracheotomy); that the tracheotomy wound becomes septic, and infection
of the trachea and bronchi is apt to occur, with consequent bronchitis;
that the air which passes into the lungs is devoid of moisture and heat;
that the trachea becomes surrounded by adhesions; and that it is
altogether unnecessary. The objections in my opinion outweigh the
advantages claimed; it is better to perform tracheotomy as a first stage
in the operation of removal, except in cases where there is great
laryngeal obstruction, where dyspnœa is present, or where bronchitis
fails to yield to other forms of treatment. In such cases tracheotomy
should be performed first, and the second operation should be carried
out a week or ten days later when all the conditions are favourable.

When operating upon the larynx the surgeon must use every precaution to
prevent blood from running into the lower air-passages, and this may be
accomplished by a tampon in the trachea or by keeping the head of the
patient lower than the body. The former method appears to me to be more
reliable than the latter; and I prefer to use a Hahn’s canula, although
the sponge requires from ten to fifteen minutes to swell. This canula is
more reliable than Trendelenburg’s, whose inflated bag is apt to slip or
collapse suddenly. As soon as the thyreoid cartilage has been opened, a
second sponge should be inserted above the canula, and by this means the
air-passages are completely blocked.

If an ordinary tracheotomy tube be used, the operation must be performed
either with the head lower than the body (Rose’s position), or with the
whole body inclined (Trendelenburg’s position), or with a combination of
the two; and in any case a sponge should be placed in the upper part of
the trachea after the thyreoid has been opened. Many surgeons prefer the
combined method. Under no conditions must blood be allowed to pass below
the tube. Whatever form of canula is used, it should be fitted with a
Hahn’s tube and funnel (Fig. 266), so that the anæsthetist can give the
chloroform without interfering with the surgeon. The patient should lie
upon the back on a flat table, the head extended slightly over a small
cushion in the position for tracheotomy.

_First stage._ A vertical incision is made in the middle line from the
hyoid almost to the sternum, so as to expose the thyreoid cartilage and
the pretracheal muscles; these are retracted, so that the anterior
aspect of the trachea is exposed; the isthmus of the thyreoid gland is
completely divided, and search made for bleeding points until the wound
is quite dry. A large opening is made accurately in the middle line of
the trachea; this will be at least two rings below the cricoid cartilage
in order that the tube may be well away from the region of the growth.
In adults, if a Hahn’s tube be employed, the section should include at
least three rings of the trachea.

_Second stage._ The anterior aspect of the thyreoid cartilage, and the
crico-thyreoid membrane, are freely exposed, the infrahyoid muscles
being separated by at least one inch and, if necessary, retracted. Ten
minutes after the tube has been inserted, the crico-thyreoid membrane is
punctured, exactly in the middle line, in order to admit the inner blade
of the bone forceps; the latter is pushed upwards, slowly and without
force, between the posterior portions of the vocal cords, until the
whole length of the thyreoid cartilage is included between the blades;
the forceps are then forcibly closed, great care being taken that the
outer blade is cutting exactly in the middle line. By quickly opening
the cartilage in this manner, there is practically no danger of
destroying the anterior attachments of the vocal cords, or cutting
through the substance of one of them. The two halves of the larynx are
forcibly separated and retained in this position by hooked retractors,
so that the interior of the larynx is exposed. In order to give a free
exposure, it is necessary, as a rule, to divide with a knife the
crico-thyreoid membrane; but the thyreo-hyoid membrane should not be
touched, nor should the attachments of the epiglottis be disturbed. The
separation must be performed carefully in order to avoid a fracture of
the cartilages. The pharynx is plugged with gauze, so that no saliva can
enter the wound, and after all secretion has been removed from the
larynx a small sponge or plug is inserted into the upper end of the
trachea. Cocaine, 20%, is freely applied with a swab of wool to every
part of the larynx in order to constrict the vessels; persistent
hæmorrhage can be controlled by plugging the cavity with wool soaked in
cocaine; ‘this fully suffices ... and the employment of adrenalin, as I
have personally experienced in one case, increases the risk of secondary
parenchymatous hæmorrhage’ (Semon). Further, and this is of importance,
by the use of cocaine the irritability of the larynx and the laryngeal
reflex are destroyed. The tumour can now be inspected; it must be
thoroughly exposed by cutting through the soft or hard structures
(cricoid if necessary) so that its limits can be determined, thus
enabling the surgeon to decide whether it is possible to obtain a
satisfactory result by local removal.

[Illustration: FIG. 261. THYROTOMY. Showing exposure of the larynx, and
tube for the anæsthetic.]

_Third stage._ In the words of Butlin[13]: ‘an incision is carried
around it (the tumour) with knife or scissors, including more than half
an inch of the surrounding apparently healthy tissues, without respect
to the after use of the voice or any other consideration except the
complete removal of the disease. The included area is cut out right down
to the cartilage, which is laid bare and finally scraped absolutely bare
with Volkmann’s sharp spoon.’ The cavity is then plugged for a few
moments until the bleeding has been controlled. The hæmorrhage is never
serious, and can be controlled by catgut ligature if necessary. The
wound must be completely dry. It is then dusted with a powder such as
orthoform; the retractors are removed, and the alæ of the thyreoid
cartilage allowed to fall together. In relation to the removal of the
tumour, Butlin has shown that there is ‘little liability of malignant
disease infiltrating the cartilage of the larynx’, so that, as a general
rule, the latter can be left if all the soft tissues, including the
perichondrium, are removed from its surface; this is comparatively easy
to accomplish in the case of the thyreoid, but more difficult with the
arytenoids and cricoid cartilage. C. Jackson has criticized the use of a
sharp spoon as likely to cause infection of the cartilage.

[13] _Op. Surg. Malig. Dis._, 2nd ed., p. 191.

_Fourth stage._ In some instances it is possible partially to unite the
divided mucous membrane, and so to lessen the granulating area: when
this is done it is of the utmost importance that the lumen of the larynx
should not be constricted, as any constriction will increase the danger
of stenosis. In many instances it is not advisable to attempt to repair
the wound that has been produced.

In suturing the external wound the alæ of the thyreoid are brought
accurately into the position which they occupied before division, in
order that the anterior attachments (if left) of the vocal cords should
heal at their proper level. In some instances the cartilages fall
naturally into the desired position, especially if one or two catgut
sutures are inserted into the thyreo-hyoid membrane; in other cases it
may be advisable to insert one or two similar sutures through the
cartilage itself and thus obtain correct apposition. These sutures
should lie on the outer aspect of the mucosa, so as not to traverse the
cavity of the larynx itself. In cases where only the anterior portion of
a vocal cord has been removed, Semon recommends that the divided end be
sutured to the ventricular band; it is reasonable to suppose that, by
attention to this detail, a better voice will be afterwards obtained.
The infrahyoid muscles are approximated with one or two catgut sutures
in the upper part of the wound; the skin is united with a continuous
silk suture, as far downwards as the lower part of the thyreoid
cartilage. The lower part of the wound is left open, to procure free
drainage through the crico-thyreoid and tracheal openings. The whole of
this lower wound is packed very loosely with gauze, so that discharges
are not retained. It is necessary to emphasize the importance of not
plugging the cavity of the larynx. The Hahn’s tube is removed as soon
as the operation is completed, and replaced by a tracheotomy canula; the
whole wound is covered by a loose pad of antiseptic gauze, which is kept
in position by tapes or loosely applied bandages. No dissection for
removal of lymphatic glands is required.

The above may be called the typical operation for malignant disease in
which the growth is intrinsic; it gives a better exposure of the parts
than other operations such as transverse laryngotomy (division of the
thyreoid cartilage at the level of the ventricles), subhyoid
pharyngotomy, partial thyrotomy, cricotomy, and crico-tracheotomy; the
removal of tumours is therefore easier, and better after-results are
obtained. If the growth be found more extensive, it may be necessary to
modify the procedure. For example:

(_a_) When the epiglottis is involved, an extensive dissection of the
thyreo-hyoid membrane can be made in order to expose and remove the
growth thoroughly together with any soft parts or cartilage which appear
to be involved. Branches of the superior thyreoid arteries, or the hyoid
branch of the lingual artery, will be ligatured. The superior laryngeal
nerves should always be preserved whenever possible, as loss of
sensation increases the liability of food passing into the larynx.

(_b_) When the aryteno-epiglottidean fold is involved, a transverse
incision can be made through the thyreo-hyoid membrane, immediately
above the thyreoid cartilage on the same side, and the wound enlarged
until the tumour is exposed. In this manner I was able to remove the
large carcinoma shown in Fig. 254, including the soft parts of the right
half of the larynx, the right half of the epiglottis, the right
arytenoid, and the wall of the pharynx in relation to the right pyriform
fossa: the lymphatic glands were not removed. One year later the patient
continued to enjoy good health with no signs of any recurrence. In this
connexion it is important to emphasize that when the disease is very
extensive, and particularly when the posterior portion of the cricoid
and arytenoids is involved, such an operation is useless, and the
surgeon must decide whether partial or complete laryngectomy should be
performed. In rare instances the operation should be abandoned in favour
of tracheotomy (palliative).

(_c_) When the tumour extends downwards into the subglottic region, it
is necessary to split the cricoid anteriorly and divide the upper rings
of the trachea, after which the tumour can be removed with as much of
the structures as may be desirable.

(_d_) When the growth extends across the middle line in the anterior
commissure, or when a second growth is situated directly opposite on the
other side of the larynx, the whole disease must be removed regardless
of damage to the tissues which are not affected.

(_e_) When the operation is performed for stenosis, it is necessary to
remove freely all the fibrous tissue without attempting to preserve any
part that is diseased. The hæmorrhage is generally severe and
necessitates preliminary plugging of the trachea with a Hahn’s canula.

=After-treatment.= This must be conducted so as to prevent the chance of
broncho-pneumonia and sustain the strength of the patient. With Butlin’s
method the patient is placed on his side, or face downwards, with the
head low and with only a small pillow, so that all secretions pass out
of the air-passages through the external wound. This undoubtedly gives
better drainage to the wound, and is less exhausting than the upright
position during the early stages of convalescence. The dressings on the
wound must be changed, especially in the early days, as often as they
become soaked; it is also an advantage to insufflate an orthoform
powder, or an antiseptic parolein preparation, with the object of
cleansing the larynx. The tracheotomy tube should be retained, usually
from ten to twenty days, until the patient can swallow well and as long
as there is a flow of pus from the wound.

‘During the day of the operation nothing is swallowed, although
fragments of ice may be kept in the mouth for the comfort of the
patient. If there is fear of collapse and the patient is feeble and very
old, brandy and beef-tea may be administered by the rectum. On the
following morning the first attempt is made to swallow. The patient
leans far forwards with the head down, and the dressing is taken off the
wound, beneath which a basin is placed. Cold water is drunk out of a
glass. If the experiment is successful, all the water passes down into
the stomach; if it is only partially successful, some escapes into the
larynx; but the posture of the patient ensures that the liquid runs out
through the wound and does not pass into the air-passages. As soon as
water can be readily swallowed, milk, beef-tea, and other liquids may be
drunk, for the fear of “Schluck-pneumonie” is practically at an end. The
wound is generally closed within ten or twelve days of the operation,
and the patient is rarely confined to the house for more than ten days’
(Butlin). It is probable that the healing by this, which is called the
‘open’ method, is as rapid as with Moure’s, in which the whole length of
the incision is closed; the open method would also appear to be safer
and less often attended by complications.

=Complications.= (1) _Broncho-pneumonia_ is most to be dreaded. Death
from shock or collapse, from hæmorrhage, from septic conditions of the
wound, or from iodoform poisoning, is now rarely met with and can more
easily be prevented. Even pneumonia is uncommon, owing to more
scientific methods of treatment. It is still to be feared in very old
patients; in those who already suffer from bronchial catarrh at the time
of the operation; in alcoholics; and in cases with old-standing renal,
pulmonary, or heart affections. The improvement in this direction is due
to greater antiseptic precautions, and to the prevention of aspiration
of blood and septic secretion during and after the operation by free
drainage of the wound.

(2) _Stenosis._ It sometimes happens that a considerable mass of
granulation tissue appears in the anterior commissure, or upon the
surface of the cartilage that has been bared by the operation; if this
be left untreated it may gradually enlarge in size until a prominent
cushion is produced, which reaches to the opposite side and thus causes
stenosis with definite laryngeal obstruction. Such a swelling may be
mistaken for recurrence, but is nearly always of inflammatory character.
It is by no means certain what is the causation of this condition, which
appears to occur more with some surgeons than with others; it has been
suggested that the presence of sutures in the region of the anterior
commissure may cause an irritation, especially if silk is used. It
appears to me, having in mind similar conditions in other surgical
wounds, that the cause is to be found in some form of sepsis, and that
it can be prevented to a great extent by precautions at the operation
and by proper after-treatment. If there be any obstruction to breathing,
the larynx is inspected and the projecting granulations are removed by
intralaryngeal forceps. The remainder of the mass generally shrinks and
disappears. If the stenosis be troublesome (chiefly in syphilitic
cases), the prolonged use of a laryngo-tracheal canula (Fig. 540), or of
an intubation tube, or dilatation with bougies, may be necessary. In
rare instances a permanent tracheotomy tube is required, with a valve to
encourage expiration through the mouth.


HEMI-LARYNGECTOMY

This operation is suitable for certain cases of malignant disease which
is strictly limited to one half of the larynx. The requirements and
_first and second_ stages of the operation are similar to those for
thyrotomy (see pp. 490, 491).

_Third stage._ A transverse incision is made on the side affected along
the upper border of the thyreoid cartilage, through the skin and fasciæ;
and, if necessary, a second transverse incision is made at the level of
the lower border of the cricoid so that a skin flap can be turned back.
The affected half of the larynx must now be considered as a tumour to be
removed. The infrahyoid muscles are dissected away from the ‘tumour’ and
retracted; the upper part of the lateral lobe of the thyreoid gland (the
isthmus having been previously divided) is displaced outwards by blunt
dissection, and the soft tissues above the thyreoid are similarly
treated: the larynx should be pulled well over to the opposite side
while this is being effected, great care being necessary to avoid
wounding the carotid artery in the deeper part of the dissection. The
branches of the superior thyreoid artery, the crico-thyreoid artery, and
the veins of this region are ligatured with catgut. In some instances,
when the growth has not perforated the cartilage, the separation can be
performed subperiosteally. Superiorly, the thyreo-hyoid membrane is
completely divided on the same side, and the mucosa is cut through above
the upper limit of the growth. If the growth extends upwards, the
epiglottis may be removed either totally or partially. Inferiorly, a
transverse incision must be made through the crico-thyreoid or
crico-tracheal membrane, or lower in the trachea. The inferior
constrictor of the pharynx is divided as close to the attachment to the
thyreoid as possible, and the cavity of the pharynx is opened behind the
growth. The cricoid plate is split with bone scissors in the
interarytenoid interval, and the final attachments are rapidly divided
with a few touches of the knife.

In this operation, as with other operations for cancer, the main thought
of the surgeon must be to remove the tumour thoroughly, including the
soft tissues of the neck when these are diseased, the lateral wall of
the pharynx, and the cervical glands upon the same side, whether they
are known to be affected or not. In this respect the operation differs
materially from thyrotomy; and I agree with Semon that, if
hemi-laryngectomy is necessary, the lymphatic glands of the same side
should in all cases be removed. The two dissections may be accomplished
at the same time, or one may be performed later at a second operation;
in the latter event an incision along the anterior border of the
sterno-mastoid muscle is preferred. The operation must be very complete
in order to be successful, and requires a knowledge of the anatomy of
the lymphatics.


THE ANATOMY OF THE LARYNGEAL LYMPHATICS.

The following description is Cuneo’s[14] and has been confirmed by de
Santi.[15]

[14] Poirier and Cuneo, _Lymphatics_, Eng. ed., 1903, p. 286.

[15] De Santi, _Malignant Disease of the Larynx_, 1904, p. 10.

The lymphatics which drain the mucous membrane of the larynx are divided
into two distinct regions, namely, the supraglottic and the infraglottic
zones. These regions are separated by the inferior vocal cords, and
injection of the cords themselves generally passes into the upper zone.
The upper region is most densely supplied, and covers the epiglottis,
the aryteno-epiglottidean folds, the superior vocal cords, and the
ventricles.

The lymphatics communicate freely in the posterior wall of the larynx
(not in the anterior commissure), but though an injection into one half
of the larynx easily passes into the mucous membrane of the other side,
it is exceptional for it to pass as far as the corresponding glands of
that side. The lymphatics of the larynx anastomose to a large extent
with the networks of the adjacent organs (tongue, pharynx, trachea).

The supraglottic lymphatics perforate the thyreo-hyoid membrane where
the superior laryngeal arteries enter, and end in (1) a
substerno-mastoid gland under the posterior belly of the digastric; (2)
glands on the internal jugular vein opposite the bifurcation of the
carotid artery; and (3) glands on the same vein opposite the middle of
the lateral lobes of the thyreoid gland. The glands in the front of the
thyreo-hyoid membrane receive lymphatics from the pharynx, but none from
the larynx.

The subglottic lymphatics perforate the crico-thyreoid membrane in two
places (_a_) anteriorly, near the middle line, ending in (1) a
prelaryngeal gland which lies in the V-shaped space between the
crico-thyreoid muscles or under one of the same (a gland above the
isthmus of the thyreoid gland is rarely present), and (2) a pretracheal
gland (or glands) below the isthmus; (_b_) laterally, to end in (1) the
glands which lie parallel to the recurrent laryngeal nerve, from which
trunks run to (2) the substerno-mastoid group and (3) the
supraclavicular glands.

It is important also to consider the question from the clinical aspect.
With ‘intrinsic’ growths, involvement of glands is very uncommon unless
the posterior (cricoid) zone is affected; it seems to be equally rare
with tumours of both supra- and infraglottic zones; extension to the
lymphatics of the opposite side is likewise improbable. With ‘extrinsic’
growths, the glands are rapidly involved; tumours that were originally
intrinsic follow this rule as soon as they begin to affect the
cartilages and extrinsic lymphatics of the larynx. These facts must be
remembered because palpation of the neck may be quite misleading in
early stages of the disease. On the other hand, in many advanced cases,
such as those requiring palliative tracheotomy, the glands become
massive and form definite tumours. The substerno-mastoid chain is,
clinically, the situation that is specially affected; and any of its
glands, from the digastric muscle above to the supraclavicular region
below, may be involved. The prelaryngeal gland is rare, as are likewise
the pretracheal and recurrent forms; nevertheless, the recurrent glands
become attacked by advanced disease, affecting the upper part of the
trachea.


TOTAL LARYNGECTOMY

=Indications.= This operation is performed for malignant tumours which
have affected (_a_) the whole of the interior of the larynx, including
the cartilages, or (_b_) the posterior portion of the larynx, including
the arytenoid cartilages and pharyngeal aspect of the cricoid plate. In
other words, it is employed in cases of extrinsic cancer in which the
growth is not too advanced to render the prospect of its eradication
hopeless. The operation should not be performed for tuberculosis.

It is essential that the patient should be in good health; one who is
emaciated or who has organic disease, especially incurable bronchitis,
is quite unsuitable for laryngectomy. On no account ought the operation
to be undertaken unless the diagnosis of malignant disease has been
confirmed, and unless the growth is known to be too extensive for
thyrotomy. In many instances, therefore, thyrotomy is the first stage in
the operation of total laryngectomy.

=Operation.= The instruments, anæsthetic, and position require the same
consideration as with thyrotomy (see p. 489).

_First stage._ A vertical incision is made, in the middle line, from the
hyoid to a point one inch above the sternum, and the anterior aspects of
the thyreoid cartilage and trachea are exposed, with complete division
of the isthmus of the thyreoid gland. The infrahyoid muscles are
dissected from the larynx and widely retracted. By blunt dissection the
upper part of the lateral lobes of the thyreoid gland is separated and
bleeding arrested. The trachea, having been isolated in this manner, is
divided obliquely from the front, upwards and backwards, as close to the
cricoid cartilage as the disease allows without injury to the œsophagus;
the lower end is carefully freed from the œsophagus, and two strong
catgut sutures are passed through it with which the divided stump can be
drawn forwards. If possible, a small transverse incision is made through
the skin immediately above the suprasternal notch and made to
communicate with the upper incision; the trachea is brought beneath the
bridge of skin into the button-hole thus formed, and firmly attached by
means of sutures. In some cases the trachea is sewn into the lower part
of the original incision. A tracheotomy tube is inserted, through which
the anæsthetic is continued. By this means the lower air-passages are
completely cut off from the region of the tumour, and no blood or septic
matter can pass into the lungs.

[Illustration: FIG. 262. TOTAL LARYNGECTOMY. A, Crico-thyreoid muscle;
B, Attachment of inferior constrictor of pharynx to thyreoid cartilage;
C, Cut edge of inferior constrictor; D, Thyreo-hyoid membrane; E,
Œsophagus; F, Trachea.]

_Second stage._ The lateral aspect of the larynx is freely separated so
that the attachment of the inferior constrictors is defined. The
superior laryngeal artery is ligatured on each side, and divided,
together with the internal laryngeal nerves. The thyreo-hyoid membrane
is transversely divided, and the pharynx is opened so as to expose the
upper limit of the growth; this may necessitate a transverse incision
through the skin, or a vertical division of the hyoid bone in the middle
line with retraction of its two halves. The larynx having been isolated
above, below, and laterally, its removal can be completed according to
the situation of the growth, in most cases from below. The lower end of
the larynx is hooked forward, and dissected away from the œsophagus by
means of scissors or a sharp scalpel (Fig. 262). While this is being
effected, the extent of the growth must be constantly examined by
inspection and palpation, so that the whole mass is removed, including,
if necessary, the pharynx and upper part of the œsophagus. It is
important not to drag upon the œsophagus; C. Jackson has shown
experimentally that this causes severe shock by affecting the depressor
fibres of the vagus, which may result in death. It follows, therefore,
that this part of the operation, though easy in the dead body, requires
the utmost care and detailed technique. The division of the
constrictors should be as close to their attachment as possible, and
the final division of the pharyngeal mucosa should be half an inch
beyond the limit of the growth. The epiglottis should generally be
removed.

_Third stage._ The toilet of the pharynx and œsophagus remains to be
decided. In order to restore the cavity of the pharynx, the upper end of
the œsophagus is brought upwards whenever possible and accurately united
to the pharynx in the region of the hyoid bone, this being accomplished
by a double layer of catgut sutures uniting the mucous membranes. The
infrahyoid muscles are then brought together by a vertical row of
stitches, so as to cover and support the line of union. The wound having
been thoroughly packed with gauze, the skin is sutured, excepting the
lower end, which remains open for drainage. In cases where the pharynx
is thus completely closed, a tube must be passed previously through the
nose into the œsophagus, and retained for purposes of feeding. This is
preferable to sewing the tube into the wound itself, and is rarely
troublesome if the tube is sufficiently stiff to prevent its
displacement by retching. At the conclusion of the operation the
tracheotomy tube is replaced by an ordinary silver canula, and the
wounds are lightly dressed.

=After-treatment.= This is conducted upon similar lines to those adopted
in the after-treatment of thyrotomy. During the first ten days, until
the pharyngeal wound is firm, the patient must be fed through the tube
and by rectal administration. Sterilized water may be sucked uphill,
and, as swallowing improves, food may be administered by the mouth. In
most cases a pharyngeal fistula results, which may require a later
plastic operation. A second operation is necessary for the removal of
lymphatic glands, probably on both sides of the neck.

The complications are similar to those following thyrotomy (see p. 494).

=Modifications.= The above operation, which in the main has been planned
by surgeons in America (S. Cohen, Keen, &c.), is preferable to the
numerous modifications, of which the following may be mentioned as
examples:--

Gluck’s operation. In this there is no preliminary tracheotomy. A large
rectangular flap is turned to one side to expose the front of the larynx
and trachea, the latter being isolated laterally and the thyreoid
isthmus divided. A transverse incision is made through the thyreo-hyoid
membrane in order to expose the upper aperture of the larynx thoroughly.
By plugging the pharynx and adopting a low position for the head, saliva
and blood are prevented from running into the air-passages. The interior
of the larynx having been cocainized, a tracheotomy tube is inserted
between the vocal cords. This is sutured in position in such a manner
that the cavity of the larynx is completely shut off from the pharynx.
If a general anæsthetic be employed, it can be continued through the
canula by a Hahn’s adjustment (Fig. 266). The larynx, and any part of
the pharynx or œsophagus which is diseased, are separated from above
downwards, the trachea being severed transversely as a final stage and
sewn into a button-hole immediately above the sternum. A soft rubber
tube having been introduced through the nose into the œsophagus, the
walls of the latter are united over the tube by a double row of catgut
sutures, completely isolating the gullet. The cavity is covered with
gauze, and the skin flap is partially sutured into its original
position. An ordinary canula is placed in the trachea and the wounds are
dressed.

[Illustration: FIG. 263. TOTAL LARYNGECTOMY. GLUCK’S METHOD. Tracheotomy
canula with rubber tube for Hahn’s adjustment tied into the upper
opening of the larynx. A, Epiglottis; B, Superior cornu of thyreoid
cartilage; C, Posterior surface of cricoid with crico-arytenoid muscles;
D, Trachea; E, Œsophagus.]

In cases where the pharynx has been extensively removed a fistula
remains, but Gluck has devised a plastic operation by means of which
this can afterwards be closed. In some cases this fistula may be
obliterated by the natural falling in of the parts, without further
operation, and in the meantime the patient is provided with a funnelled
tube for feeding, placed in the œsophagus with the upper end below the
base of the tongue.

The advantages claimed by Gluck for this operation are the avoidance of
preliminary tracheotomy, the prevention of blood from passing into the
trachea, the complete separation of the trachea from the gullet, and the
early feeding through the mouth. These, however, are chiefly met by the
former operation.

Chiari and le Bec perform the operation in two stages. In the first, the
trachea is isolated and divided transversely, the lower end being
sutured above the sternum. The second operation, undertaken one or two
weeks later, consists of a complete removal of the disease.

Föderl suggests the possibility of uniting the lower end of the trachea
(after laryngectomy is completed) to the tissues beyond the hyoid bone,
and thus restoring the air-passages; but the method is not free from
danger, and the trachea is apt to slough.

S. Handley[16] performed a complete transverse resection of the pharynx,
with laryngectomy, for malignant growth in the following manner:
Preliminary gastrostomy was performed; a week later, when the patient
had recovered, a low tracheotomy was effected, the trachea being plugged
with gauze above the tube. The whole of the larynx and a complete
section of the pharynx were then removed as described in Gluck’s method;
and, the trachea having been brought into the lower part of the wound,
the pharynx and œsophagus were closed by sutures. The patient recovered
with a pharyngeal fistula through which the saliva passed, the latter
being led to the stomach through the gastrostomy opening. In a second
similar case the result was fatal. ‘The patient died on the table,
apparently from irritation of the vagus, after the operation was
practically complete.’ Handley believed that the failure was due to a
defect in his technique, and that, if he had frozen the two vagi below
the point at which he was working, death would not have occurred.

[16] _Proc. Roy. Soc. Med._, London, vol. i, No. 4, 1908, Clin. Sect.,
p. 66.


COMPARATIVE RESULTS OF THE DIFFERENT EXTRA-LARYNGEAL OPERATIONS

In order to obtain a trustworthy idea of the value of the various
operations for malignant disease, it is necessary to refer to the
history of the operations.[17] Czerny, in 1870, was the first to
demonstrate by experiments on dogs the possibility of removing the
entire larynx, and various attempts were afterwards made by different
surgeons, notably by Billroth, to accomplish the same in man. In 1881
Foulis was able to collect twenty-five cases of total laryngectomy, and
found that not one of them was alive twelve months after the operation.
Partly in consequence of this, thyrotomy was given a trial, and in 1887
P. Bruns collected nineteen cases, with two deaths and sixteen local
recurrences. He therefore concluded that ‘attempts to extirpate the
disease by means of thyrotomy have shown themselves to be altogether
insufficient and useless’; and so it came about that all external
operations, at this date, were considered by most authorities to be
unsatisfactory. Much attention was, however, drawn to the subject by the
illness of the German Emperor, and Semon particularly emphasized the
great importance of early diagnosis. The result of this was marvellous.
The importance of Krishaber’s division of carcinoma of the larynx into
two forms, intrinsic and extrinsic, was recognized by Butlin, to whom
the greatest credit is due for having first shown that thyrotomy ought
to be reinstated. Butlin and Semon have since perfected this operation,
which has rightly been described as the English operation. It is now
recognized throughout this country as the operation which gives
perfectly ideal results, so long as it is restricted to early stages of
intrinsic malignant disease (in which an early diagnosis is
indispensable) and is thoroughly carried out. As Semon concludes, ‘if
these demands be complied with, the position of thyrotomy, as being the
operation in the early stages of malignant disease of the larynx, will
remain impregnable, so long as we have to fight malignant disease by
operation.’ That this is true will be seen by the results mentioned
later.

[17] An account of the history of these operations will be found in a
paper by Sir F. Semon, _Brit. Med. Journ._, 1903, vol. ii, p. 1113.

It is also necessary to refer to the other side of the question, namely,
the position of laryngectomy. Many well-known surgeons in Europe and the
United States have been convinced that laryngectomy, partial or
complete, is the only possible treatment for cancer in this region.
Gluck[18] says:

[18] _Brit. Med. Journ._, 1903, vol. ii, p. 1123.

    ‘As showing the progress that has been made during the last fifteen
    years in this subject, I may mention that in my first series of ten
    cases only two were successful, and in nine cases of another series
    I had four deaths. Since then I have performed many operations with
    ever improving results. Thus in one series of thirty-five
    hemi-laryngectomies I had three deaths: one twenty-four days after
    the operation, of heart failure, when the wound was already healed;
    another independently of the operation, of phlegmon of the right
    gluteal muscle; the third of pneumonia five days after operation.

    ‘My most recent results show a series of twenty-two complete
    laryngectomies with one death, that of a man of seventy, who died on
    the eleventh day of iodoform poisoning. Of the partial extirpations
    of the larynx and pharynx, generally combined with removal of
    infected glands, I can point to a series of twenty-seven cases with
    only one death. This was a case in which the carotid had been tied,
    and death occurred from hemiplegia five days after the operation.

    ‘At present I could show you thirty-eight living patients who have
    been cured by these operations; the oldest case was operated on
    thirteen years ago. Of those already dead, a number have lived 11,
    8, 6-1/2, 5-1/2, 4-1/2 and 3-1/2 years after the operation in good
    health, and some have died of other illnesses, not of recurrence.
    One man, nine years after hemi-laryngectomy, had recurrence in the
    other half of the larynx and in the glands; after the second
    operation he lived over two years, and died at seventy-six. The
    operations lengthened his life for eleven years.

    ‘A man of seventy-six had the larynx and pharynx extirpated, and
    lived 11-1/2 years after the operation. Twice I have performed
    complete laryngectomy for tubercle; one case died in spite of that
    of consumption; the other was done four years ago and the patient is
    perfectly well.

    ‘In all I have performed 125 of these operations since the year
    1888, and the record is one of great progress, both in technique and
    also in the elaboration of plastic operations and mechanical
    appliances for the improvement of the post-operative condition.’

Many large operations of this description have undoubtedly been
performed because of the statement that it is impossible to obtain a
lasting cure by performance of thyrotomy. Even at the present day this
opinion holds its ground, and so long as there is a general grouping of
the cases, progress cannot be made.

=Thyrotomy.= I shall attempt to show that thyrotomy is the best
operation for early malignant disease, whether carcinoma or sarcoma, so
long as it remains intrinsic. No attempt will be made to separate the
different forms of these diseases. The points to be considered are the
following:--

The _mortality_ of the operation itself has been greatly reduced; von
Bruns[19] states that ‘between 1890 and 1898 there was an immediate
fatality of 15%’ in sixty cases collected by Schmiegelow and himself. In
comparison with these figures, the recent results of English surgeons
have been very favourable. Thus Butlin and Semon have performed
forty-eight thyrotomies for malignant disease since 1890 with only two
deaths. In Butlin’s case the patient was over seventy years of age, very
obstinate, very intractable, and persisted in sitting up from the time
of the operation. He died, in the course of three or four days, of
septic pneumonia. The results of other surgeons have been excellent, but
are not included for three reasons: There is still considerable
confusion in the selection of cases suitable to this operation; the
operation is often performed by those who are not conversant with the
difficulties and dangers that may arise; and it has sometimes to be
undertaken for a patient who is also suffering from bronchitis or
constitutional disease. Moreover, the above figures are sufficient to
show that the immediate mortality from this operation under favourable
circumstances is not large.

[19] Bergmann, E. von, _Sys. Prac. Surg._, vol. ii, p. 245.

_Recurrence_, in Semon’s cases, occurred in 13.6%, which is not a large
proportion. It usually occurs early or not at all. Semon and Jackson
noted that none of their patients suffered from recurrence after the
lapse of the first year. This is a point of great importance; and in
this connexion Semon points out, as an additional advantage of
thyrotomy, ‘that even in the cases in which either the operation has not
been complete, or in which unfortunately genuine recurrence has taken
place, the operation does not bring us to the end of our resources; but
that, on the contrary, by a repetition of the operation, or by
hemi-laryngectomy, or by total extirpation of the larynx, a lasting cure
may still be obtained, where the minor operation has failed.’

_Cures._ I hope it will soon become generally recognized that the
radical operation of thyrotomy for removal of early intrinsic malignant
disease is attended by a remarkable number of complete cures, and
compares favourably with almost any other operation for similar
conditions in other parts of the body. Butlin (see Table, p. 507),
Semon, and C. Jackson have all obtained, in recent years, from 60 to 80%
of lasting cures. In Semon’s twenty-five cases,[20] one died of the
operation, three cases recurred within a year, and one was too recent to
be included, the remaining twenty were cured for varying periods,
namely:

    1 case over 15 years.
    4 cases between 10 and 15 years.
    4 cases between 5 and 10 years.
    2 cases over 4 years.
    3 cases over 3 years.
    2 cases over 2 years.
    1 case just 2 years.
    1 case 1 year and 10 months.
    1 case died 5 years after operation from pulmonary embolism.
    1 case died 4 years after operation from pneumonia.

In both the last cases recurrence was excluded.

[20] _Trans. Med. Soc._, London, 1907, vol. xxx, p. 130.

The _condition_ of the patient after thyrotomy. The voice results are
often surprisingly good even when a free excision of soft parts,
including one or both vocal cords, has been required. In from 40 to 60%
of cases that are cured, the voice is practically normal, though rough
and reduced in volume and range. Of the remainder, the majority recover
sufficiently to produce a considerable whisper, and only a few suffer
complete loss of voice. The causes of a complete loss of voice, when it
occurs, are chronic inflammation, cicatricial contractions, or improper
union of the cartilage. Further, a loss of voice is probable in the
event of a recurrence of the growth.

The breathing is not affected unless the operation is followed by
stenosis. The power of swallowing is soon regained, and the general
condition of those who are cured is one of complete happiness and
general excellence of health.

These results may now be briefly compared with those obtained by
laryngectomy, whether partial or complete.

=Hemi-laryngectomy.= The immediate _mortality_ of this operation also
has been greatly reduced. Sendziak collected 108 cases, up to 1894,
showing a mortality of 26.3%; von Bruns 106 cases, between 1890 and
1898, with a mortality of 17%; Gluck has performed thirty-five such
operations with only three deaths--8.1%. The number of cases reported in
England is too small to be of value, chiefly because thyrotomy or total
extirpation has been considered better. Taking, therefore, the best
published results, it appears that the mortality is at least twice as
great as with thyrotomy.

The danger of _recurrence_ is also greater, partly because the glands
are affected. Statistics show that recurrence occurs in at least
one-fourth of the cases, possibly more, and is generally fatal. It is
impossible to give a prognosis as to cure in the early stages after
operation, but there are instances of life being prolonged for many
years; a case of Gluck’s lived for eleven years.

The _after-condition_ is not unsatisfactory. The permanent wearing of a
tracheotomy tube is rarely necessary. Swallowing is soon recovered, and
the voice is often good.

=Total laryngectomy.= Although the mortality of this operation has been
greatly reduced by many improvements in recent years, it still remains
higher than that of thyrotomy. As far as can be judged from the small
number of cases that have been reported by English surgeons, there seems
to be a direct mortality of at least 20% from these operations. C.
Jackson[21] has, however, performed eight consecutive total
laryngectomies without a death in the first thirty days. He writes: ‘Of
eight total laryngectomies done by me, three were hemi-laryngectomies
followed by recurrence and the total operation. Of the eight
laryngectomies, one lived seven years. I felt justified in claiming a
cure, but upon inquiry a few weeks ago I was informed by relatives that
he died of cancer of the stomach. One case lived three years without
recurrence, dying of cerebral hæmorrhage, and one eight months, dying of
alcoholism. Of the remaining five, three recurred within a year, one
apparent cure was lost to observation after a year, and one is too
recent to record: one of the three prompt recurrences had metastases in
the lungs, liver, and pancreas. Thus, of eight laryngectomies, no
absolute ultimate cures can be claimed, though three were apparent cures
at the end of one year.’

[21] _Brit. Med. Journ._, 1906, vol. ii, p. 1480.

Butlin has performed total laryngectomy upon seven patients, only one of
whom died from the operation. He says: ‘I first removed a large mass of
glands on both sides, and later took out the larynx, which was so
diseased, that the surrounding parts were infiltrated for a considerable
distance. He lived six weeks after the second operation, and then died
of double pneumonia, which was attributed to an attack of influenza when
he was up and about his room. I do not know whether the pneumonia was
due to that cause or to sepsis of the lungs, for we had on several
occasions some difficulty in feeding him, and in getting a tube properly
down his œsophagus.’

The following is a table showing Butlin’s operations since the year
1890, from a paper which was read at the Second Congress of the
International Surgical Society at Brussels in 1908:--

              _Operations._

            23 Thyrotomy[1]            21 patients
             1 Hemi-laryngectomy        1 patient
             7 Laryngectomy[2]          6 patients
            --                         --
            31 operations on           28    "

    Died of the operation (1 thyrotomy, 1 laryngectomy)        2
    Died of recurrence                                         4
    Died of intrathoracic disease, probably cancerous glands,
      within 2 years                                           1
    Died of cancer of tongue[3]                                1
    Lost sight of after operation                              1
    Alive after operation for recurrence                       2
    Well within 3 years                                        3
    Died of other disease after 3 years                        1
    Well after 3 years[4]                                     13
                                                              --
                                                              28

[1] In two patients the operation was repeated.

[2] In one patient thyrotomy was followed by laryngectomy, but the
patient was included amongst the thyrotomies only.

[3] This was regarded as a second attack of cancer, for the disease of
the tongue was some distance from the larynx, and there was no sign of
cancer of the intervening parts. Also more than a year elapsed before he
began to suffer from cancer of the tongue.

[4] Periods during which patients remained well lasted from 3 to 15
years.

Recurrence after laryngectomy is, therefore, more frequent than after
thyrotomy, and it is difficult to estimate the proportion of cases that
are cured by this operation. Butlin writes: ‘Of the six patients who
survived the operation, one died of probable cancerous glands in the
mediastinum, one had inoperable recurrence in the cervical glands, three
were alive within three years, and one was well three years after the
operation.’ He says: ‘I began to perform laryngectomy three years ago on
account of Gluck’s success, and of the excellent modification due to
Solis Cohen. I wish I had begun to perform it earlier. I am sure that
several of the cases on which I performed thyrotomy were much better
fitted for laryngectomy, and I cannot help thinking I might have saved
one or two patients in whom recurrence took place if I had then removed
the larynx. I think the glands ought to be removed in every case in
which there is extensive carcinoma of the larynx, even if it be
intrinsic, unless the disease is limited to the middle zone of the
interior of the larynx. Even in these cases it would probably be a wise
precaution to remove the glands. I have never removed the glands and the
larynx at one sitting.’ Von Bruns,[22] from statistics of all total
operations since 1890, gives the following proportions:--

    Cure, over 3 years        8.6%
    Cure, 1 to 3 years       17.4%
    Cure, under 1 year       32.0%
    Recurrence               23.4%
    Death due to operation   18.5%

[22] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 245.

_The voice_ after laryngectomy. Many efforts have been made to replace
the lost voice. The artificial larynx, as first devised by Gussenbauer,
consisted of three distinct parts: a tube for the trachea through which
the patient inspired; a tube communicating with the pharynx so as to
allow of expiration through the mouth; and a phonation canula which
fitted into the former. This canula was supplied with a valve which
closed during expiration so as to allow of breathing through the mouth,
and a phonation apparatus for production of the voice. A large number of
modifications of this larynx have been made at different times but have
rarely been successful. The irritation and pain caused by the pharyngeal
portion, the difficulty in swallowing and in keeping the tubes clean,
and the exhaustion caused by prolonged use, have combined to make the
apparatus unsatisfactory.

As the result of recent improvements in laryngectomy, most surgeons
isolate the trachea as already described, and thus entirely shut off all
communication with the mouth. The patient then has a choice of two
methods--(1) the bucco-pharyngeal voice, or (2) a phonetic apparatus
such as that described by Gluck, consisting of (_a_) an external
tracheotomy canula for breathing, (_b_) an internal canula, possessing a
valve which closes during expiration and causes the air to pass upwards
to another compartment containing a small rubber band or tongue, the
vibration of which forms the voice, and (_c_) a third tube of rubber,
which is easily fitted to the upper part of the inner canula and is of
sufficient length to reach the mouth. When the patient wishes to speak,
the upper end of the last-mentioned tube is either placed in the angle
of the mouth or passed through the nose to the back of the pharynx, and
the air which has been made to vibrate in the inner tube is thus carried
to the mouth. This instrument is easy to adjust and clean, produces
remarkable phonetic effects, and is much the most ingenious and
serviceable device that has so far been invented. In some cases,
however, a patient can make himself understood without an instrument of
any kind. ‘A whispered voice remains even after the pharynx has been
completely shut off from the air-passages and, as shown by experience,
may be developed by practice until it is quite sufficient for the
demands of the patient. Hans Schmidt’s case has become more or less
celebrated, in which, under conditions of this sort, a loud though rough
and monotonous voice was developed. One of Mikulicz’s patients was even
able to sing. Gottstein explains the development of a pseudo-voice by
the formation of an air-chamber in the pharynx and œsophagus, which is
voluntarily inflated and emptied by the patient’ (von Bruns).

_Swallowing_ after laryngectomy is satisfactory, and the general health
in many cases improves. The mental condition of the patient is often
disappointing. ‘Even in favourable cases, when the tumour does not recur
after laryngectomy, the patient finds himself in such a condition of
inferiority to his fellows, that he may, with some reason, ask himself
(at least in certain cases) whether death would not have been preferable
to such an existence as is left to him’ (Moure[23]). With recurrence of
the disease the patient’s life is terribly sad.

[23] _Brit. Med. Journ._, 1903, vol. ii, p. 1148.

It must therefore be admitted that laryngectomy is at present an
operation of necessity, suitable for certain cases only, capable of
prolonging life, and, rarely, of curing the patient. It is difficult to
foreshadow the future of this operation; but, in the words of Gluck,
‘our first object must be to save life; our next, to leave the patient
in such a physical condition that the life so saved is worth living.’

The above statistics are sufficient to show that the results of
laryngectomy for extrinsic disease compare unfavourably with the results
obtained by thyrotomy in intrinsic forms of cancer. In this country
there have not been sufficient cases to estimate accurately the
percentage of recoveries. The disease may recur at any period after the
operation, and the prospect of a cure is always doubtful.

It is, however, to be hoped that, with improved methods of examination,
earlier diagnosis, and a careful selection of the cases, better results
will in future be obtained. Authorities such as Butlin and Semon support
this view, and agree that further attempts must be made to make this
operation successful.


INFRATHYREOID LARYNGOTOMY

In order to avoid confusion with other operations included under
laryngotomy, this term is used to denote the operation in which the
larynx is opened through the crico-thyreoid membrane. The operation is
an easy one in adults, but in children the crico-thyreoid space is so
small that it is almost impossible to introduce a tube without division
of the cricoid cartilage (see Crico-tracheotomy, p. 529).

[Illustration: FIG. 264. INFRATHYREOID LARYNGOTOMY. Position of the
incision.]

A tube introduced through the crico-thyreoid membrane lies in the
subglottic space well below the vocal cords, and the latter should not
be injured when the operation is performed with care. If inflammation
supervenes, there may be a swelling of the subglottic region, making the
tube difficult to manipulate; and for this reason the operation is
particularly suited to cases which require a tube for a short period
only, such as--

=Indications.= (i) Sudden laryngeal obstruction due to impaction of food
or other foreign body. This is more common in adults: in children
dyspnœa is rarely so urgent as to necessitate an operation.

(ii) Sudden œdema of the larynx caused by trauma, fracture, or acute
inflammation, when the equipment for tracheotomy is not obtainable; or,

(iii) As a preliminary to major operations upon the upper air-passages,
in order to prevent blood from passing down into the trachea.

This last method of treatment marks a distinct advance in the surgery of
the throat. Attention was first directed to it by Bond[24], who has
used the method for the past sixteen years with intent to make such
operations less dangerous to life, and to increase, therefore, the
number of cases that could be operated upon. His objects were to prevent
respiration through the pharynx, thus obviating the coughing and
struggling due to imperfect anæsthesia and making the anæsthetic easier
and safer to administer; to shorten the operation and make it easier for
the surgeon; and to get rid of preliminary tracheotomy whenever
possible.

[24] _Brit. Med. Journ._, 1907, vol. i, p. 7.

The value of this practice is well recognized by many surgeons. Butlin
writes: ‘I do not know how many times I have employed this preliminary
laryngotomy, but certainly more than a hundred times, so that I am now
in a position to urge the importance of it on the profession.’ It has
now been adopted at many of the hospitals in England before removal of
tumours in the naso-pharynx, the upper and lower jaw, the tongue,
palate, floor of mouth, and tonsil, in those cases where bleeding is
likely to be severe.

In order to ascertain the feeling of my colleagues on this subject I
have collected, with the assistance of Mr. Boyle, all the major
operations performed upon the upper air-passages during the last six
years at St. Bartholomew’s Hospital. These are tabulated below.

    TABLE SHOWING OPERATIONS UPON THE UPPER AIR-PASSAGES DURING THE
    YEARS 1902-7 INCLUSIVE AT ST. BARTHOLOMEW’S HOSPITAL

  -----------------------------+------------------+------------------
                               |      _With       |    _Without
                               |   Laryngotomy._  |   Laryngotomy._
                               +--------+---------+--------+---------
                               |_Cases._|_Deaths._|_Cases._|_Deaths._
  -----------------------------+--------+---------+--------+---------
  Excision of Tongue           |   20   |    3    |   13   |    2
  -----------------------------+--------+---------+--------+---------
     "     "  half Tongue      |   25   |    2    |   46   |    1
  -----------------------------+--------+---------+--------+---------
     "     "  Floor of Mouth   |   13   |         |   13   |    1
  -----------------------------+--------+---------+--------+---------
     "     "  Tongue and Floor |    5   |    1    |    1   |    1
                of Mouth       |        |         |        |
  -----------------------------+--------+---------+--------+---------
     "     "  Palate           |    8   |         |    1   |
  -----------------------------+--------+---------+--------+---------
     "     "  Upper Jaw        |   12   |         |   13   |
  -----------------------------+--------+---------+--------+---------
     "     "  Lower Jaw        |    1   |         |    9   |
  -----------------------------+--------+---------+--------+---------
     "     "  Tumour of Gums   |    1   |         |        |
  -----------------------------+--------+---------+--------+---------
     "     "  Tonsil           |    2   |         |    1   |
  -----------------------------+--------+---------+--------+---------
     "     "  Naso-pharyngeal  |    3   |         |        |
                Tumour         |        |         |        |
  -----------------------------+--------+---------+--------+---------
                      Total    |   90   |    6    |   97   |     5
  -----------------------------+--------+---------+--------+---------

This table shows that nearly half the cases were treated by laryngotomy.
In sixty-three of these, where the tongue or floor of the mouth was
concerned, no preliminary ligature of the lingual artery was performed;
of the seventy-three similar cases treated without laryngotomy there was
preliminary ligature of one lingual in thirty-one cases (42.5%), and of
both arteries in twelve cases (16.4%).

From this it is apparent that lary[n]gotomy has to some extent taken the
place of preliminary ligature of one or both linguals. The operation is
simple, rapid in execution, and meets all requirements; it is not
surprising to find, therefore, that in recent years the number of
laryngotomies has proportionately increased.

    TABLE SHOWING OPERATIONS AS PERFORMED IN DIFFERENT YEARS

    +---------+----------+---------------+---------------+
    |         |          |    _With      |   _Without    |
    | _Year._ | _Cases._ | Laryngotomy._ | Laryngotomy._ |
    +---------+----------+---------------+---------------+
    |  1902   |    39    |      19       |      20       |
    |  1903   |    35    |       5       |      30       |
    |  1904   |    31    |      16       |      15       |
    |  1905   |    32    |      18       |      14       |
    |  1906   |    29    |      18       |      11       |
    |  1907   |    21    |      14       |       7       |
    +---------+----------+---------------+---------------+
    |  Total  |   187    |      90       |      97       |
    +---------+----------+---------------+---------------+

=Operation.= In cases of extreme emergency the operation can be
performed with almost any kind of knife, but the following instruments
are preferred: a sharp-pointed bistoury or tenotome, a sharp-pointed
dilator (Fig. 265, B), a tube and introducer. The tube should be small,
short, with a fixed collar, and made of silver; an introducer such as
Butlin’s is a great advantage (Fig. 265, A). As bleeding may occur, it
is necessary to prepare dissecting forceps, retractors, pressure forceps
and catgut.

[Illustration: FIG. 265. INSTRUMENTS FOR LARYNGOTOMY. A, Tube and
introducer (Butlin’s); B, Sharp-pointed dilator (Bailey’s).]

A general anæsthetic is usually employed when infrathyreoid laryngotomy
forms the first stage of the main operation, but it should be remembered
that the amount of chloroform required is less when given through a
tube.

The preparation of the skin and the position of the body are the same as
for tracheotomy. A transverse incision one inch in length is
recommended, and this should lie directly over the crico-thyreoid
interval, which is easy to determine in the adult. The incision can be
made quickly by pinching up a vertical fold of skin, transfixing
immediately above the cricoid, and cutting outwards: with this method
the anterior jugular veins are rarely wounded, but if any vessel has
been pricked it should be seized and tied at once.

The sharp dilator, placed exactly in the middle line immediately above
the cricoid, is pushed backwards between the infrahyoid muscles until
the resistance caused by the crico-thyreoid membrane is reached. It is
then firmly stabbed into the larynx and widely dilated so as to tear
open the membrane: the dilator having been withdrawn, the tube, with
tapes attached and mounted upon the introducer, is rapidly inserted, a
proceeding which is made easier by first smearing the instrument with a
small amount of glycerine. The whole operation can be performed in less
than a minute, and is rarely attended by serious hæmorrhage; moreover,
when the original puncture is immediately above the cricoid there is
less danger of wounding the crico-thyreoid artery. The operation is
attended by few difficulties, and is superior to one in which dissection
or cutting is employed.

[Illustration: FIG. 266. LARYNGOTOMY CANULA FITTED WITH INNER TUBE.
Funnel for administration of anæsthetic.]

At this stage a prolonged period of apnœa is usually encountered, and
this symptom is more marked than with tracheotomy; when seen for the
first time it may be alarming, and it is therefore of practical
importance. In a few moments, however, the patient settles down to the
altered conditions of respiration; coughing may be excited but soon
disappears. When the breathing becomes regular, the tapes are tied round
the neck and a rubber tube is attached (Fig. 266) similar to that used
with Hahn’s apparatus, and through the tube the chloroform is continued.
This method has the following advantages: it gives far more room to
surgeon and anæsthetist, and enables the latter to manipulate the
laryngotomy tube and to prevent it from tilting in such a way that the
lower end impinges against the front of the trachea with consequent
obstruction; further, the opening into the larynx is completely blocked,
blood and lotion being unable to enter from outside.

As soon as true anæsthesia with regular automatic breathing has been
obtained, the lower part of the pharynx should be plugged with a soft
marine sponge to which a piece of tape or silk is attached, this being
pushed down behind the tongue and firmly wedged in position; it is
advisable to use a large sponge, as this blocks the pharynx and pushes
forward the tongue, an advantage to the surgeon when operating upon that
structure. If the mouth be obstructed by a tumour, the same result can
be obtained by two or more smaller sponges passed in succession; or, as
suggested by Bond, a small sponge may be pulled down into the larynx. As
soon as the pharynx has been completely shut off, the main operation can
proceed, and those who have once used this method can appreciate how
much more quickly it can be performed and how much more comfortably for
all concerned.

At the conclusion of the operation, when all bleeding has been
controlled, the laryngotomy tube should be removed. The wound should not
be sutured or plugged, and only a light dressing should be applied: the
latter can be kept in place by a bandage, which, however, must on no
account be tight, owing to the danger of emphysema.

=Complications= may arise--(_a_) _During the operation._ There may be
troublesome bleeding owing to pricking of a vein, superficial or deep,
or of the crico-thyreoid artery; this occurred in eight of the cases
mentioned above, and in four was severe. In one of the latter the
bleeding continued for thirty minutes before the vessel was finally
secured. The condition is simple to treat: the wound must be enlarged,
and the infrahyoid muscles separated so that the crico-thyreoid membrane
is thoroughly exposed; the bleeding vessel can then be seized and tied,
after which the tube is inserted. This is preferable to attempting to
stop the bleeding by the introduction of the tube.

Difficulty in introducing the tube may occasionally occur. It may be due
to imperfect division of the membrane; thus in one case the tube was
passed down between the coats of the larynx and not within its cavity;
and another case is recorded where the mucous membrane was similarly
pushed backwards owing to the dilator having split the cricoid
cartilage. Care must be taken, therefore, that the membrane is properly
punctured, and that the opening is thoroughly dilated before any attempt
is made to introduce the tube. Replacement of the tube was necessary in
only one case, on the second day, owing to recurrence of bleeding from
the wound in the mouth.

(_b_) _After the operation._ Emphysema occurred in six of the ninety
cases; in two it was slight; in three it was extensive and involved the
chest, neck, and face; and in one, where death supervened twelve hours
after the operation, there was emphysema of the mediastinum. In two of
these cases the laryngotomy wound had been sutured; in two others the
operation was attended with severe hæmorrhage, and the mouth was plugged
with gauze to control it. It is probable that emphysema is more likely
to occur if there is any obstruction to breathing through the mouth
after the operation, such as may be caused by the falling back of the
remaining part of the tongue. The following precautions should be
observed to prevent it: The laryngotomy wound must always be left open,
and covered by a loose piece of gauze which does not press upon the
neck; the patient must be nursed on his side, not upon the back;
suturing the remaining part of the tongue is not sufficient; if plugging
is left in the mouth, the tube must be temporarily retained, and removed
after a few hours when breathing is not obstructed; early removal,
however, is preferred.

Bronchitis is mentioned in two of the cases already quoted, pneumonia in
one case, pneumonia and empyema in one, and purulent mediastinitis in
one, with three deaths in all. Of these five cases, four had operations
upon the tongue. On the other hand, without laryngotomy, bronchitis was
rather more common (seven cases) and broncho-pneumonia occurred in two,
both of which died. In order to throw more light upon the subject, we
have examined the charts of all the cases after the operation, and have
found that in most of them there was a rise of temperature to 99° F., or
slightly higher, which lasted for periods varying from one to seven
days; the pulse and respiration were little affected. In laryngotomy
cases there were only eighteen instances of temperatures of over 100°
F., as against twenty-five where no laryngotomy had been performed. Here
again the pulse and respiration were only slightly affected, so that the
condition was probably due to local inflammation and not to involvement
of the lung. The results are by no means conclusive, but justify the
general feeling that laryngotomy does not increase, but probably
diminishes, the danger of infection of the lungs.

Healing of the wound may take place in normal conditions in about five
days, but the period is frequently longer--from ten to twenty days;
suppuration is uncommon, and was only mentioned in two instances where
the wound had been sutured. The scar left after laryngotomy is often
depressed for several months, but eventually becomes loosened and is
then scarcely noticeable.

Death occurred in six cases, but there was no evidence to show that
there was any connexion with the laryngotomy; on the contrary, the
operations were more severe, and infrathyreoid laryngotomy was performed
partly for the very reason that the condition of the patients was less
favourable.

From my experience, the advantages which were originally claimed by
Bond, Butlin, and others have been completely upheld; the larger
operations upon the upper air-passages are easier to perform and can be
more thoroughly completed; and it is very possible that the
after-results may be improved by the greater facility which is thus
afforded. I would strongly urge laryngotomy in all large operations of
this region; the tube should be removed early, and the wound should not
be sutured.




CHAPTER III

OPERATIONS UPON THE TRACHEA


TRACHEOTOMY

There is evidence to show that this operation was known to the ancients,
and that it has been practised during at least two thousand years
chiefly for the treatment of foreign bodies in the air-passages. From
the sixteenth century to the present time it has been frequently
performed, and the discovery of diphtheria in 1881 by Bretonneau opened
up a new field for the operation.

It is uncertain when tubes were introduced in the after-treatment of
tracheotomy, but Dr. George Martin in 1730 was the first to describe a
double tube which allowed of the removal of the inner part for purposes
of cleaning. The movable collar was invented by Luer, and the angular
tube now generally used is associated with the name of R. W. Parker, to
whose research we owe many of the recent improvements in connexion with
this operation.

=Indications.= Obstruction to respiration is the most important, and
must be distinguished carefully from the dyspnœa which is due to
pulmonary affections, disease of the heart, or organic lesions in other
parts of the body. Laryngeal obstruction may be due to--

(i) _Diphtheria._ The extent to which diphtheritic obstruction has to be
taken into account is shown by the following table:--

    TABLE SHOWING THE NUMBER OF CASES ADMITTED TO THE FEVER HOSPITALS OF
    LONDON (M.A.B.) DURING THE YEARS 1902-7, INCLUSIVE[25]

    +----+------------------+-----------------+-----------------+
    |    |  _All forms of   |   _Laryngeal    |  _Tracheotomy   |
    |    |   Diphtheria._   |      Cases._    |     Cases._     |
    |    +------+-----+-----+-----+-----+-----+-----+-----+-----+
    |    |  _C  | _D  |_M p | _C  | _D  |_M p | _C  | _D  |_M p |
    |    |   a  |  e  | o e |  a  |  e  | o e |  a  |  e  | o e |
    |    |   s  |  a  | r r |  s  |  a  | r r |  s  |  a  | r r |
    |    |   e  |  t  | t   |  e  |  t  | t   |  e  |  t  | t   |
    |    |   s  |  h  | a c |  s  |  h  | a c |  s  |  h  | a c |
    |    |   ._ |  s  | l e |  ._ |  s  | l e |  ._ |  s  | l e |
    |    |      |  ._ | i n |     |  ._ | i n |     |  ._ | i n |
    |    |      |     | t t |     |     | t t |     |     | t t |
    |    |      |     | y ._|     |     | y ._|     |     | y ._|
    +----+------+-----+-----+-----+-----+-----+-----+-----+-----+
    |1902| 6,839|  741| 10.8|  639| 134 | 20.9|  264|  86 | 32.5|
    |1903| 5,422|  504|  9.3|  560| 102 | 18.2|  223|  67 | 30.0|
    |1904| 4,639|  464| 10.0|  659| 116 | 17.6|  247|  79 | 32.0|
    |1905| 4,224|  346|  8.2|  706| 116 | 16.4|  255|  72 | 28.2|
    |1906| 4,937|  444|  9.0|  702| 127 | 18.1|  275| 101 | 36.7|
    |1907| 5,674|  544|  9.6|  981| 169 | 17.2|  432| 129 | 29.9|
    +----+------+-----+-----+-----+-----+-----+-----+-----+-----+
    |    |31,735|3,043|  9.6|4,247| 764 | 17.9|1,696| 534 | 31.5|
    +----+------+-----+-----+-----+-----+-----+-----+-----+-----+

[25] _Metropolitan Asylums Board’s Ann. Rep., Med. Supplement_,
1902-1907.

An examination of the above figures shows that in recent epidemics 13%
of the cases developed symptoms of laryngeal affection; that about 40%
of these laryngeal cases were treated by tracheotomy (in some cases
preceded by intubation); and that the mortality in all the cases of
tracheotomy was 31.5%. Tracheotomy in diphtheria, therefore, must still
be regarded as a serious operation.

[Illustration: FIG. 267. SKIAGRAM SHOWING AN ANGULAR TRACHEOTOMY TUBE IN
THE TRACHEA. H, Body of hyoid; PH, Pharynx; CR, Posterior plate of
cricoid; L, Larynx; OE, Œsophagus; T, Trachea.]

The operation is required chiefly during the early years of life,
namely, from one to six (see table on p. 543). Although the larynx
cannot be inspected in children, it is easy to determine whether
mechanical obstruction is present; for inspiration is noisy and
accompanied by stridor, the voice is lost or reduced to a whisper, and
attempts to cough are frequent. The alæ nasi are dilated, the extra
muscles of respiration are called into action, and laryngeal excursion
is seen. On examining the chest, recession is evident; and during
inspiration the supraclavicular fossæ, the intercostal spaces, and the
epigastrium are all indrawn. The amount of recession depends more upon
the muscles of the chest than upon dyspnœa, and is marked in weakly
children. When dyspnœa becomes urgent the restlessness increases, and
this is an important indication that an operation is required. In very
serious cases the face is drawn, livid, or extremely pale; respiration
is deficient, and the chest expansion feeble. An examination of the
lungs shows the air entry to be imperfect; the bases are dull to
percussion, and all sounds absent. The action of the heart is feeble,
rapid, or intermittent; no nourishment can be swallowed. It is always
difficult to determine how much of this collapse is due to toxin; but by
relieving the obstruction the most distressing feature of the disease is
removed, better aeration of the blood is obtained, and the heart is
relieved from strain. The operation also drains the trachea, and the
amount of poison absorbed is thus diminished. There is abundant evidence
to show that the best results are obtained by early operation,
especially in young children, in whom the larynx is comparatively small.
It should be remembered that dyspnœa is often worse at night, and that
at any moment there may be spasm.

(ii) _Infectious diseases_, such as (_a_) secondary diphtheria, by no
means uncommon in the fever hospitals of London: in the five years 1902
to 1906, thirty cases are recorded, with sixteen deaths (53%), a very
high mortality; (_b_) scarlet fever or measles, which provided 118 cases
in which tracheotomy was performed, with eighty-seven deaths (74.3%
mortality); (_c_) erysipelas, small-pox, typhoid fever, influenza and
whooping-cough, which occasionally cause dyspnœa, calling for
tracheotomy.

(iii) _Acute laryngitis_ (other forms) in which œdema supervenes as the
result of septic infection, or of the inhalation of steam, boiling
water, or irritating chemicals, or as the result of trauma with or
without fracture of the cartilages, or in the course of renal or heart
disease. Brandy in excess, and certain drugs such as iodide of
potassium, may also cause œdema of the larynx, and two cases are
recorded by Fournier where death occurred before tracheotomy could be
performed, as the result of taking iodides.

For conditions such as these tracheotomy is better than intubation, and,
as the swelling may extend into the trachea, the high operation is not
advised. Although the operation should not be undertaken until other
treatment has been tried, it is well to remember that collapse of the
lung, broncho-pneumonia, and complications, are likely to arise when the
obstruction is allowed to persist.

(iv) _Syphilis._ In the tertiary stages of either acquired or congenital
syphilis (rare) the larynx may be affected, and in long-standing cases
of over ten years, when the mucosa is much thickened, there is a danger
of obstruction. Even when energetic antisyphilitic treatment has been
advised the disease may become acute. Tracheotomy may be necessary for
the relief of (_a_) œdema, likely to occur suddenly with necrosis,
perichondritis, or the breaking down of gummata; (_b_) fibrous stenosis,
which may cause a gradual increase of dyspnœa or become suddenly acute
from spasm or œdema (iodides?); (_c_) adhesions, whether simple bands or
webs; or (_d_) fixation of the vocal cords in the middle line, resulting
from inflammation of the laryngeal joints or from paralysis of the
abductor muscles.

(v) _Tubercle._ This rarely causes true laryngeal obstruction, excepting
in those acute cases where subglottic œdema, abscess, or sequestrum is
present. Tracheotomy was at one time used in certain cases in order to
give complete rest to the larynx, but this has been abandoned as
unsatisfactory; it should not be performed unless there is urgent
laryngeal obstruction, since ‘it has many and grave disadvantages. It
materially diminishes the efficiency of the cough, the secretion from
the lungs is apt to accumulate in the bronchi and alveoli, and set up
miliary tuberculosis. Again, the patient can often ill withstand even
this slight operation; his power of speaking is diminished or lost and
his mental anxiety is increased. Not rarely also, the tracheotomy wound
becomes infected with tubercle. For these reasons tracheotomy should
never be performed in phthisis except for severe dyspnœa’ (Lack[26]).

[26] Cheyne and Burghard, _Manual of Surg. Treat._, 1901, Pt. v, p. 449.

(vi) _Certain nervous diseases_, such as abductor paralysis. Urgent
dyspnœa may occur in (_a_) advanced bilateral abductor paralysis, or
(_b_) unilateral abductor paralysis associated with pressure upon the
trachea by tumours. In the bilateral form it is difficult to determine
when to operate; but the danger of suffocation, increased during the
night, makes it necessary to overrule the objections of the patient.
Tracheotomy (or intubation) may be performed merely as a temporary
relief where the paralysis results from diphtheria, syphilis, toxic
neuritis, &c.; in more serious cases the tube must be worn permanently,
unless total recurrent paralysis supervenes (as it may do, though rarely
in tabes) accompanied by cadaveric position of the cords and the
restoration of free breathing. This latter condition can be induced by
total division of both recurrent laryngeal nerves, but the operation,
which has been performed on one or two occasions, has not been attended
with satisfactory results. In cases of long duration the tube may be
plugged during the day, or a valve may be added to the canula, so that
the patient can speak by expiration through the larynx.

(vii) _Tracheal compression_ by tumours of the neck or mediastinum, of
the thyreoid or thymus, or by aneurism, or by tuberculous bronchial
glands. In these conditions inspiration and expiration are equally
affected, and if the obstruction is low down, a long canula (such as
König’s, Kocher’s, or Salzer’s) will be required in order to relieve the
dyspnœa. The pressure of such tubes may cause ulceration of the wall of
the trachea, and hæmorrhage may occur. This danger is especially to be
feared when an aortic aneurism presses upon the trachea (see p. 542).

Tracheotomy should, therefore, be reserved for extreme cases, where it
is impossible to remove the cause of the obstruction: on the other hand,
dyspnœa caused by tumours of the neck which are removable (_e.g._
thyreoid tumours) should be relieved by radical operation without
tracheotomy.

(viii) _Congenital laryngeal stridor_, glottic spasm, laryngismus
stridulus, epilepsy, congenital webs and diseases of the crico-arytenoid
joint such as ankylosis (true or false) or luxation. In these cases
tracheotomy is rarely necessary, but when the operation is advisably
undertaken the dyspnœa may require a permanent tracheotomy tube or
prolonged intubation unless a radical removal of the disease can be
effected.

(ix) _Cut-throat._ Tracheotomy is advised as a preliminary to further
plastic operations in all cases where any part of the air-passages has
been opened, in order to avoid the danger of suffocation and to prevent
hæmorrhage into the trachea.

(x) _Fracture_ of either the hyoid, thyreoid, or cricoid cartilage, that
of the thyreoid being the most common, and of the cricoid the most
serious. These fractures are always associated with hæmorrhage and œdema
of the mucous membrane, sometimes with emphysema; and the swelling thus
caused within the larynx may be so great that tracheotomy or laryngotomy
becomes urgently necessary for the relief of dyspnœa. Theoretically it
is advisable to expose the fracture, so that it may be sutured or wired
in its proper position, but, even in those instances where this is
attempted, it is advisable to retain the tracheotomy tube for a few days
until all swelling has subsided.

(xi) _Sudden dyspnœa during surgical operations_, due to--

(_a_) Mechanical obstruction to respiration, such as is caused by
impaction of foreign bodies within the larynx (tooth-plates, teeth,
blood, pus, vomited food, &c.), by faulty position of the head or
falling backwards of the tongue, by a swollen condition of the larynx,
by tumours or abscesses (retropharyngeal) which obstruct the air-way,
by cicatricial contraction of the pharynx or larynx, by paralysis of the
vocal cords, or by spasm of the muscles of the jaws so often associated
with a similar condition of the glottis and auxiliary muscles of
respiration. In a case reported by Boyle, a well-nourished muscular man
was anæsthetized for the operation of internal urethrotomy; considerable
difficulty was encountered with his breathing, and only towards the end
of the operation was it discovered that he had well-marked stenosis of
the upper opening of the larynx.

The entrance into the larynx of vomited food or blood is certainly
dangerous, and may occur during the simplest operations even when
properly performed, as, for instance, during removal of tonsils or
adenoids. It is more likely to occur if the patient has not been
prepared for an anæsthetic, or if the latter be badly administered, if
the laryngeal reflex be lost, if the patient be in a bad position or
suddenly moves, or if the surgeon allows too much blood to collect in
the pharynx.

(_b_) Failure of respiration from an overdose of chloroform or other
anæsthetic. To remedy such conditions it is essential that the air
should be expelled from the chest as rapidly as possible. Artificial
respiration can only be successful when the air passes freely both into
and out of the lungs: in rare instances there may be so much difficulty
in maintaining a free passage that tracheotomy should be performed.

(xii) _Multiple papillomata of the larynx._ Here tracheotomy is required
for the relief of dyspnœa and as a preliminary to other operations. It
has also been suggested as a method of curing the papillomata by giving
rest to the larynx. After the performance of tracheotomy the congestion
is relieved and the growths decrease in size; in some cases they
completely disappear, but the treatment is uncertain and not to be
recommended (see p. 485).

(xiii) _Malignant disease of the pharynx or larynx which is too advanced
for other forms of treatment._ Palliative tracheotomy may be employed in
order to relieve dyspnœa or as a means of giving rest to the larynx. It
is most commonly used for cases of extrinsic carcinoma of the larynx:
thus C. Jackson reported twenty-nine such cases, in twenty-one of which
he advised palliative tracheotomy and in only eight laryngectomy. Of the
former, tracheotomy was actually performed in nine, but none of the
patients lived for more than thirteen months. It seems doubtful whether
tracheotomy has any marked effect in retarding the course of malignant
disease, though it sometimes gives relief.

(xiv) _Foreign bodies in the air-passages._ It makes no difference what
views are held as to the advisability of tracheotomy in the treatment of
these cases. The fact remains that the first essential is the safety of
the patient, and, if the dyspnœa is urgent, relief must be afforded.
When a foreign substance has been inhaled the surgeon must always be
prepared for tracheotomy, and it is not advisable for him to leave the
patient, even for a short interval, without proper supervision. In
addition, the operation has been advocated as the proper treatment for
all cases of foreign bodies in the lower air-passages: nevertheless,
removal by Killian’s method gives far better results (see p. 559).

(xv) _As a preliminary to operations upon the upper air-passages_
tracheotomy is rarely necessary, its place having been taken by
infrathyreoid laryngotomy: it is, however, often performed before
undertaking the larger operations upon the larynx (see p. 489).

=Anatomy.= The length of the trachea of an adult is about 4-1/2 inches,
of which 2-1/2 inches lie above the level of the sternum; the cervical
portion, which consists of eight or more rings, extends from the cricoid
cartilage above to the suprasternal notch below. In order to determine
the upper limit of the trachea it is advisable to palpate the following
structures, which lie in the middle line, from above downwards: namely,
the hyoid bone with its greater cornua, the thyreoid cartilage which
forms the greatest prominence on the front of the neck, and the cricoid
cartilage; in this manner it is possible to detect whether there is any
deflexion of the trachea from the middle line as the result of a tumour
lying in one side of the neck.

The anterior border of the sterno-mastoid muscle on each side is also an
important landmark; the two muscles approach each other as they descend
to their attachments to the sterno-clavicular joints, thus forming an
angle the position of which corresponds to the notch in the manubrium
sterni. By drawing a line transversely across the cricoid cartilage to
the anterior borders of the sterno-mastoid muscles, a triangular space
is marked off which may be described as the _tracheotomy triangle_ (Fig.
264).

Beneath the skin and superficial fascia lie the two anterior jugular
veins; these run from above downwards, to communicate with a branch
which crosses the middle line of the neck, commonly in the lower part of
the tracheotomy triangle, and there is an interval between them which
is, in most cases, sufficiently large to prevent their being injured by
a central incision. The pretracheal muscles, namely, the sterno-hyoids
and sterno-thyreoids, are closer together; but the interval can be
recognized by the greater thickness of the deep fascia which passes
between them. When the latter is incised, these muscles can be
separated, and the trachea is exposed, together with the structures that
lie on its anterior aspect. These are the following:--

[Illustration: FIG. 268. ANATOMY OF THE LARYNX AND TRACHEA AND THE
POSITION OF INCISIONS FOR THE OPERATIONS IN THIS REGION. A, Subhyoid
pharyngotomy; B, Thyrotomy; C, Infrathyreoid laryngotomy; D, ‘High’
tracheotomy; E, ‘Median’ tracheotomy; F, ‘Low’ tracheotomy; 1, Platysma;
2, Crico-thyreoid muscle; 3, Sterno-hyoid muscle; 4, Isthmus of thyreoid
gland; 5, Sterno-thyreoid muscle; 6, Sterno-mastoid muscle; 7,
Crico-thyreoid artery; 8, Anterior jugular vein; 9, Inferior thyreoid
vein; 10, Innominate artery; 11, Right innominate vein; 12, Left
innominate vein.]

(_a_) _The isthmus of the thyreoid gland_, which varies greatly in size.
It may be either a thin band with few vessels of importance, covering
the second, third, and fourth tracheal ring; or hypertrophied and
vascular, extending higher in the neck even to the front of the cricoid
or thyreoid cartilage. This condition also results when a pyramidal lobe
is present.

(_b_) _The pretracheal fascia_, which encloses the isthmus of the
thyreoid gland and, when traced upwards, finds attachment to the
anterior aspect of the cricoid cartilage, thus forming the suspensory
ligament of the isthmus. Passing downwards it covers the anterior
surface of the trachea, and, though somewhat indefinite, can easily be
traced behind the sternum as far as the pericardium, with which it
blends. This is a point of great practical importance in determining the
extension of inflammation into the mediastinum.

(_c_) _Veins._ Small transverse branches of the superior thyreoid veins
run upon the upper border of the isthmus between the layers of the
fascia which surround this structure. The inferior thyreoid veins,
larger in size, run from the lower border of the isthmus vertically
downwards in front of the trachea to communicate with the left
innominate; in their upper part they may consist of several small veins
which join together to form two main branches, of which the left may lie
directly in the middle line; small communicating branches of these veins
run transversely across the lower border of the isthmus. The left
innominate vein crosses the front of the trachea somewhat obliquely, and
may lie at least half an inch above the suprasternal notch.

(_d_) _Arteries._ The crico-thyreoid artery runs transversely across the
crico-thyreoid space, being placed in front of the suspensory ligament,
and gives off numerous branches, which enter and supply the interior of
the larynx, as well as small descending branches which run to the
isthmus of the thyreoid gland. A small branch of the inferior thyreoid
artery is also constantly found behind the isthmus, and in rare
instances a thyreoidea ima branch of the innominate, varying greatly in
size, may pass upwards in front of the trachea.

In young children the same relations are found, but with certain
differences. Owing to the larynx being relatively high in the early
years of life, the length of the cervical portion of the trachea is
almost 2 inches when the head is extended, and the bifurcation is
considerably higher than in the adult; further, the trachea is more
movable and is smaller in diameter. The laryngeal cartilages are
difficult to distinguish, but a mass composed of the thyreoid and
cricoid cartilages can always be felt, and its position determined by
careful inspection. It is very important to remember that, even when the
head is extended, the cricoid cartilage lies rather less than 2 inches
above the upper margin of the sternum. In very young children it is
common to find two transverse creases in the skin, of which the upper
usually lies over the upper border of the thyreoid and the lower over
the cricoid cartilage. The lower crease thus assists in determining the
upper limit of the trachea.

The anterior jugular veins in young children are comparatively large;
the infrahyoid muscles are less defined and more difficult to recognize;
and the isthmus of the thyreoid gland is very broad, appears to be part
of the lateral lobes, and occupies a higher position in the neck, often
passing in front of the crico-tracheal membrane as well as the first and
second tracheal rings. The inferior thyreoid veins are larger, more
numerous, and more difficult to separate; the left innominate vein is
somewhat higher in the neck; the thymus gland, which gradually decreases
in size with the increase of age, may extend into the neck, in front of
the trachea, and may even reach as high as the isthmus of the thyreoid;
the fasciæ are softer and less definite, and the fascia which covers the
trachea is easily stripped from its surface.


TRACHEOTOMY IN DIPHTHERIA

=Operation.= As local anæsthetics are of little practical value in the
case of children, the surgeon must decide whether a general anæsthetic
shall be used; for any nervousness on his part increases the danger of
death upon the table. A general anæsthetic is not necessary, but
undoubtedly has certain advantages: the operation is easier and can be
performed more rapidly; the patient is more likely to fall asleep; and
any vomiting that occurs is beneficial rather than harmful. On the other
hand, children suffering from diphtheria are apt to die suddenly under
chloroform; and it should never be administered when there is any sign
of heart failure, when obstruction is very marked, when cyanosis is
present, or when the patient is prostrate. The danger has probably been
exaggerated, and depends more upon the experience of the anæsthetist
than upon the actual disease; in my opinion it is as a rule safer to
employ a small quantity of chloroform, which should be given on the
operating table after everything has been prepared. The child should be
allowed to choose its own position, generally curled up on one side, and
the administration must be slow. By observing these precautions it
usually happens that the child becomes quiet, and that with the loss of
consciousness the breathing improves; the child can then be placed in
the proper position, and the more difficult part of the operation can be
completed before restlessness returns.

The instruments required are: a small scalpel, scissors, two dissecting
forceps, three or more fine-pointed pressure forceps, two double hook
retractors, one blunt hook, an aneurysm needle, and a suitable dilator
for the wound; some form of aspiration apparatus may also, in rare
instances, be necessary (Fig. 278). Three or four tracheotomy tubes such
as described by Parker, and a small tube containing sterilized catgut,
which is eminently suitable for the tying of vessels, and for that
purpose preferable to silk, should also be in readiness. All the
instruments should be kept together in a metal case, as well for private
as for hospital practice, so as to be ready in case of emergency. They
should be boiled for at least twenty minutes both before and after each
operation, and should be laid out separately upon a dry sterilized towel
in the position selected by the surgeon.

[Illustration: FIG. 269. TUBES FOR TRACHEOTOMY. A, Parker’s; B,
Durham’s; C, Baker’s rubber tube.]

Tracheotomy tubes may be made of silver, rubber, vulcanite, celluloid,
or a gum-elastic material, but most surgeons prefer a silver tube in the
early stages of treatment. An angular form should be used, for ‘with the
ordinary quarter circle tube, the lower extremity tends to impinge on
the anterior wall of the trachea, and this is attended with many
inconveniences and even with grave risks’ (Parker[27]). A movable shield
is equally important, and this should be flush with the neck in order to
avoid the possibility of its being removed by the patient. Further, the
tube should consist of two parts--an outer tube to which the shield is
attached, and an inner tube which projects slightly beyond the outer and
can be removed for purposes of cleaning. To encourage breathing through
the larynx, a window may be added in the upper part of the tubes.
Parker’s tube, which meets all the above requirements, is the one most
commonly used in England. When longer tubes are necessary, either
Durham’s or Stewart’s is recommended: in these, the position of the
shield can be altered, and the length of the tube arranged, to suit the
patient. In cases of long duration the use of rubber tubes such as
Morrant Baker’s is indicated. An introducer is rarely necessary except
for rubber or long tubes. As taper and bivalve tubes are liable to
injure the trachea, their use is not advised. The tube chosen should fit
loosely, and should project far enough into the trachea to be secure
from slipping out during coughing or struggling. Short tubes are
preferable, and the wider the tube the easier the breathing and the
better the drainage. The approximate diameter of the trachea varies at
different ages, and the size of tube suitable in each case varies
chiefly according to the trachea, but partly also according to the
fatness of the neck. The accompanying table indicates the appropriate
dimensions.

[27] _Tracheotomy in Laryngeal Diphtheria_, 2nd ed., p. 42.

    TABLE SHOWING SIZE OF TRACHEA AND OF TUBE REQUIRED AT DIFFERENT AGES

    +--------------+------------+------------+---------------------+
    |              |_Approximate|_Approximate|  _Number of tube._  |
    |    _Age._    | diameter of| diameter of+----------+----------+
    |              |  trachea._ |   tube._   |_Parker’s_|_Durham’s_|
    +--------------+------------+------------+---------------------+
    |6 months      |  4 mm.     |    4 mm.   |    16    |    --    |
    |1-1/2--2 years|  6-8 mm.   |    7 mm.   |    20    |     1    |
    |2-4 years     |  8-10 mm.  |    8 mm.   |    24    |     2    |
    |4-10 years    |  10-12 mm. |    9 mm.   |    28    |     3    |
    |10-20 years   |  12-19 mm. |   10 mm.   |    30    |     4    |
    +--------------+------------+------------+----------+----------+

Tracheotomy, even under favourable circumstances, is attended by _many
difficulties_; the urgency of the case, the restlessness of the patient,
the movements of the larynx, the frequent absence of a proper operating
table and equipment, the importance of a good light, of sensible
assistants, of a trained nurse, and, above all, of a calm disposition,
make this one of the most anxious and difficult operations in surgery,
yet there is no medical man who may not be called upon to perform it.

It is important to make the best possible preparations. A table of
suitable height can usually be improvised and placed in a good light. If
the operation be at night, gas lamps or candles can be used, and the
illuminant should be placed in a definite position rather than held by
the parents. The child should be wrapped in a large towel in order to
control the movements of the arms, body, and legs, and should then be
placed upon the table; it is advisable to leave him in ignorance of the
operation, whatever his age, until the last moment. The skin of the neck
should be rapidly washed or sponged with ether, and the head extended
over a small pillow or rolled towel. The operation must never be
commenced until the proper position is obtained; on the other hand,
extension of the head should not be too great for fear of increasing the
dyspnœa. Three assistants are preferred--one to hold the head firmly in
the middle line so that the point of the chin is exactly in line with
the suprasternal notch (this is probably the anæsthetist), a second to
hold the body at the opposite end of the table, and a third to assist
the surgeon with sponges or retractors. It should be the duty of the
last named to prevent any membrane or pus from being coughed over the
principals after the trachea has been opened.

There are four varieties of the operation, viz.:

1. _Crico-tracheotomy_ (with division of the cricoid cartilage).

2. _High tracheotomy_ (involving section of the trachea above the
isthmus of the thyreoid gland).

3. _Low tracheotomy_ (section of trachea below the isthmus of the
thyreoid gland).

4. _Median tracheotomy_ (section of trachea through the isthmus of the
thyreoid gland).

=Crico-tracheotomy= is an easy operation owing to the superficial
position of this portion of the air-passage, but is inadvisable for the
following reasons:--

(1) The larynx being narrower than the trachea, a smaller tube is
required; (2) the swelling of the mucosa often extends downwards and
causes constriction of this region; (3) the tube is not well tolerated;
(4) pressure ulcers, necrosis of the cricoid, and granulations are
frequent complications; and (5) retained tube is more common than with
other operations, this really being the most important consideration.
The comparative value of the remaining operations is largely a matter of
opinion.

It is not uncommonly stated that tracheotomy is better done by touch
than by sight: the object to be achieved is to find the trachea, and
there are two methods of doing this. The first is the _deliberate
method_, suitable for patients in good condition when there is no urgent
dyspnœa; it can be performed entirely by sight, and the greater the
experience of the surgeon the fewer his difficulties. In such cases
skilful technique is of far greater value than haste. The high operation
is preferred, because the trachea is more superficial, less movable, and
easier to find; it has less complicated relations, the blood-vessels are
less numerous, the fasciæ are not so loose, the tube is easier to fit
and unlikely to slip out, healing of the wound is more rapid, and
complications seldom occur. In cases where the isthmus is very broad or
highly placed, so that the upper parts of the trachea and cricoid are
covered, a median operation is recommended. Low tracheotomy is rarely
necessary.

The second is the _rapid method_, to be applied in cases of emergency.
Turner, of the South Eastern Hospital, strongly advocates such an
operation without an anæsthetic. The incision made is from 1/2-5/8 of an
inch in length, this being repeated without attention to the bleeding
until the trachea is reached. The latter is opened in the usual manner.
The tip of the finger is placed in the wound in order to control the
hæmorrhage, and as a guide to the dilators. When these have been
introduced, the child is at once drawn beyond the end of the table so
that the head hangs downwards. The bleeding usually ceases in a few
moments, though in some cases the tube is inserted to control it. The
advantages claimed for this method are that the operation is quicker,
and that no distinction between ‘high’ and ‘low’ is required. The wound
is smaller, there is less danger of sepsis, and the eventual scar is
hardly visible; no hooks or retractors are used, so that the trachea
cannot be displaced. If the wound be in the middle line it is impossible
to miss the trachea. This operation is performed entirely by touch, and
the bleeding is not considered. Its adoption may be necessary to save
the patient’s life, but in the hands of an inexperienced surgeon the
operation is attended with great difficulties.

=High tracheotomy.= The incision must be exactly in the middle line;
this can be accomplished easily if the surgeon keeps in mind two
important landmarks, namely, the point of the chin, and the suprasternal
notch. To determine the upper end of the incision, a point is chosen
midway between the anterior borders of the sterno-mastoid muscles at the
level of the cricoid cartilage. The thyreoid cartilages being steadied
between the fingers and thumb of the left hand, a bold incision is made
from the upper point, 1-1/2 inches in length, extending in a young child
almost to the suprasternal notch. A long incision is generally
preferable, and, when the neck is fat, should commence over the middle
of the thyreoid cartilage. The skin and superficial fascia are divided
between the two anterior jugular veins, and any bleeding is controlled.
The incision is repeated so as to divide the deep fascia lying between
the sterno-hyoid muscles, close to one another in the upper part of the
incision, and these are separated with the knife. It is now advisable to
pause and to seize the bleeding points, allowing the pressure forceps to
fall on both sides of the wound to act as retractors. The infrahyoid
muscles are separated by at least an inch, and, if retractors are
necessary, care must be taken that the muscles alone are included and
that the retraction is equal on the two sides. If there has been no
‘tailing’ of the wound the following structures are then exposed from
above downwards: the lower border of the thyreoid cartilage, and the
front of the cricoid, both easily seen or felt; and a vascular mass,
namely, the isthmus of the thyreoid gland, covered by fascia and
completely concealing the trachea. The landmark that is required at this
stage is the cricoid arch; this should be found, and a small transverse
incision should be made along its lower border to divide the suspensory
ligament; the handle of the scalpel or a blunt hook is introduced
beneath the pretracheal fascia, and the isthmus dragged downwards into
the lower portion of the wound, an operation which can be accomplished
easily if done without hesitation. The upper rings of the trachea are
now exposed; and, unless the superficial veins have been divided, there
should be no bleeding. The trachea should not be opened until it has
been exposed completely and all bleeding has been arrested. It is
unnecessary to ligature the vessels at this stage unless the forceps
have been so placed as to interfere with the part of the trachea chosen
for section, or an artery of considerable size is encountered; in the
latter instance there is a danger of subsequent hæmorrhage if the
ligature is applied close to the tube. While the trachea is being
opened, it is necessary to overcome the movements of the larynx by
grasping the cricoid with the finger and thumb of the left hand. The
scalpel should be gently stabbed into the middle of the trachea to
ensure puncturing the mucous membrane as well as the outer wall, and the
opening should be quickly enlarged in an upward direction until three
rings have been divided, preferably the first, second, and third. It is
imperative that this incision should be in the middle line, should not
be too small, and should only pass through the anterior tracheal wall;
if force be used there is danger of puncturing the œsophagus, or even of
striking the bodies of the vertebræ.

At the moment when the trachea is opened there is a sudden rush of air
out of the lungs. This is reassuring to the surgeon, and at this point
the dilator should be introduced and the anæsthetic abandoned. Temporary
cessation of breathing is common after the first inspiration, but the
great improvement in colour shows that there is no cause for alarm; with
the return of consciousness the child begins to cough, and this has two
results, partly clearing the tubes of mucus, pus, or membrane, and
partly promoting deeper inspiration and better expansion of the lungs.
Cyanosis is thus speedily removed, unless membrane is abundant; and even
where this is the case, it is advisable to encourage coughing in order
to dislodge the membrane, which can be grasped with forceps or caught
with a sponge as it appears in the wound. The use of a feather or a soft
rubber catheter for irritation of the trachea to promote coughing should
be abandoned, as such instruments often displace the membrane downwards.
As soon as breathing is regular and the cough allayed, the vessels can
be ligatured.

A tube of suitable size having next been selected, the opening in the
trachea is widely dilated and the point of the canula quickly inserted
into position, the outer tube alone being used, with tapes for tying
attached. Unless the tube ‘sits’ well without tilting, different sizes
should be tried until the breathing becomes easy, a sure sign that the
lower opening of the canula is pointing in the right direction. The
tapes are tied firmly on the right side of the neck, after which the
inner tube is introduced and fixed in position.

The wound remains to be treated. Various methods have been recommended
to guard against infection: the use of antiseptic watery solutions,
such as perchloride of mercury, chloride of zinc, carbolic acid, and
perchloride of iron, is dangerous; insufflation of powders, on the other
hand, such as orthoform, aristol, and the like, is certainly effective
in keeping the wound clean, and is better than the employment of an oil
emulsion; suturing the wound is unnecessary and is not recommended. A
dry antiseptic gauze is applied to the wound and kept in position by the
pressure of the shield. Lastly, a thin covering of gauze is placed over
the front of the neck, and the patient returned to bed.

=Low tracheotomy.= The incision should be rather longer than in the
‘high’ operation and should reach almost to the suprasternal notch. The
fasciæ, anterior jugular veins, and infrahyoid muscles are treated as
before, and there must be no ‘tailing’ of the wound. The landmark
required is the isthmus of the thyreoid gland, and its lower border must
be determined and dragged upwards by a blunt hook. It is important to
remember that the lower part of the trachea lies deeper in the neck and
is more difficult to expose owing to the blood-vessels that lie anterior
to it; the thymus gland, also, may extend upwards and require to be
retracted. Whereas in high tracheotomy practically the whole operation
is best done by clean cutting, in the lower operation this is more
dangerous, and the deep dissection must be performed partly with forceps
or blunt director; if an artery be divided or venous bleeding occurs, it
should be controlled immediately. No attempt should be made to perform
this operation rapidly owing to the relations of the parts; nor should
the trachea be opened before its rings are exposed thoroughly, as
complications may arise after imperfect division of the pretracheal
fascia. In the opening of the trachea and the further stages, the
operation is similar to high tracheotomy.

=Median tracheotomy.= The child being placed in the required position as
before, an incision is made, from the lower border of the thyreoid
cartilage almost to the sternum, through the skin and superficial
fascia. With a series of cuts, exactly in the line of the original
incision, the fascia lying between the pretracheal muscles is divided;
the bleeding points are seized with pressure forceps, and retractors are
introduced to expose the isthmus. The isthmus itself is treated in one
of two ways: in urgent cases it is boldly divided by one or two cuts of
the knife; but if time can be spared, a threaded aneurysm needle may be
passed under it, first on one side and then on the other, after which
the needle is withdrawn, and the two ligatures can be tied so as to
leave between them a space of one-third of an inch in which a cut can be
made without hæmorrhage. The tracheal rings are thus exposed and can be
divided as before.

=Accidents.= The accidents that occur are less numerous than might be
expected when it is considered how often this operation is performed by
those who are quite unpractised in surgery; many of them are the direct
result of inexperience or arise because the operator becomes confused.
If the patient be in a bad position, or if a wrong incision be made, the
trachea is difficult to find, and it is better to expose the thyreoid
cartilage and prolong the incision downwards until the windpipe has been
discovered.

Hæmorrhage, however, is the chief difficulty, and is sometimes
unavoidable; it may be arterial or venous. The arteries of this region
are generally small, being branches of the superior or inferior
thyreoids, and this accounts for the fact that severe arterial bleeding
is rare. Nevertheless, the smaller vessels may at times be very
troublesome: for instance, the crico-thyreoid artery or one of its
branches may be divided, in which case the cut ends will retract and
will be difficult to seize; and if the trachea has been opened, blood
may continue to enter in sufficient quantity to cause troublesome
coughing. Abnormal arteries, such as the thyreoidea ima, are not of
great practical importance.

Venous hæmorrhage is far more common, and, taking into account the
anatomical relations of the veins, and their great size (increased by
cyanosis) in children, it seems remarkable that bleeding is so seldom
fatal; in desperate cases a very small amount of blood is sufficient to
cause suffocation. Venous bleeding will stop only when respiration
becomes free, and this is not possible so long as blood is being sucked
into the air-passages. Every effort should be made, therefore, to
prevent blood from passing into the trachea, either by hanging the head
over the end of the table as soon as the dilators have been introduced,
or by introducing a canula against which the walls of the trachea can be
compressed.

Failure to breathe, after an opening has been made, is due to either
obstruction or collapse and requires rapid treatment. The trachea must
be widely dilated, and forceps used to remove any membrane which
presents itself in the wound; the assistant must then slowly compress
the ribs two or three times to empty the chest and encourage
respiration. If consciousness returns, the patient begins to cough and
mucus or membrane is expelled from the air-passages. On the other hand,
it is useless to continue artificial respiration if the obstruction is
not relieved; aspiration must be employed if special instruments are at
hand. The fact that a number of surgeons have lost their lives as the
result of sucking through a catheter in the attempt to save the child is
sufficient to condemn this practice; but good results have been obtained
by passing a catheter low down into the trachea and blowing through it
with a syringe or even with the mouth. As soon as the trachea has been
emptied by one of these methods, artificial respiration should be
continued, and collapse treated by injections of strychnine, brandy, or
ether. No attempt should be made to introduce a canula until the
breathing is restored. As Turner remarks: ‘Heart failure during
operation generally recovers with artificial respiration, and twelve
hours later the condition is indistinguishable from that of a case who
has not so closely approached death. The real remedy against such an
accident is never to postpone operation until the heart is exhausted.’

=After-treatment.= Although this is a subject which has produced a great
deal of discussion, there is a widespread impression among the younger
members of the profession that it is of little importance. Much has been
said about the dangers of interference, and any suggestion put forward
has been criticized by those who have had large experience, with the
result that confusion is prevalent. As a matter of fact, the subject is
one of the greatest importance, for there is no operation in surgery in
which the after-treatment can be neglected. Care should be exercised in
choosing a nurse who has special knowledge of children and of the
after-treatment of tracheotomy. Great discretion is required in the
management of such cases, and there is little doubt that harm may result
where too much attention is shown. At many of the hospitals a special
nurse is appointed for attendance on the more desperate cases only. The
main duty of the nurse is to watch the child, for any difficulty in
breathing requires immediate attention. It is necessary that she should
understand the proper management of the tube; she must see that the
inner tube never becomes clogged, and if the tube slips out of the
trachea it must be reintroduced or a dilator inserted; she must also be
responsible for the feeding of the child. The difficulties that arise
during the first few days after operation call for much tact and
experience.

It is unnecessary to enter here into the discussion about food,
stimulants, or general treatment, except to point out that swallowing
may be very difficult. The food must be nourishing, fluid being in most
cases preferred; occasional sips of water should be administered to find
out whether coughing is produced, in which case nasal feeding can be
advised without hesitation. A short rubber catheter should be passed
through the nose at regular intervals according to the nature of the
case. As a general rule a small quantity of nourishment should be given
every two hours, studying, as far as possible, the likes and dislikes of
the patient. By the observance of these principles the child soon
becomes tolerant, and proper nourishment can be administered, thus
removing one of the great difficulties of after-treatment.

_The atmosphere of the room._ The value of steam for producing warmth
and moisture is undoubted; the amount required depends on the case. The
main object to be kept in view is to encourage secretion from the mucous
membranes, and so to prevent the formation of crusts. When secretion is
scanty a large amount of moisture is required, and _vice versa_; also,
when much pus is present, extra moisture is of value to prevent it from
becoming dried and to allow it to be expectorated. The value of
disinfectants is doubtful, but on general principles it may be said that
the more septic the secretion the greater the indication for their use:
tincture of benzoin, oil of eucalyptus, and thymol act as sedatives;
carbolic acid, creosote, and numerous other drugs are useful
disinfectants; soda and potash, recommended by R. W. Parker, tend to
liquefy the exudations. Steam, however, is more important than all
these, and should be advised as being likely to encourage the quicker
healing of the wound: even in catarrhal conditions improvement is more
rapid when this practice is adhered to.

The most important point in the after-treatment, however, as far as the
surgeon is concerned, is to prevent recurrence of the obstruction.
Obstruction is most often due to the blocking of the inner tube by
secretions, a condition easy to recognize from the symptoms which are
produced. The inner tube should be removed, thoroughly cleaned, and
reintroduced. This usually suffices to allow the child a period of quiet
breathing, and sleep may be obtained. To keep the tube free it is very
necessary to repeat the removal at regular intervals. In those cases
where the secretion is tenacious, the tube constantly becomes blocked,
but it is better to remove it again than to allow a feather to be
passed. Nothing is gained by attempting to hurry the separation of
crusts, and the passage of a feather tends to force downward far more
than can be extracted, and so to increase the danger of
broncho-pneumonia. If dyspnœa continues after removal of the inner tube,
a spray should be used, or a small amount of fluid should be dropped
into the trachea to moisten the secretions.

Changing the outer tube rarely presents any difficulty because the
tissues of the neck soon become matted together, a funnel being thus
produced along which the canula is introduced with ease. A new tube
should be prepared before removal of the old, and dilators should be at
hand for use if the child is frightened, struggles, or coughs: the
canula should be introduced quickly and without hesitation, sufficient
force being employed to overcome any obstruction. Unless the original
opening in the trachea was too small, it should be possible to introduce
a tube equal in size to that which was removed. Frequent changing of the
outer tube should be avoided.

_The time for removing the outer tube._ In every case of diphtheria
there is a certain amount of catarrh, with swelling of the mucosa,
increased secretion, and some difficulty of breathing. In addition, the
habit of breathing through a canula is difficult to alter; the child
shows an aversion to breathing through the natural air-passages, and is
often frightened or bad-tempered. As soon as the secretion becomes small
in amount and serous rather than purulent in consistence, an attempt
should be made to discard the tube: the canula should not be retained a
day longer than is necessary, the usual period varying from five to
fifteen days. Various methods may be adopted:--

1. If the outer tube be provided with a window, the tip of the finger
can be placed on the opening to compel the child to breathe through the
larynx; breathing may be difficult, but by this means an indication can
be obtained as to whether it is advisable to persist.

2. If the above method be successful, the tube may be removed. A small
pad of gauze is placed over the wound and the child further encouraged
to breathe through the larynx. Expiration is generally easier than
inspiration, and older children should be encouraged to blow out a
candle or to sound a whistle, this process being continued so long as
the child can endure it, but not to the stage of exhaustion. It is often
possible to remove the tube at the first attempt.

3. The canula may be plugged with a cork which the nurse removes when
necessary: it is often possible to replace the plug while the child is
asleep without his becoming conscious of the fact, thus showing that the
dyspnœa is largely mental.

4. In some children breathing is easy so long as the tube is simply
plugged and is not removed; in such cases the canula can be replaced by
a shield and a plug which does not pass into the trachea. This may
completely deceive the child.

5. The silver tube can be changed for one of rubber, and this can be
shortened daily until nothing remains but the shield.

If these various methods have been tried with no success it is probable
that the case is abnormal, but before this can be conceded it is
necessary to repeat that, in the large majority of cases, the difficulty
of removing the tube is due not so much to definite stenosis of the
larynx as to the bad habit acquired by the patient.

=Complications= arising after tracheotomy and preventing removal of the
tube:--

1. _Wound infection._ This rarely occurs at the present time, and
diphtheritic wounds are seldom seen. Some inflammation of the wound is
natural under the conditions, and may be associated with œdema of the
surrounding tissues; this generally yields to antiseptic treatment in a
few days. In very weakly children suffering from a virulent form of
disease the healing of the wound may be slow, and septic conditions are
apt to arise ending in cellulitis of the neck or even typical
erysipelas. Owing to the disposition of the fasciæ there is a tendency
for the infection to spread in a downward direction, and for mediastinal
inflammation or suppuration to occur: this appears to be more common
after low tracheotomy. The prognosis in such cases is not good, and
every endeavour should be made to prevent the possibility of their
occurrence by absolute cleanliness at the operation and by suitable
after-treatment of the wounds.

2. _Septic conditions_ of the trachea are less common since the
introduction of antitoxin, but occur in cases where false membrane is
abundant. There may be swelling of the mucosa, or copious discharge
which persists for long periods.

3. _Ulceration_ may be due to sepsis or to pressure from a badly fitting
tube, especially when the latter has been worn for a protracted period
(Fig. 270). It may cause perforation and localized abscess either in
front of the trachea or in the neighbourhood of the œsophagus, and may
result in a communication with the latter. In the region of the cricoid,
ulcers are liable to cause necrosis. The signs of such ulceration are:
continuance of purulent discharge, discoloration of the tube, bleeding
from the wound, and, above all, difficulty in removing the tube.

[Illustration: FIG. 270. TRACHEA SHOWING ULCERATION CAUSED BY A BADLY
FITTING TUBE. A, Tracheotomy opening; B, Ulcer caused by the end of the
tube. (_From Specimen No. 1659a in the Museum of St. Bartholomew’s
Hospital._)]

At the first indication of ulceration the cause of irritation should be
removed. It is advisable to discard a metal in favour of a rubber tube,
or, if possible, to remove the tube altogether. Strenuous efforts must
then be made to disinfect the trachea by the insufflation of
antiseptics, either as powders or in solution. The healing of such
ulcers is very slow, and granulations are apt to form resulting in
obstruction and preventing removal of the tube. In later stages
contraction of fibrous tissue causes stenosis; this is more common in
the neighbourhood of the cricoid, especially when the latter has been
divided at the time of the operation.

4. _Granulations._ The possible presence of granulations must always be
borne in mind. I believe this condition is far less common than is
generally supposed, and that in many cases the granulations are entirely
limited to the neighbourhood of the wound, where they can be seen. It is
doubtful whether they are responsible for the dyspnœa which occurs.
Great ingenuity and patience are required for the treatment of this
condition. The wound must be kept scrupulously clean and all source of
irritation removed. A rubber canula should be substituted in place of a
metal one; if it were possible it would be advisable to discard the tube
altogether, but as yet no form of dilator has been devised which will
take the place of the canula. If the granulations be large they should
be removed either with a sharp spoon or with suitable forceps, the area
having been anæsthetized previously by a small quantity of the novocaine
and adrenalin mixture. When small, the use of silver nitrate is
preferable. It may be necessary to repeat this after a few days, and as
soon as seems advisable a further attempt should be made to dispense
with the tube. At this stage time must be allowed for the various
tissues to regain their normal condition. Should this treatment prove
unsuccessful, a thorough investigation must be made under chloroform.
The wound is enlarged as far upwards as the cricoid, bleeding being
arrested with the mixture just described. By throwing a strong light
into the wound, the condition of the mucous membrane can be inspected
and granulations removed. If there be no granulations in the trachea, a
tube speculum can be passed through the mouth to ascertain the condition
of the larynx (see p. 480). Such a method of procedure is preferable to
the passage of probes, forceps, sponges, and other articles through the
larynx, in the hope that any obstruction may be removed. If ulceration
or necrosis of cartilage be discovered, it is impossible to relieve the
condition by surgical means without prolonged treatment with tubes and
the constant use of antiseptics. Under these conditions it is advisable
to consider the removal of the tracheotomy tube in favour of intubation.
In the hands of many foreign authorities the use of intubation tubes
covered with gelatine, in which antiseptic is introduced, has been
attended with such conspicuous success that further attempts should be
made in this country; there is little doubt that, as our knowledge of
the treatment of such wounds improves, better results are daily
attained. Whatever treatment is considered it is important first of all
that the actual cause should be distinguished. This is now possible
owing to the great advances made in methods of examining the larynx.

5. _Stenosis_ of the larynx or trachea occurs in old-standing cases, as
the result of ulceration, after some cases of crico-tracheotomy, and
especially where a tube has been worn for a very protracted period.
Breathing through a tube, if continued for a long time, interferes with
the natural growth of the air-passage above it. The child grows, but the
larynx remains stationary. This condition is aggravated by the fact that
some inflammation is constantly present, especially in the neighbourhood
of the wound, so that the tissue become fibrous and hard. The fibrous
tissue contracts and stenosis is caused. According to von Bruns,
Kohl,[28] and others, constrictions of the trachea may in rare instances
result from some kinking of its wall. Such conditions as a bulging of
the posterior wall due to the approximation of the posterior ends of the
cartilage secondary to the spreading of the anterior portions, inversion
of the tracheal margins from too small an incision, overlapping of the
tracheal wound, and cicatricial union between the thyreoid and cricoid,
must be exceedingly rare. Here, again, a definite diagnosis can always
be made by proper investigation, but treatment is more difficult.
Dilatation must be attempted by either continuous or intermittent
methods. If preferred, a short piece of rubber tubing can be passed
upwards from the tracheotomy wound into the larynx and kept in place for
several hours by two silk sutures, one passing out of the tracheal
wound, the other out of the mouth; or a stenosis canula can be inserted
with some form of hollow plug which passes upwards into the larynx (Fig.
272). The question whether the tracheotomy wound should be kept patent
is difficult to answer. When stenosis is extreme there is no
alternative, and the open wound allows of the constant passage of
graduated bougies, which is more easily accomplished from below than
from above. If treatment be persistent the prospect of a good result is
not unfavourable, and there is every reason to believe that in the
future the number of cases which require a permanent tracheotomy tube
will be reduced to a minimum.

[28] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 270.

[Illustration: FIG. 271. STENOSIS FOLLOWING TRACHEOTOMY. (_From Specimen
No. 1659d in the Museum of St. Bartholomew’s Hospital._)]

6. _Paralysis._ In the larynx there may be paralysis of the sensory or
of the motor nerves. In the former case food may enter into the trachea
and cause troublesome coughing and possibly ‘Schluck-pneumonie’. When
the motor nerves are affected, the paralysis is commonly abductor and
may be unilateral or bilateral, the latter associated with inspiratory
dyspnœa. ‘Complete paralysis of the recurrent laryngeal nerve may also
occur, but is nearly always confined to one side’ (C. A. Parker[29]).
Such paralyses may last from a few days to several months, and are very
troublesome when associated with the passage of food into the trachea;
when severe, nourishment should consist of fluids which can be
administered by a nasal tube.

[29] _Nose and Throat_, 1906, p. 94.

[Illustration: FIG. 272. TUBES USED IN THE TREATMENT OF STENOSIS OF THE
LARYNX. A, Lack’s; B, Störk’s; C, Schimmelbusch’s.]

Further complications arising during the after-treatment of tracheotomy:

7. _Broncho-pneumonia._ This occurs in the worst forms, and is
accompanied by high temperature with definite signs in the lungs. The
absence of septic discharge, the restlessness of the patient, and the
rapidity of the breathing (in many instances accompanied by ‘recession’
not caused by obstruction in the tube) make the condition easy to
recognize. There is no satisfactory treatment for septic
broncho-pneumonia which has already developed, but it may be prevented.
Within recent years it has become less common. This is due to better
technique in the operation, and to careful attention during the
after-treatment. The habit of passing feathers into the trachea has been
abandoned with advantage to the patient. When possible the child should
be removed from septic influences which are liable to infect the throat,
for the occurrence of tonsil[l]itis as a sequel to tracheotomy is
always to be feared in wards containing septic cases.

8. _Emphysema_ may occur in the neighbourhood of the wound, or in rare
cases may be extensive and involve the whole of the face, neck, and
chest. Champneys[30] was the first writer to call attention to this
complication of tracheotomy. After a large number of observations and
experiments, he was of opinion that emphysema of the anterior
mediastinum occurs in a certain proportion of tracheotomies and is of
frequent occurrence in cases that are fatal; that it may be associated
with pneumothorax; and that the conditions which favour its production
are a low division of the deep cervical fasciæ in the neighbourhood of
the sternum, combined with obstruction of the air-passages and strong
inspiratory efforts; artificial respiration, especially if improperly
performed; and want of skill on the part of the operator; further, that
the dangerous period of the operation is between the division of the
deep cervical fascia and the efficient introduction of the tube. To this
may be added those cases in which the tube slips out of the trachea into
the cellular tissue above the sternum and thus causes more or less
obstruction to breathing. It seems probable that the air is sucked into
the cellular tissues beneath the pretracheal fascia, rather from the
outside than from the trachea, and that with forced expansion of the
chest it finds its way beneath the fascia into the mediastinum.

[30] _Trans. Med. Chirurg. Soc._, vol. lxv, p. 85; vol. lxvii, p. 102.

[Illustration: FIG. 273. TRACHEA SHOWING ULCERATION INTO THE INNOMINATE
ARTERY AFTER TRACHEOTOMY. (_From Specimen No. 1622a in the Museum of St.
Bartholomew’s Hospital._) A, Aorta; B, Ulcer; C, Right subclavian; _D_,
Right common carotid; E, Left common carotid; F, Left subclavian.]

9. _Hæmorrhage_ may occur as the result of slipping of a ligature during
an attack of vomiting or struggling after the operation; it is usually
venous and requires nothing but passing notice. Secondary hæmorrhage may
result from ulceration into one of the larger arteries or veins.
Kocher[31] states that ‘the number of cases recorded is now about
eighty-seven, of which fifty-six are associated with the innominate
artery. Unfortunately it is not known how often in these cases inferior
tracheotomy had been performed. Low tracheotomy was performed in my case
because an excision of the larynx for cancer had been undertaken.
Doubtless the danger of these fatal complications is much greater with
inferior tracheotomy owing to the pressure of the canula.’ Von Bruns[32]
also agrees that ‘the vast majority of fatal hæmorrhages were in cases
of inferior tracheotomy. Of thirty-six cases in which the source of
hæmorrhage was given, twenty-eight were traced to the innominate vein,
two to the right carotid, and one each to the superior thyreoid, the
left innominate, the right jugular and the left jugular.’ Bleeding is
also recorded in cases of aneurism of the aorta, in which tracheotomy
has been performed, as the result of erosion of the tracheal wall and
the bursting of the sac. Further, troublesome oozing may take place from
the mucous membrane of the trachea when this is inflamed, or when
granulations are present, or when there is much sloughing of tissues,
and especially after a metal tube has been worn for a considerable
period. Hæmorrhage from an enlarged thyreoid isthmus is also described.
When due consideration is given to the septic condition of the wounds
and the close relation of large vessels, it is surprising to find that
hæmorrhage proves so seldom fatal.

[31] _Chirurg. Operat._, 1907, p. 631.

[32] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 265.

[Illustration: FIG. 274. ANEURISM OF THE AORTA PERFORATING THE TRACHEA.
(_From Specimen No. 1500 in the Museum of St. Bartholomew’s Hospital._)
A, Aorta; B, Left subclavian; C, Left common carotid; D, Ulcer in sac of
the aneurism.]

10. _Cardiac paralysis_ may also complicate tracheotomy. When
supervening in the acute stages of the disease, the patient becomes
prostrate and vomiting is persistent, while the heart gradually fails.
In other cases death occurs suddenly and unexpectedly, in mild as well
as in severe disease; this may happen at any period, during the first
days or later, during convalescence. Heart failure is more common in
diphtheria than in any other infectious disease which is met with in
this country.

=Prognosis.= It may be said that all cases of laryngitis caused by
diphtheria are of a serious nature, and especially those which require
tracheotomy (see Table, p. 517). The mortality amongst tracheotomized
patients during five years was 31.5%, and the variations in each
separate year were slight. Such results are far from satisfactory, but
it must be remembered that in pre-antitoxin days less than 30% recovered
after tracheotomy (Goodall[33]). The use of antitoxin, first suggested
by Behring, is undoubtedly responsible for this remarkable decrease in
the mortality. The sooner the serum is injected the better the prognosis
with tracheotomy. A large dose should be given, 8,000 to 18,000 units,
irrespective of age, and the dose may be repeated on the second day if
required. Improvement generally commences between twelve and twenty-four
hours after injection; the swelling of the mucosa subsides, and
secretion is diminished; false membrane is not so copious, and rarely
extends to the trachea and bronchi; crusts become less adherent, and are
expelled by the patient. In this manner the whole area of the disease
becomes clean, and there is less absorption of toxins. It is now
generally agreed that serum should be used in all suspicious cases, and
some authorities inject at once not only the patient, but also other
children living in the same house. It is hoped by early injection to
avoid the necessity for tracheotomy.

[33] _Brit. Med. Journ._, 1899, vol. i, p. 199, ‘On the Value of the
Treatment of Diphtheria by Antitoxin.’

The age of the patient is very important, as the following table shows:

    TABLE SHOWING TOTAL DIPHTHERIA TRACHEOTOMIES PERFORMED AT THE FEVER
    HOSPITALS IN LONDON DURING 1902-6, INCLUDING THOSE IN WHICH
    INTUBATION WAS PREVIOUSLY PERFORMED AND THOSE IN WHICH NO ANTITOXIN
    WAS USED

    +---------+----------+-----------+----------------+
    | _Age._  | _Times._ | _Deaths._ | _Percentage of |
    |         |          |           |   Deaths._     |
    +---------+----------+-----------+----------------+
    | Under 1 |     62   |     40    |      64.5      |
    |  1-2    |    256   |    123    |      48.0      |
    |  2-3    |    272   |     87    |      31.9      |
    |  3-4    |    231   |     54    |      23.3      |
    |  4-5    |    196   |     45    |      22.9      |
    |  5-6    |    119   |     19    |      16.0      |
    |  6-7    |     67   |     18    |      26.9      |
    |  7-8    |     22   |      5    |      22.7      |
    |  8-9    |     12   |      3    |      25.0      |
    |  9-10   |      9   |      3    |      33.3      |
    | Over 10 |     16   |      6    |      37.5      |
    +---------+----------+-----------+----------------+
    |  Total  |  1,262   |    403    |      31.9      |
    +---------+----------+-----------+----------------+

From these figures it is apparent (1) that children less than one year
of age rarely recover after tracheotomy; this is especially true of
diphtheria, although in other forms of laryngeal obstruction cases of
recovery have been reported in children of six months; (2) that in the
early years of life tracheotomy is most commonly needed, especially
between the ages of one and five years; (3) that the death-rate
gradually decreases between the ages of one and six years, after which
there is a rise.

In explanation of these facts it appears probable that after five years
of age the larynx and trachea are increased in size, so that obstruction
is only met with where there is a large amount of membrane, namely, in
the worst cases; in patients over ten, the age which marks the change to
the adult type of larynx, the air-passages become so large that
obstruction seldom occurs even when much membrane is present; dyspnœa,
in these cases, points to extension of the disease to the smaller tubes,
and tracheotomy is unable to give the same relief.

In considering the prognosis, not only must the symptoms peculiar to the
case be taken into account (as for instance the pulse, temperature,
respiration and general condition), but also any complications that
arise. It must be borne in mind that tracheotomy does not cure, although
it can relieve, the patient; that nearly one-third of the cases die;
that the disease, and not the operation, is responsible for most of the
deaths. Moreover, the amount of toxæmia depends upon the virulence of
the infection, which is variable in different epidemics; upon the area
of mucous membrane infected; and upon the constitution of the patient.
In so-called hæmorrhagic diphtheria the result is always fatal.

_The effect on after-life._ It was stated by Landouzy at the Berlin
Tuberculosis Congress in 1899 that, judging by the rarity of the scar,
few tracheotomized children reach adult life, but inquiries in Germany
showed that this was incorrect. H. W. L. Barlow, in reviewing the
literature of the subject, concludes that ‘in the large majority of
cases the cure is permanent and complete’. In cases where a tracheotomy
tube has been retained for a long period, however, complications are
liable to arise; these include stenosis of the larynx or trachea,
bronchitis, pneumonia, and possibly tuberculosis (see p. 485).


TRACHEOTOMY IN CONDITIONS OTHER THAN DIPHTHERIA

The indications for tracheotomy in conditions other than diphtheria have
already been described. Although local anæsthetics are of little
practical value in children, their use is much preferred where adults
are concerned. The three drugs most commonly used at the present time
are eucaine, cocaine, and novocaine, and of these novocaine is
unquestionably to be preferred for subcutaneous injection as being less
toxic, less irritant to the tissues, and at least as efficient in
producing anæsthesia. Whichever drug is chosen, a small quantity of
chloride of sodium should be added in order to make the solution
isotonic with the blood serum, and thus to render it practically
non-irritant. Many surgeons add adrenalin to contract the vessels in the
injected area and so to prevent the drug from being absorbed into the
general circulation: owing to the large size of the vessels and their
proximity to the heart this is important, but it must also be remembered
that with strong solutions there is great contraction of vessels, and
that when the effects have disappeared there is a slight danger of
recurrent hæmorrhage. Semon has drawn attention to this danger in
connexion with operations upon the larynx, and after minor operations in
other regions of the body it is not uncommon to find a small hæmatoma
which necessitates reopening the wound.

In order to ensure the full effects of local anæsthesia with the least
possible disadvantage, the drug should be used in weak solution, and the
injection should be made at least a quarter of an hour before the
operation is commenced. It is only necessary to prick the skin at one
point, namely, at the upper end of the proposed incision; a small
quantity of the fluid should be expelled, after which the needle may be
withdrawn. After a short interval it is possible to reinsert the needle
(or a larger one if preferred) and to push it deeper, until the whole
length of the incision has been injected, without distress to the
patient.

The following solution will be found effective:

    ‘Novocaine, 4% solution           ɱ x = 1.3%
    Sodium chloride, 4% solution      ɱ vj = 0.8%
    Adrenalin, 1-1,000                ɱ i = 0.003%
    Distilled water to                ɱ xxx

       [Transcriber’s note: ɱ (approximation to symbol in the text) is
        thought to mean drops, minims, or parts by volume;
        hence ɱ x = 10 parts/drops, ɱ vj = 6 parts/drops, ɱ i = 1 drop
        made up to a total of 30 parts/drops with distilled water]

    ‘These local anæsthetics are all, more or less, rapidly decomposed
    and rendered inactive in the presence of even traces of an alkali or
    alkaline carbonate. If boiling is resorted to in order to sterilize
    the syringe, great care must be taken that no soda is
    present.’--LANG.

Moreover, the finished solution cannot be boiled without decomposing the
adrenalin, and it is customary therefore to add thymol or Ol. Gaultherii
(0.1%), which keeps the solution antiseptic without being irritant.

The operation, which is often required in adults, must be carried out
upon the lines already described. The enlargement of the thyreoid and
cricoid cartilages, the small amount of fat, the small size of the
thyreoid isthmus and of the pretracheal vessels after puberty, make the
trachea easy to find. Difficulties, however, arise and are determined by
the urgency of the case and the nature of the disease. Thus, with
inflammation, the neck may be so swollen that the trachea is many inches
from the surface; with tumours the trachea may be displaced, or the
obstruction may be in the thorax. Under such conditions it is important
to note the probable position of the trachea before the operation is
commenced, and to be prepared for serious hæmorrhage.

The after-treatment also corresponds to that which is adopted in
diphtheria. It is important to keep the tube clean and to prevent it
from irritating the trachea. The time for removal of the canula varies
according to the condition. Thus, when tracheotomy is performed for a
foreign body, the tube may be removed as soon as the object has been
extracted; on the other hand, when treating stenosis of the larynx it
may be necessary to advise permanent wearing of the canula.

Complications are less common than with tracheotomy for diphtheria.
Under favourable conditions there is little danger of pneumonia unless
the wound becomes infected, as may happen when the operation is
undertaken for the relief of septic inflammations.

Although tracheotomy is in itself a slight operation, it should be
reserved for cases that demand it. The mortality of the operation under
favourable conditions is probably very small; on the other hand, in
acute septic conditions and in patients suffering from bronchitis there
are grave dangers of complications.


TRACHEO-FISSURE AND RESECTION OF THE TRACHEA

Although these operations are very rarely performed, advance has been
made in their technique during recent years.

=Indications.= (i) _Tumours of the trachea._ These are uncommon.
Thiesen[34] in 1906 collected from literature 135 cases, of which 89
were innocent and 46 malignant. The majority of the former were
papilloma (25), fibroma (24), enchondroma (17), and intratracheal struma
(10). Of the latter, carcinoma (28) was more common than sarcoma (18).
More than half of these tumours were situated high up in the trachea.
These cases were collected from a period covering seventy-five years,
which proves that they are extremely rare as compared with tumours of
the larynx.

[34] _Trans. Amer. Laryng. Assoc._, 1906, p. 264, ‘Tumours of the
Trachea.’

(ii) _Stenosis due to previous inflammation._ Stenosis may be caused by
diphtheria or other fevers, syphilis, the presence of a foreign body, or
the inhalation of corrosive acids or chemical fumes. Such cases are
generally treated by endotracheal methods (see p. 559).

(iii) _Cut-throat, or injury._ An operation may be necessary after
crushing or bullet wounds, or, in later stages, owing to the development
of stenosis.

The diagnosis of these conditions is now comparatively easy, and with
the help of direct laryngoscopy and X-ray photography the exact
condition can, in many cases, be determined. In some instances the
tumour may be removed by endotracheal operation, especially if the
growth is innocent.

=Tracheo-fissure= is more reliable, and should always be performed when
there is any suspicion of malignancy. The preliminary stages are similar
to those of tracheotomy. A section of the trachea is first made in the
region of the tumour, and the opening is enlarged so that the growth can
be thoroughly explored; this can be better accomplished when the trachea
is illuminated by a good electric lamp, in some instances a Killian’s
tube being required. When possible, a tampon canula is inserted into the
lower part of the trachea. When the growth is low down, the patient is
placed in the Trendelenburg position in order to prevent the inspiration
of blood. Should the diagnosis be uncertain, a portion of the tumour can
be excised and a frozen section made. If proved to be innocent, the
growth can then be freely excised with scissors or galvano-cautery. The
bleeding is arrested, and the tracheotomy tube is retained for several
days. The after-treatment must be conducted on lines similar to those
laid down for laryngectomy, the patient being turned on the face in
order to prevent pneumonia. ‘Up to the present time about two dozen
operations of this sort have been reported. The author has removed in
this manner four intratracheal thyreoids with permanent result’ (von
Bruns).[35]

[35] Bergmann, E. von. _Sys. Pract. Surg._, vol. ii, p. 249.

[Illustration: FIG. 275. SARCOMA OF THE TRACHEA. (_From Specimen No.
1658a in the Museum of St. Bartholomew’s Hospital._)]

=Resection.= If the tumour be malignant, the surgeon must first decide
whether its removal is practicable or whether palliative tracheotomy is
preferable. In the former case the trachea is isolated laterally and
divided transversely well below the growth. Whenever possible the lower
end is then brought outwards and temporarily attached to the lower part
of the incision above the sternum. The resection of the trachea is then
carried out, so that the growth is freely removed, care being taken to
preserve the recurrent laryngeal nerves. ‘Where the section of the
trachea to be removed is limited to 4 centimetres or less, the two ends
can generally be approximated and united, restoring the calibre of the
tube and normal mouth respiration’ (Brewer).[36] This is accomplished by
numerous catgut sutures some of which include the entire thickness of
the tube. The muscles can be approximated so as to cover the incision,
and the wound can be drained freely. On the other hand, the lower end of
the trachea may be permanently fixed in the wound as described under
laryngectomy (see p. 498). Von Bruns has removed a cancer on the
posterior wall of the trachea with six tracheal rings, thus giving the
patient six years of life. He remarks: ‘operative treatment in tumours
of the trachea shows brilliant results. Untreated the condition leads to
death from suffocation. In seven cases operated upon by me, the results
were all favourable.’

[36] _Keen’s Surgery_, 1908, p. 510.




CHAPTER IV

INTUBATION OF THE LARYNX


Intubation, or ‘tubage’, was first recommended by Loiseau and Bouchut in
France; in 1880 attention was drawn to the subject by Sir W. Macewen in
England, and soon afterwards O’Dwyer[37] of New York published articles
which resulted in its being extensively tried in America; since that
time it has continued to be popular in that country for the treatment of
laryngeal diphtheria. ‘The good results which American physicians have
secured by intubation may be explained, perhaps, by the circumstance
that according to their reports diphtheria takes a milder form in
America’ (Tillmanns).[38] Intubation has been extensively used in
Europe, especially in Germany, but never to the same extent as
tracheotomy, and in England it has been practised at only a small number
of hospitals; thus, of the nine M. A. B. fever hospitals in London only
three used it regularly during 1906-7, and none of them so often as
tracheotomy.

[37] _New York Med. Journ._, 1885, vol. xlii, p. 145.

[38] _Text Book of Surgery_, 1900, vol. ii, p. 625.

=Intubation versus Tracheotomy in Diphtheria.= Since the introduction of
the newer method of treatment in 1880 the subject has been widely
discussed in America, on the continent of Europe, and in England. There
is no evidence to show that treatment with antitoxin has been beneficial
to one operation more than to the other.

The _advantages_ claimed for intubation are:

1. No anæsthetic is required.

2. Consent of friends is easily obtained.

3. No cutting: great rapidity.

4. No wound to heal.

5. Tube worn more easily than the tracheotomy tube.

6. Breathing through natural passages, so that warmth and moisture are
added to the air.

7. Its earlier performance.

8. Its better results in children under five.

9. Recovery is quicker.

The practical _disadvantages_ are:

1. Quite unsuitable except at special hospitals, as great dexterity and
constant practice are necessary.

2. Respiration is interfered with during introduction, so that celerity
is indispensable, accidents are frequent, and failure is common.

3. Tube may be coughed up (28%, Goodall[39]), blocked (12%, Goodall),
and does not provide good drainage for secretions.

4. Swallowing difficult.

5. Complications common: Broncho-pneumonia, ulceration, cicatrization.

6. After-treatment difficult and constant watching required.

7. Necessity for secondary tracheotomy (32.6%), which has a greater
mortality (death in 46.1%, see table below).

8. Retained tube.

[39] _Edin. Med. Journ._, 1902, p. 235, ‘Observations on Intubation of
the Larynx.’

In considering the above it is the obvious duty of the surgeon to advise
what he considers the better operation for the case, and this must
depend largely upon the amount of his experience; the argument that the
operation is superior because it can be previously practised on the
cadaver is a bad one, and implies a failure to realize the many
difficulties which will be encountered in the selection of cases, the
operation itself, and its after-management.

I am strongly of opinion that the operation ought not to be tried
indiscriminately by those who have no knowledge of these difficulties.
In the hands of an expert it is a justifiable method of treatment which
is suitable for selected cases, and it is one which can be used early;
tracheotomy, on the other hand, is naturally delayed, or used for
serious cases and those which have not derived relief from intubation.

Although intubation has received extensive trial, the published results
show great variations and do not prove that intubation is superior to
tracheotomy, but rather the reverse.

    TABLE SHOWING DETAILS OF CASES DURING 1906 AND 1907 AT THE M. A. B.
    HOSPITALS WHERE INTUBATION IS FAVOURED

    +-------+------------+------------+------------+------------+
    |       |_Intubation |   _Both    |_Tracheotomy|  _Total    |
    |       |   only._   |operations._|    only._  |operations._|
    +-------+---+---+----+---+---+----+---+---+----+---+---+----+
    |       |_C |_D |    |_C |_D |    |_C |_D |    |_C |_D |    |
    |       | a | e |    | a | e |    | a | e |    | a | e |    |
    |       | s | a |    | s | a |    | s | a |    | s | a |    |
    |       | e | t | %. | e | t | %. | e | t | %. | e | t | %. |
    |       | s | h |    | s | h |    | s | h |    | s | h |    |
    |       | ._| s |    | ._| s |    | ._| s |    | ._| s |    |
    |       |   | ._|    |   | ._|    |   | ._|    |   | ._|    |
    +-------+---+---+----+---+---+----+---+---+----+---+---+----+
    |Eastern| 78|  4| 5.1| 44| 19|43.1| 30| 13|43.3|152| 36|23.6|
    |Western| 25|  7|28.0| 10|  4|40.0|126| 41|32.5|161| 52|32.2|
    |Park   | 31|  3| 9.7| 11|  7|63.6| 16| 11|68.7| 58| 21|36.2|
    +-------+---+---+----+---+---+----+---+---+----+---+---+----+
    |Total  |134| 14|10.4| 65| 30|46.1|172| 65|37.7|371|109|29.3|
    +-------+---+---+----+---+---+----+---+---+----+---+---+----+

Certain points in the table deserve attention:

1. In cases treated by intubation only, the results are excellent,
namely, death in 10.4%.

2. In cases where tracheotomy was afterwards performed the mortality is
high, _i.e._ 46.1%.

3. Where tracheotomy was the original operation the mortality is also
high, _i.e._ 37.7%.

4. The total operations at these hospitals taken together show a rather
higher mortality than appears in the table below.

As regards the first three points, the facts are the same as in any
published statistics dealing with the relative advantages of the two
operations. I wish to emphasize that the results obtained by intubation
depend very largely upon the selection of the cases and I agree with
Turner and Cuff that, in order to arrive at any conclusion in the
matter, it is necessary to compare the total results of those hospitals
where intubation is favoured with those of the hospitals where
tracheotomy is chiefly employed.

    TABLE SHOWING COMPARATIVE RESULTS AT ‘INTUBATION’ AND ‘TRACHEOTOMY’
    HOSPITALS

  +-------+------------------+--------------------+-----------------+
  |       |     _Three       |       _Six         |     _Total      |
  |       |   ‘Intubation’   |   ‘Tracheotomy’    |     Cases._     |
  |       |    Hospitals._   |     Hospitals._    |                 |
  +-------+------+-----+-----+--------+-----+-----+-----+-----+-----+
  |       | _C   | _D  |_M p |  _C    | _D  |_M p | _C  | _D  |_M p |
  |       |  a   |  e  | o e |   a    |  e  | o e |  a  |  e  | o e |
  |       |  s   |  a  | r r |   s    |  a  | r r |  s  |  a  | r r |
  |       |  e   |  t  | t   |   e    |  t  | t   |  e  |  t  | t   |
  |       |  s   |  h  | a c |   s    |  h  | a c |  s  |  h  | a c |
  |       |  ._  |  s  | l e |   ._   |  s  | l e |  ._ |  s  | l e |
  |       |      |  ._ | i n |        |  ._ | i n |     |  ._ | i n |
  |       |      |     | t t |        |     | t t |     |     | t t |
  |       |      |     | y ._|        |     | y ._|     |     | y ._|
  +-------+------+-----+-----+--------+-----+-----+-----+-----+-----+
  |   1902| 76   |  23 | 30.2|  222   |  71 | 32.0|  298|  94 | 31.5|
  |[1]1903|      |     |     |        |     |     |     |     |     |
  |   1904|156   |  47 | 30.1|  173   |  47 | 27.1|  329|  94 | 28.5|
  |   1905|157   |  46 | 29.3|  184   |  40 | 21.7|  341|  86 | 25.2|
  |   1906|166   |  58 | 34.9|  188   |  51 | 27.1|  354| 109 | 31.5|
  |   1907|205   |  51 | 24.8|  289   |  86 | 29.7|  494| 137 | 27.8|
  +-------+------+-----+-----+--------+-----+-----+-----+-----+-----+
  | Total |760[2]| 225 | 29.6|1,056[3]| 295 | 27.9|1,816| 520 | 28.7|
  +-------+------+-----+-----+--------+-----+-----+-----+-----+-----+
    [1] No return.
    [2] Of these more than 400 were intubations.
    [3] Of these 23 or more were intubations.

From these figures it will be seen that the total result for five years
is a mortality of 27.9% as against 29.6%, in favour of tracheotomy. This
serves, in my opinion, to strengthen the position of those hospitals
which rely upon tracheotomy. Upon a comparison of this sort it would
certainly appear that the results of intubation, at any rate in England,
are not so good as has been stated. I am aware that this opinion is not
shared by many authorities and that Stack[40] writes, ‘taking everything
into consideration, my impression is that under the most favourable
conditions of operating, nursing, &c., the mortality is almost halved by
doing intubation as a routine instead of tracheotomy.’

[40] Allbutt and Rolleston, _Sys. of Med._, 1905, vol. i, p. 1025.

It has been claimed that intubation gives better results in children
under five. This question has been worked out by H. W. L. Barlow,[41]
who concludes that ‘the younger the child, the longer will it require
the tube, and the more frequently, therefore, has the latter to be
inserted’, and ‘from the mortality alone, there is no indication that
one operation is better suited for certain age periods than another, but
since secondary tracheotomy appears to be rarest at three years old and
the intubation fatality is least between four and six years, it follows
that children from three to six are best adapted for intubation’.

[41] _Metropol. Asylums Board’s Ann. Rep., Med. Supplem._, 1904, p. 319.

_Conclusions._ Intubation is justifiable for diphtheria of a mild type
if sufficient experience can be obtained and if the after-treatment can
be personally carried out. The success of the operation depends largely
upon a proper selection of the cases; in other words, it is not suitable
for the worst types of this disease. It should never be performed upon a
patient in whose case the question of tracheotomy does not arise.

In my opinion it is not a good operation for those general hospitals
where there is constant change among the resident officers; it seems
probable that it will remain the treatment of a small number of
physicians who have frequent opportunities of practising their art.

=Indications.= (i) _In diphtheria_, intubation is justifiable when the
disease is of a mild type without great toxæmia, where early diagnosis
has been made, and antitoxin has been administered. It is not
recommended when there is great pharyngeal inflammation, or in cases
with bronchitis or pneumonia, or when the patient is prostrate, nor for
severe obstruction caused by excessive swelling or false membrane in the
larynx or trachea. In the last-mentioned condition intubation is
difficult to perform, and the patient may be choked by false membrane
which has been pushed down: intubation should be abandoned in favour of
tracheotomy when immediate relief is not obtained.

(ii) _In other forms of septic laryngitis_, there is evidence to show
that with intubation the mortality is higher than with tracheotomy; in
œdematous laryngitis, such as follows the inhalation of steam, every
effort should be made to prevent laryngeal obstruction by other forms of
treatment, for intubation is difficult to perform owing to the swollen
condition of the tissues; moreover, injuries are common, and there is a
danger that the upper opening of the tube will become obstructed. Again,
the tube may be expelled by coughing, and the child suffocated without
relief.

(iii) _In chronic stenosis_, intubation is now extensively employed.
Fibrous contraction such as follows some cases of thyrotomy, or syphilis
and other inflammatory diseases, can be treated successfully by this
method. Short light tubes, of vulcanite or similar material, are
inserted and retained in position for long periods, three months or
longer; with the pressure so exerted the amount of fibrous tissue
appears to be diminished, and the lumen of the larynx is dilated.

=Operation= (in diphtheria). The apparatus required consists of a gag
for opening the mouth, a set of tubes with a gauge showing the size for
each age, an instrument for intubation and extubation, and equipment for
tracheotomy.

[Illustration: FIG. 276. INSTRUMENTS FOR INTUBATION OF THE LARYNX. A,
Gag (O’Dwyer’s); B, Forceps for intubation and extubation (Thorner’s);
C, Gauge; D, Tubes: 1, O’Dwyer’s; 2, Thorner’s.]

The tubes recommended by O’Dwyer are of gilded bronze, but other
materials such as vulcanite or hard rubber are sometimes used. The tubes
have undergone frequent modifications and those designed by Bayeux are
shorter, lighter, and a great improvement (Goodall). In Thorner’s type
(Fig. 276) the lower end has been cut off at an angle, so that it may
pass more easily between the vocal cords; the intubator and extubator
have been replaced by a single pair of beaked forceps with a ratchet
attached to the handles, so that, when the beaks are separated, the
tube is gripped firmly and cannot be disengaged until the trigger of the
ratchet has been pulled; with these forceps the tube is not obstructed
while it is being taken in and out of the larynx, and there is less need
for hurry; further, the top of the tube has a funnel-shaped opening
‘which greatly facilitates the introduction of the beaks when the tube
is in the larynx, inasmuch as it allows the beak to glide from any point
of the rim almost automatically into the opening, and what this means
can be appreciated by those who have had experience with the old
extractor’ (Kyle).[42]

[42] _Diseases of the Nose and Throat_, 1907, p. 726.

No preparation of the patient is required, but a blanket must be wrapped
round the arms, body, and legs to control the struggling. Two assistants
are required, one to hold the patient, the other to steady his head and
manipulate a gag. The upright position is preferred by many surgeons
because the patient is less frightened, and the breathing is easier; but
the child may be laid upon a table, with the head slightly extended and
exactly in the middle line of the body, or the head may be allowed to
hang over the end of the table and the tube passed from behind, in a
manner similar to that used for direct laryngoscopy. No anæsthetic is
necessary. The first assistant or nurse should sit on a low chair with
the child on his knee, holding him so that he directly faces the
surgeon; a second assistant stands behind with a gag in his hand. A tube
of suitable size, with a thread attached, and mounted on the introducer,
is taken in the right hand; the assistant introduces the gag, opens the
mouth to the fullest extent, and steadies the head with his two hands;
the surgeon now passes the left index-finger over the back of the
tongue, so that the tip of it passes behind and below the epiglottis
until the cricoid is felt; this is the most important landmark, and as
soon as it is located the finger is drawn upwards and forwards in order
to hook up the epiglottis, and the introducer and tube are rapidly
passed over it; the method of introduction being that used for all
laryngeal instruments. As soon as the end of the tube is level with the
end of the finger, the handle of the introducer is raised so as to throw
the point as far forward as possible; the instrument is then bodily
lowered, so as to drive the tube downwards through the larynx until it
rests firmly and securely against the ventricular bands, which prevent
further passage of the collar; the tube is now held in place with the
left index-finger until the introducer is removed. The whole operation
in experienced hands should take from three to five seconds only, and
must be performed without force.

If the tube has been properly introduced, it is usual for the child to
begin coughing, and this may continue for a short time, accompanied by
noisy and rattling inspiration; the cough gradually disappears and
breathing becomes easy. The tube causes temporary aphonia, which may
persist for a few days after its removal, but is otherwise well
tolerated; the patient is not conscious of the presence of the canula
unless it becomes blocked.

The operation is simple in the hands of those who are accustomed to the
use of laryngeal instruments; in a normal larynx there is no difficulty
in introducing a tube, but in diphtheria the parts are inflamed and
obstruction is present. Children are often intolerant or frightened;
they are liable to retch or choke during introduction, but the latter
can sometimes be accomplished by waiting for an inspiratory effort; if
the struggling is very troublesome a small quantity of chloroform
(cocaine in adults) may be given with safety.

=Difficulties= of the operation. The difficulty of passing the tube over
the base of the tongue can be avoided by pulling the tongue downwards
and forwards and passing the introducer through the mouth with the hand
to the left of the patient’s face and rotating downwards when the point
is in the pharynx. Failure to find the opening of the larynx is often
due to not keeping the instrument exactly in the middle line. The tube
may be too large (even when it corresponds to the age of the child)
owing to swelling either in the larynx or in the subglottic region; in
such a case a smaller tube must be tried, and it is essential that no
force should be used to drive the tube into place, or dangerous
complications may arise. Even a smaller tube may not be passed on the
first occasion, and the surgeon has to decide whether he will try the
same tube again or one that is smaller; the latter may not be suitable
for the age. The tube may be too small, and this may be recognized by
the ease with which it passes; as a result, the first strong cough
expels it out of the larynx, and another must be introduced. A tube of
correct size may be in the larynx without relieving the dyspnœa; this
may be due to one of the following causes: (_a_) some membrane may have
been pushed in front of the tube, an event which is evidenced by the
noisy and difficult respiration, and which requires that the tube shall
be withdrawn with the thread and again introduced, after an interval;
(_b_) the tube itself may become blocked with membrane, with the result
that it is at once coughed out; or (_c_) the child may be asphyxiated so
that tracheotomy becomes a necessity. This last is a point that must
always be remembered: intubation should never be performed unless
everything has been prepared for opening the trachea. The tube may pass
into the œsophagus in spite of all care, and this may increase the
dyspnœa by pressing upon the posterior part of the larynx, in which case
it must be withdrawn by the thread and a further attempt made. It has
frequently happened that the tube with its thread has passed down the
œsophagus into the stomach, an accident which ought to be avoided. No
serious consequences are likely to occur, as the tube will be passed per
rectum, or in rare instances vomited.

The question arises as to how many attempts should be made before
intubation is abandoned. This varies in each case and depends upon the
amount of distress caused by the previous attempts. With each further
trial the child becomes more and more restless, and if the third attempt
fails, it is better to desist, or to allow at least an interval of half
an hour. When the dyspnœa becomes urgent there must be no hesitation,
and either the tube must be reintroduced or tracheotomy performed; both
operations are difficult under these circumstances, and the surgeon
should choose the method of which he has the greater experience.

It is very important to remember that tracheotomy is required in nearly
a third of the cases at one stage or another; at the M. A. B. fever
hospitals of London during 1902-6 there were 429 cases of intubation for
diphtheria, and of these 117 required tracheotomy later, _i.e._ 27.2%.
As Goodall says: ‘Every case that was intubated four or more times came
to tracheotomy. I therefore lay down the rule that if three insertions,
each of several hours’ duration, fail to cure the laryngeal obstruction,
tracheotomy should be performed. Frequent expulsion of the tube by
coughing a few minutes after its insertion is also an indication for
tracheotomy.’

=After-treatment.= A case of intubation requires more personal attention
than one of tracheotomy. It is essential that the doctor should remain
within easy call, as the tube may be blocked or coughed out at any
moment. This danger is not so great as it appears; when the tube is
coughed out there is no immediate asphyxia, and a fatal result is
uncommon; an interval of at least twenty minutes usually occurs before
the dyspnœa becomes urgent, in which time the doctor can be called; it
may even happen that the tube is not required again, and that the
obstruction has disappeared. When the tube becomes blocked, the state is
more serious; in most cases it will be coughed out of the larynx, but if
the child is very weak or the tube very firmly fixed, the obstruction
must be at once relieved. It is for this reason that some surgeons
prefer to leave a thread attached so that the nurse can extract the
tube, but the latter has a disadvantage, namely, that the child may pull
the tube out. This can be prevented by tying up the hands of the child
while the tube is being worn, but even then the child may bite the
string; the general practice therefore is to remove the thread, and the
tube is then expressed by lateral pressure on the sides of the trachea,
or by passing the finger below and behind the larynx and so pushing out
the tube. The method is termed ‘enucleation’,[43] and where it fails the
extubator must be used. A nurse must be chosen who has had previous
experience of intubation; she must understand the symptoms which
necessitate interference with the tube, and the feeding of the child.
Swallowing is often difficult, and liquids tend to pass through the
canula into the trachea; the patient chokes and may cough up the tube.
The danger of pneumonia is also increased. To overcome the dysphagia the
patient should be made to suck uphill through a tube, or semi-solids may
be tried: in other cases nasal or rectal feeding can be ordered:
temporary removal of the tube has also been recommended for purposes of
feeding, but vomiting often occurs with reintroduction immediately after
a meal. In very troublesome cases there is distinct danger in repeated
intubation; tracheotomy should be performed if the child is becoming
exhausted from want of nourishment.

[43] For a description of this method see _Metropol. Asylums Board’s
Ann. Rep., Med. Supplem._, 1898, p. 187.

_Changing the tube._ O’Dwyer recommends that the tube should be retained
for forty-eight hours without change, after which it should be removed
once a day: it must, however, be remembered that while the tube is
retained coughing is greatly impeded, so that septic material collects
in the trachea and is liable to cause pneumonia.

Extubation by the thread and by enucleation has already been mentioned,
but these methods are not applicable in every case. Extubation is
difficult to perform, especially if respiration is obstructed and the
patient struggling; whenever necessary, chloroform should be given. The
preparation required is similar to that for intubation; a table and
tracheotomy instruments are made ready; the upright position is
preferred, and two assistants are required to hold the child and the
gag; expanding forceps are introduced as if intubation were being done,
and the tube is grasped securely and rapidly extracted, the whole
operation being carried out as quickly as possible and without any
suggestion of force. In experienced hands no danger is to be feared, but
if two or three attempts are unsuccessful, tracheotomy should be
performed. The time for removal of the tube varies from a few hours to
four or five days in favourable cases. The main object is to dispense
with the tube as soon as possible, and to err on the side of too early
removal even in spite of the fact that reintroduction may be necessary.

=Complications= may occur, but there is no evidence that they are more
numerous than with tracheotomy. Injury to the larynx is liable to
result, especially from inexperience of the method, and this may be
followed by hæmorrhage, emphysema, or abscess. In rare instances a
false passage has been made, generally through the ventricle of the
larynx: pressure ulcers may form, there may be necrosis of the
cartilage, peritracheal abscess, or cicatricial contraction; or, as with
tracheotomy, subglottic swelling may persist and granulations may be
formed. When urgent dyspnœa follows the removal of the tube, one of
these conditions must be suspected. O’Dwyer maintains that ‘the cause of
persistent stenosis following intubation in laryngeal diphtheria can be
summed up in a single word--traumatism,’ but ‘paralysis of the vocal
cords may possibly furnish an occasional exception to this rule’
(Jacobson).[44]

[44] _Operations of Surgery_, 5th ed., vol. i, p. 640.

‘_Retained tube_,’ which is the term applied to cases of more than five
days’ duration, is certainly more common after injury, but does not
occur more frequently than with tracheotomy; many cases have been
reported where intubation tubes were used for long periods with ultimate
recovery, but the method is uncertain unless the exact condition of the
larynx can be determined (see p. 480).

_Pneumonia._ It has been shown that large numbers of bacilli are present
in the lungs, where they may cause inflammation quite apart from any
operation; in laryngeal cases the danger is increased owing to the
obstruction which causes deficient aeration of, and improper
expectoration from, the lung. Where tracheotomy is performed the dyspnœa
is relieved and the expectoration easy; with intubation, on the other
hand, there is no stage of apnœa after introduction, which seems to
indicate that the air does not pass so easily through the smaller tube;
coughing is more difficult and the amount of expectoration less; mucus,
pus, or membrane in small pieces, can all be expelled through the tube,
but not so freely as through the larger canula, and are more likely to
be swallowed. For these reasons it would appear that pneumonia is less
to be feared after tracheotomy; there is, however, considerable
difference of opinion on this point, and statistics have not proved of
great value.




CHAPTER V

TRACHEOSCOPY AND BRONCHOSCOPY


=Indications.= (i) _Foreign bodies._ Accidental inhalation of foreign
bodies is more common in children than in adults in the proportion of
about two to one. The character of the foreign body should be considered
before treatment is advised, and for this purpose the inhaled bodies may
be divided into three classes:

  (_a_) Pointed; such as bones, needles, teeth, nails, &c.
  (_b_) Rounded; i. Hard, such as coins, stones, or buttons.
                ii. Soft (in some cases capable of swelling),
                       such as meat, beans, peas.
  (_c_) Fluid; such as blood, pus, or vomited food.

To these may be added pieces of necrosed cartilage from the larynx,
trachea, or bronchi; and calcareous concretions from bronchial glands,
which occasionally perforate the walls of the air-passages.

Any of the above may become impacted in the trachea or fall into one of
the bronchi: the right bronchus is affected nearly twice as often as the
left owing to its larger size, its direction (which is more nearly that
of the trachea), and the inclination of the septum to the left of the
middle line.

(ii) _Tumours of the trachea_ (see p. 546).

(iii) _Stricture of the trachea_ resulting from previous inflammation or
trauma. Tracheoscopy is useful both for accurate diagnosis and for
treatment of such conditions. The following case may be quoted as an
illustration: A boy of 17 was admitted to my hospital on account of
dyspnœa, caused by obstruction in the lower air-passages. The chest was
examined and a skiagram taken, the latter showing a definite shadow in
the position of the bifurcation of the trachea. This was possibly an
enlarged gland which pressed upon the trachea. I decided to give the boy
an anæsthetic and perform tracheoscopy. On passing the tube a stricture
was found in the trachea at the level of the suprasternal notch, which
was so small that a large probe completely blocked its lumen, thus
causing cessation of breathing. Under the condition it was impossible to
dilate the stricture by endotracheal methods. The trachea was therefore
exposed, but appeared to be normal. An opening was made into it above
the stricture, and it was then seen that the latter was caused by a
thickening of the anterior and lateral walls, involving two rings of the
trachea and apparently of inflammatory nature. As no history of
inflammation had been obtained the tissue was examined microscopically,
and this confirmed the diagnosis. Division of the stricture completely
relieved the dyspnœa, and after a few days the wound was allowed to
heal. Three months later there was some return of the dyspnœa, and
tracheoscopy was again performed. The stricture had to some extent
returned, but was easily dilated through the tube, and two months later
there had been no further dyspnœa. By the passage of bougies through a
bronchoscope a stricture of the bronchus has been relieved in a similar
manner.

(iv) _For diagnostic purposes_ alone, to determine the cause of pressure
upon the air-passages; as in tumours of the mediastinum, aneurism, and
the like.

The instruments required correspond in the main to those used for direct
laryngoscopy (see p. 480). The special instruments include (_a_)
bronchoscopes, which are long circular tubes of dimensions suitable to
the patient:

    LENGTH AND SIZE OF TUBE REQUIRED IN UPPER BRONCHOSCOPY (KILLIAN)

                 _Adults._        _Children._

    Length       30-40 cm.         20-30 cm.
    Diameter      9-14 mm.           5-7 mm.

These should be marked externally in centimetres, measured from the
distal end of the tube, and should be provided with a lateral window to
allow of free breathing through the opposite bronchus when the tube is
introduced into the one which is obstructed; of the various forms in
use, the sliding tube of Bruenings appears to me superior; (_b_)
instruments for extraction, including forceps and hooks according to the
nature of the body to be removed; (_c_) aspirator for removal of mucus,
and sponge-holders, the length of the bronchoscope.

=Operations= (see also p. 481). As regards the anæsthetic, chloroform is
preferable in children, but in adults cocaine may suffice. The
operations are best performed in a room which can be made dark.

=Tracheoscopy.= The preliminary stages are similar to those of direct
laryngoscopy. If the larynx be found normal, a smaller tube can be
passed through the tube-spatula between the vocal cords, and the spatula
can then be divided and removed in separate halves. In Bruening’s
instrument the inner tubes are so constructed that they can be pushed
through the outer tube and made to project like a telescope to any
desired distance. In this way the subglottic region and trachea can be
explored.

[Illustration: FIG. 277. INSTRUMENTS FOR BRONCHOSCOPY. Bronchoscopes: A,
Killian’s; B, Jackson’s; C, Bruening’s. D, Instruments for extraction.
E, Handle (Watson Williams’s).]

=Upper bronchoscopy.= The tubes are passed through the mouth, and the
inner one is projected until the bifurcation of the trachea is visible.
In order to avoid injury to the tissues, the operation should be
performed entirely by sight and with great care. Three cases have been
recorded where tracheotomy was needed for the relief of dyspnœa caused
by œdema of the larynx which had followed traumatism.

The tube having been passed, cocaine (10%) is applied to the bifurcation
of the trachea, and mucus is removed by sponging or by an aspirator. If
the secretion be excessive, the foot of the table should be raised so
that the mucus drains away from the part to be explored.

It is the duty of the anæsthetist or some competent assistant to note
that normal respiration is maintained, and the necessity for tracheotomy
or artificial respiration must always be borne in mind.

[Illustration: FIG. 278. INSTRUMENTS FOR BRONCHOSCOPY. A, Aspirator for
mucus; B, Sponge-holder; C, Hooks.]

If the operator be experienced, bronchoscopy can be performed without
endangering the patient’s life even in the case of a young child. A baby
of eight months has been successfully treated by this method.

=Lower bronchoscopy.= Preliminary tracheotomy (median or low) having
been performed, a wide tube is introduced into the bronchus through the
wound in the trachea. This method has the following advantages: It is
easier to perform, and the surgeon requires less experience of
technique; the tube, being wider, is more readily illuminated; there is
little danger of asphyxia; in passing the tube no organisms are
introduced from the mouth, and there is less danger of pneumonia. If
these advantages are weighed, it becomes apparent that the lower
operation is preferable for surgeons without experience. In all cases
with urgent dyspnœa preliminary tracheotomy is practically essential.

By a combination of the above methods the diagnosis of foreign bodies
can be positively determined in the majority of cases. As Killian said
in 1902: ‘We have now reached a position in which, in many cases at
least, one can not only obtain a positive result but with confidence can
assert that the foreign body is not present.’ In support of this
statement numerous cases have been reported, especially in Germany and
America. Von Eicken, in 1904, collected 42 cases of bronchoscopy, in 35
of which a definite diagnosis of a foreign body was made; in 4 it was
shown that none was present; and in 3 only were negative results
obtained. Since that time the results have been equally good, for in
1907 Killian increased this number to 164 reported cases in which a
foreign body had been actually discovered.

As soon as the foreign body is clearly seen, a pair of forceps is
selected and introduced through the tube. The object is grasped and
drawn through the tube, if this be possible, or the tube and forceps may
be withdrawn together from the trachea. If the foreign substance be
broken the operation can be repeated until all of it has been removed.
If the patient becomes collapsed it may be necessary to postpone the
continuation of the treatment until the following day. A second attempt
is often successful when the first has proved a failure.

Bronchoscopy is comparatively easy to perform (_a_) when the foreign
body lies in the trachea or main bronchus; (_b_) when the foreign body
has been accurately located; or (_c_) when the operation can be
performed early, before inflammation has supervened. In the rare
instances where the body lies in one of the secondary or tertiary
bronchi, or has penetrated the substance of the lung, the difficulties
are much increased, and in such conditions the question of the
advisability of lower bronchoscopy should be considered.

=Complications= seldom occur after removal of foreign bodies by these
methods if the surgeon is careful to avoid injury when passing the
tubes. There may be temporary hoarseness owing to congestion of the
mucous membrane. Ingals has reported two cases in which death occurred
soon after the operation, with symptoms like those of delayed poisoning
from an anæsthetic, and has raised the question whether it is advisable
to use cocaine or atropin[e] in these operations. Delavan, on the other
hand, suggests that injury to the pneumogastrics may account for such
collapse. As stated above, the combination of chloroform and cocaine
does not appear to be dangerous if used with discretion.

[Illustration: FIG. 279. UPPER BRONCHOSCOPY WITH THE PATIENT IN THE
DORSAL POSITION.]

[Illustration: FIG. 280. LOWER BRONCHOSCOPY WITH THE PATIENT IN THE
DORSAL POSITION.]

=Results.= Removal of foreign bodies by bronchoscopy gives far better
results than the older methods of treatment such as tracheotomy,
bronchotomy, and thyrotomy. With the last-named operations more than
one-third of the cases have been fatal: while on the other hand, taking
the 164 cases[45] collected by Killian, it is found that in 159 (leaving
out 5 with unknown result) only 21 (or 13%) died, viz. 2 from cocaine; 2
because it was impossible to remove the object on account of bronchial
stenosis; 1 from suffocation in spite of upper and lower bronchoscopy;
and the remaining 16 of pulmonary complications--5 with the foreign body
in the lung, and the others in spite of its removal. Upper bronchoscopy
was fully successful in 54 cases, and lower bronchoscopy in 63. The
result of the remaining 21 operations is not stated.

[45] _Trans. Amer. Laryng. and Otol. Soc._, 1907, p. 80, ‘The Treatment
of Foreign Bodies in the Respiratory Tract and Esophagus.’

Speaking of his own cases, Killian writes: ‘My own statistics give
perhaps a better judgment for the future of cases of foreign bodies in
the deeper air-passages than the general, since I have gradually
acquired a larger experience and more practice. Nevertheless, I have the
impression that in many cases my technic has not reached the highest
mark, and I hope to obtain better results in the future. As shown by the
list of cases, only one death resulted in the eighteen cases, and this
was six months after the removal of the foreign body, caused by severe
lung complication due to its long sojourn in the air-passages. In only
two cases was I unable to find the foreign body and in only one was I
unable to remove it on account of its being coughed up.

‘Upper bronchoscopy was performed in twelve cases, upper and lower in
five, and lower tracheo-bronchoscopy in one. However, I hope in the
future, with improved technic, to be successful with the upper method at
the first sitting and to use the lower only in the severest cases.’

To Killian of Freiburg is due the chief credit for having introduced a
safe method of treatment, the value of which is at last beginning to be
generally recognized in England. As Paterson[46] says, ‘it is earnestly
to be hoped that the time has now come when workers in this country will
recognize its enormous advantages.’

[46] _Brit. Med. Journ._, 1906, vol. ii, p. 357, ‘The Direct Examination
of Œsophagus and Upper Air-passages.’




                             SECTION V

                    OPERATIONS UPON THE NOSE AND
                       ITS ACCESSORY CAVITIES

                                 BY

      StCLAIR THOMSON, M.D., F.R.C.P. (Lond.), F.R.C.S. (Eng.)

  Professor of Laryngology and Physician for Diseases of the Throat,
                  King’s College Hospital, London




CHAPTER I

GENERAL CONSIDERATIONS IN REGARD TO OPERATIONS ON THE NOSE AND
NASO-PHARYNX


An intimate knowledge of the surgical anatomy of the nose is an
important factor in successful treatment. It is sufficient to recall the
close relations of the nasal chambers and their accessory sinuses with
the cavities of the orbit and the cranium, and to remember that the
shape and size of these air-spaces may vary considerably within
physiological limits.

The arrangements of the vascular, lymphatic, and nervous supplies, and
their connexion with neighbouring parts and the body generally, have
also to be kept in mind.

In planning and carrying out operative procedures it is also well to
keep in mind the important physiological functions of the nose.

Disease in the nose involves both medical and surgical treatment. The
general progress of surgery, improved technique, local anæsthesia, and
the control of hæmorrhage we now possess, have all tended to replace
local medication by surgical measures. But in many affections of the
nose--such as syphilis, or diphtheria--surgical relief is quite
secondary to medical treatment. In any case the surgeon cannot dispense
with a knowledge of suitable topical applications and the principles on
which they are founded.


SOURCES OF ILLUMINATION

A good source of illumination is the first necessity for satisfactory
operations on the upper air-passages. The natural sources at our
disposal are sunlight and diffuse daylight. They have the great
advantage of not altering the natural colours of the parts examined.
Reflected sunlight forms a perfect illuminant, if we are careful not to
bring the rays to an exact focus on the mucous membrane, as this might
produce a burn.

Diffuse daylight is too feeble for the examination of the cavities of
the nose and larynx, but it can be used for inspecting the mouth,
pharynx, and ear. Direct daylight is particularly serviceable for
examining suspicious rashes or patches in the mouth and pharynx, and
eruptions on the skin.

Some form of artificial light is indispensable. That furnished by an
ordinary paraffin lamp or a gas flame is sufficient for examination. The
flame should have its flat side towards the observer, and be enclosed in
a glass chimney, without a globe or shade. If neither of these lights be
available, an ordinary candle, or, better still, three candles tied
together, will suffice.

For use in the study a paraffin reading-lamp or a gas standard is
equally suitable. The latter is rendered more effective by the adoption
of an Argand burner or a Welsbach mantle. The oxy-hydrogen limelight is
the most perfect of artificial illuminants, but it is bulky and
expensive. The most convenient light is that given by a 32 or 50
candle-power electric light in a frosted globe, and with the filament
waved. The Nernst electric burner gives increased brilliancy.

[Illustration: FIG. 281. LARYNGOSCOPE LAMP.]

The electric light has the further advantage that it is unnecessary to
maintain it constantly vertical. When enclosed in a bull’s-eye, the lamp
can be rotated so as to direct the pencil of light-rays either upwards
or downwards, as well as from side to side.

Whichever light is employed the rays can be concentrated and rendered
more powerful by enclosing it in a dark chimney with a bull’s-eye
condenser. The light must also be provided with some arrangement by
which it can be raised and lowered (Fig. 281). For operating the Clar
light is useful (Fig. 282).

In all these methods the light is reflected, but the direct rays of the
electric light can be used in a small lamp fixed on the forehead, and
fed from an accumulator or direct from the street current through a
suitable resistance. It is better than reflected light in operations on
the nose and throat, and the portable accumulator and frontal photophore
(Fig. 283) are convenient for use in the patient’s own home.

[Illustration: FIG. 282. CLAR’S ELECTRIC LIGHT.]

[Illustration: FIG. 283. FRONTAL SEARCH-LIGHT.]

The lamp should be placed on a stand or table so that the light is on a
level with the patient’s ear, and 3 or 4 inches distant from it. In
Continental schools it is customary to place the light on the patient’s
right hand. In this country the lamp is usually placed close to the
patient’s left ear, _i.e._ on the observer’s right hand. As
practitioners will often be called to see patients who are confined to
a bed which can only be approached from one side, it is desirable that
they should accustom themselves to work equally well with the light on
either side, and the frontal mirror over either eye.


LOCAL ANÆSTHESIA

=Cocaine.= It is often desirable to secure a slight degree of local
anæsthesia to facilitate complete exploration of the nose. Many
operations can be carried out by rendering the nasal mucosa absolutely
insensitive with cocaine.

Applied in the nose cocaine is (_a_) an anæsthetic, (_b_) a powerful
vaso-constrictor, and, consequently, it (_c_) produces local anæmia.
Hence cocaine is of great value in nasal surgery, not only because it
renders the mucous membrane insensitive, but also because it retracts
the tissues and reduces the hæmorrhage.

_Methods of use._ A small area can be anæsthetized by placing a few
crystals of hydrochlorate of cocaine on the required spot, where the
mucus will dissolve it _in situ_. A 2 to 5% solution may be sprayed into
narrow nostrils, to facilitate examination. It is a better plan to
moisten pledgets of cotton-wool or ribbon gauze with a 10% solution, and
place them in direct contact with the part to be operated on. The
addition of a little suprarenal extract will not only facilitate
examination and treatment by its hæmostatic action, but, for the same
reason, will tend to prevent the cocaine being absorbed and producing
its toxic effects.

For the more complete anæsthesia required for operation the following
plan is advised. Equal parts of a 20% solution of cocaine and the
standard 1-1,000 extract of suprarenal gland are mixed together. Short
strips of 1-inch wide ribbon gauze are moistened with this solution and
laid flat in close contact with the nasal area to be operated on. They
are left in place for at least half an hour, and even at the end of one
hour local anæsthesia will only be more marked. While the final
preparations are being made for operation a fresh layer of moistened
gauze may be applied. Finally, if there should still remain the
slightest degree of sensation over the spot to be treated, a few cocaine
crystals will render it quite numb.

_Submucous injection of cocaine._ Great caution is necessary in making
intracellular injection of cocaine, as the drug is intensely toxic in
this form, and, fortunately, only a small dose is required. It is a good
plan never to exceed 1 centigramme (1/6 grain) of the salt. As the
hæmostatic effect of suprarenal gland extract is required at the same
time, the two are combined; 1/6 grain of cocaine, 2 drops of adrenalin,
1/6 grain of sodium chloride, and 1/50 grain of morphia are dissolved in
60 minims or more of sterilized water, and slowly injected below the
mucosa. At least 20 minutes must elapse to secure full effects.

_Substitutes for cocaine._ For submucous injection it is better to
substitute eucaine or novocaine. Eucaine can be kept in a ready and
portable form in small glass ampoules in the dose of 1/6 grain with
1/2000 grain of adrenalin, and tablets are sold containing 1 centigramme
(1/6 grain) of either of these drugs in combination with adrenalin and
chloride of sodium. One of these tablets is dissolved in 60 minims or
more of water and boiled. It is reported that as much as 1 grain of
novocaine may be injected at one sitting, but I prefer to keep to the
limit of 1/6 grain, and have always been able to obtain complete local
anæsthesia with it.

Eucaine is much less toxic than cocaine, and novocaine is said to be
still safer. They act just as well for submucous injection, but, applied
to the mucous surface, the anæsthesia is not so complete, and the
vaso-constrictor effect is less. Still, for susceptible subjects, either
is to be preferred to the more toxic cocaine.


LOCAL ISCHÆMIA

=Adrenalin.= The delicate manipulations of intranasal surgery have been
greatly facilitated by the employment of the extract of the suprarenal
gland under various names--adrenalin, adrenine, adrin, perinephrin,
adnephrin, epinephrin, suprarenalin, suprarenin, epirenin, paranephrin,
renaglandin, hemesine, hæmostasine, vasoconstrictine, renostypticin, &c.
These liquids are generally of the strength of 1 in 1,000, and can be
used undiluted on mucous surfaces. But they can be diluted with normal
saline solution, solutions of cocaine, or other drugs. If kept in
well-stoppered, tinted glass bottles the solution can be preserved for
many weeks. The solid extract is useful for those who only employ it
occasionally, and in this form it is conveniently made up with cocaine,
eucaine, or novocaine, so that solutions of the desired strength are
prepared as required.

Applied to a mucous surface adrenalin produces a local ischæmia by
contracting the blood-vessels, so that the surface becomes pale and
shrunken. At least 20 minutes are required to secure this effect and it
is only more marked at the end of an hour. An extensive operation, such
as submucous resection of the septum, can then be performed without the
loss of more than a trifling amount of blood in most cases. The
vaso-constrictor action is followed by a stage of dilatation, disposing
to secondary hæmorrhage, which, according to some authorities, may be
‘violent and sometimes serious’.[47] I have been fortunate in not
meeting with this occurrence. Its possibility can generally be guarded
against, and need never prevent the employment of the drug when
indicated.

[47] C. A. Parker, _Diseases of the Nose and Throat_, London, 1906.

Adrenalin has no anæsthetic power, but its constricting action lessens
the tendency of cocaine to be deeply absorbed, increases the latter’s
local effect, and allows of a weaker solution being employed.

Another secondary result is the very irritating rhinitis which is
sometimes induced. It passes off in 24 to 48 hours.

_Uses._ The addition of a small quantity of adrenalin to a cocaine
solution mitigates the toxic action of the latter, and its use appears
to check tendency to collapse, either from shock or chloroform, during
serious operations on the nasal cavities. Its chief use is to check
hæmorrhage and allow us to perform practically bloodless operations in
the nose.

_Methods._ Adrenalin is employed as described for cocaine.
Disappointment in the result obtained is nearly always due to neglect in
recognizing that its full effect cannot be obtained in less than 20 to
60 minutes.


BLEEDING AND ITS CONTROL

Bleeding in the nose cannot be controlled as easily and directly as in
the operations of general surgery, and there is always the risk of blood
passing into the lower air-passages.

=Causation.= Hæmorrhage is apt to be not only more free, but also more
serious, in young children and in patients over 60. The tendency is
increased with menstruation or pregnancy, and hæmophilia is to be
particularly looked for. In the nose the vascular turbinals bleed
freely; a small varicose vessel on the septum is the commonest source of
epistaxis,--often very copious. Many vascular growths are met with, and
malignant ones are apt to bleed profusely.

Secondary hæmorrhage may occur between the third and eighth day, when
clots or crusts become detached.

_The prevention of local hæmorrhage._ The patient should be prepared
more carefully than usual for an operation. Hæmophilia should be
inquired after, and if there is any suspicion of it lactate of calcium
is administered for three days beforehand, in doses of 15 to 30 grains
twice a day. If the patient be an undoubted hæmophilic, an operation
should be avoided if possible. It is well to suspend the use of alcohol
and tobacco for at least three days beforehand. Many risks are avoided
if the operation can be carried out in the home or hospital where the
patient has slept, and if he can remain there afterwards.

_The arrest of local hæmorrhage._ The preliminary use of adrenalin will
diminish bleeding in many cases (see p. 573). When it does occur, unless
the hæmorrhage is serious, it is well not to be too precipitate in
efforts to arrest it. Such attempts, by stimulating the patient,
detaching blood-clots, or exciting reflexes, may even maintain it. The
clothing should be loose, the operating-room should be well aired and
cool, and iced water should always be at hand. If freely sluiced over
the face, behind the ears, and round the neck, cold water has such a
remarkable reflex vaso-constrictor action that it alone is sufficient to
arrest hæmorrhage in the majority of operations on the nose and throat.
Its stimulating effect on the respiration and circulation is always
agreeable to the patient, and may be very valuable when he is under a
general anæsthetic.

If operated upon under a local anæsthetic, the patient’s head should be
inclined forwards, so that the blood can drip from the nose. The first
formed clots may be expelled, but then he should avoid sniffing,
sneezing, or coughing, and sit with the head forward and the nostrils
completely closed with his thumb and forefinger. Five to ten minutes in
this position will arrest the bleeding in most cases of epistaxis. A
slight oozing of blood may be allowed to go on for a few hours in
certain cases. If the bleeding persists, ice should be applied
externally and held in the mouth, the nose may be syringed with very
cold or with very warm salt and water (ʒi to the pint), and the
horizontal position assumed.

If this fails, a pledget of cotton-wool is dipped in peroxide of
hydrogen solution (10 vols. %) and introduced into the bleeding nostril,
the orifice of which is then closed by the surgeon’s thumb. This may be
repeated more than once, the patient lying on his side, face downwards,
and pinching both nostrils. If a galvano-cautery be available, and the
bleeding comes from a limited and visible point, it can be sealed with a
touch of the cautery point.

If these methods fail, plugging must be resorted to. With the nasal
speculum and good illumination, the bleeding area is cleansed with
cocaine and adrenalin and a strip of 1-inch ribbon gauze is carefully
packed on to the spot, the end being left just within the vestibule, so
that the patient can remove it for himself at the end of 12 or 24 hours.
It is better to use a single strip of gauze, instead of cotton-wool, as
portions of the latter might be detached and left behind. If there be
fear of the gauze strip becoming adherent, it can be well smeared with
plain sterilized vaseline.

If the bleeding comes from far back in the nose, or from the post-nasal
space, it may become necessary to plug the latter cavity. A sterilized
sponge, about the size of a Tangerine orange, is squeezed very dry and
tied round its centre with a piece of tape or a stout silk ligature,
leaving two free ends of about 12 inches in length. A soft rubber
catheter is passed along the floor of the nose till it appears below the
soft palate, when the end is seized with forceps and drawn through the
mouth. To this end one of the tapes is made fast, so that when the
catheter is withdrawn from the nose, the sponge is pulled up into the
post-nasal space; the other end hangs out of the mouth. The two tapes
are tied together over the upper lip. The anterior part of the nostril
can then be packed with gauze, if necessary. If the patient be under
chloroform, one tape can be dispensed with; the soft palate is simply
held forward with the forefinger of one hand, while the other passes the
compressed sponge up into the naso-pharyngeal space.

Plugs in the nose should be avoided. They are painful, interfere with
repair, prevent drainage, and may be followed by septic troubles in the
nose, accessory sinuses, middle ear, or cranial cavity. Bleeding often
recurs on their removal. In any case they should not be left unchanged
for more than 24 or, at the most, 48 hours. Removal is facilitated by
soaking them well with peroxide of hydrogen, and detaching them slowly
and gently. Ligature of the external carotid (see Vol. I, p. 384) may be
necessary in extreme cases.[48]

[48] Chevalier Jackson, _Transactions American Laryngological
Association_, 1907.


THE PROTECTION OF THE LOWER AIR-PASSAGES FROM THE DESCENT OF BLOOD

When operated upon under local anæsthesia the patient is able to prevent
blood descending from the nose or throat into the larynx or trachea. In
this he is assisted by throwing the head forwards.

When the patient is under a general anæsthetic other measures must be
taken to guard against the descent of blood into the windpipe and lungs.
The most important is to see that the anæsthesia is never so deep as to
abolish the swallowing or coughing reflexes. Fortunately these are
amongst the last to go, yet in many cases it is well to let the patient
come partly round, so as to expel blood and mucus by coughing. If the
frontal sinus is being operated upon, the nose is carefully packed
beforehand. When the ethmoidal labyrinth is being cleared, or the
sphenoidal sinus opened, a sponge may be placed in the post-nasal space
as described above until the operation is completed. During the
operation upon the maxillary sinus through the canine fossa, a sponge
placed between the last molar teeth and the cheek on the same side, and
frequently renewed, will keep any blood from entering the pharynx. In
operations upon the naso-pharynx, it is a wise precaution, when much
bleeding is anticipated, to perform a preliminary temporary laryngotomy
and plug the pharynx with a sponge (see p. 510).

In many proceedings security is attained by rolling the patient well
over to one side, so that the blood runs out of the corner of the
mouth, of blood is also swallowed. This may be vomited as consciousness
returns; if not, an aperient should be given within 24 hours to prevent
gastro-intestinal sepsis.

The descent of blood into the trachea and lungs, if sudden and copious,
may cause immediate asphyxia; or, if less abundant, it may cause septic
pneumonia. When it occurs, the anæsthesia should be stopped, and the
patient rolled well over on to his face or inverted, until the breathing
is quite unobstructed. After all nose and throat operations it is a wise
precaution for the patient to be kept on his side, the head on a low
pillow, and face downwards, while the body is arranged in the
gynæcological position.


SHOCK

Shock, particularly in operations on the nose, is apt to be marked in
young children and in elderly persons. It is for this reason that we try
to avoid the removal of adenoids in patients under 3 years of age, or of
polypi in those over 60; and that in all cases we endeavour to operate
as rapidly as possible.

This possibility of shock is guarded against and treated in the usual
way. The use of cocaine and adrenalin--even in patients under a general
anæsthetic--helps to avoid it,[49] and anæsthesia should never be too
deep or prolonged. When operating under local anæsthesia it is sometimes
wiser not to attempt too much at one sitting, _e.g._ to treat only one
side of the nose at a time. In certain conditions, and when a general
anæsthetic is employed, it may be safer to try and complete treatment at
one operation.

[49] G. W. Crile, _Journal Amer. Med. Assoc._, June 17, 1905.


SEPSIS AND OTHER COMPLICATIONS

Deaths have been recorded after the simple use of the galvano-cautery,
or the removal of nasal polypi, and of course are more to be feared
after major operations, such as the radical cure of sinus suppurations.

Septic infection from nasal operations may spread to the accessory
sinuses, meninges, ear, eye, tonsils, glands, gastro-intestinal tract,
bronchi, and lungs. From the naso-pharynx, the ears and the lower food
and air tracts are chiefly threatened. The orbit may be invaded in
operations on the ethmoid; the external muscles of the eye may be
injured in the frontal sinus operation; and optic atrophy may be due to
plugging of the ophthalmic vein.

While these accidents may sometimes be directly due to operation, it is
well to remember that in treating such septic conditions as are entailed
by nasal suppuration, the complications may only be precipitated by
traumatism and may also be purely coincident. It is not to be forgotten
that latent infection--of influenza, erysipelas, measles, scarlatina,
diphtheria, or other disease--may develop immediately after an operation
upon the nose or throat, and until its true character is recognized the
operation is often unjustly blamed. Septic infection, in these
necessarily exposed wounds of the air-passages, may be traced to
insanitary surroundings.


ASEPSIS

The field of operation in rhinology can never be rendered completely
sterile, and in many cases is particularly septic. Wounds through the
mucous membrane cannot be protected with dressings in the usual way; so
that the local methods of repair require particular study.

In the nose, when there is no suppuration, it is safer to make no
attempt to purify the cavity, beyond cleansing the vibrissæ and
vestibules. The Schneiderian membrane will not tolerate any antiseptic
lotion of such a strength as to be effective, and weaker solutions only
interfere with the action of the cilia, the protective power of the
mucus, and other defensive arrangements of the nose. If pus, scabs, or
foreign bodies exist in the nose, it should be well washed with a simple
tepid alkaline solution.

But every care should be taken to purify the surgeon’s hands, sterilize
all instruments, and see that no contamination takes place during the
operation. This is assisted by having the patient’s head surrounded by a
carbolized towel, and his face, moustache, and beard well washed, for
the surgeon’s hands and instruments come in frequent contact with these
parts.


AFTER-TREATMENT

After all intranasal operations everything should be avoided which
interferes with the drainage, ventilation, and natural repair of the
region. Protective dressings cannot be employed, and we have in most
cases to aim at healing under a blood-clot. Tags of semi-detached tissue
and loose clots of blood are removed, but otherwise the parts are
disturbed as little as possible. For the first two or three days the
nose may be left alone, and if there be no bleeding the patient is
encouraged to breathe through it. When there is much formation of thick
mucus, or blood-clots or sloughs are loosening, a tepid alkaline lotion
can be used. The pain of stiffness or dryness in the nose is relieved by
an ointment or an oily spray.

Adhesions are apt to form between the septum and the outer wall when
opposing surfaces are injured by the galvano-cautery. They may occur in
narrow cavities after cutting operations. If an adhesion be seen to be
threatening in the first few days, it should be broken down with a
probe, and strips of gauze or plates of white celluloid introduced daily
until healing takes place. If it forms later, it is wiser to wait until
the fleshy bridge becomes less vascular and contracts, when it may be
divided with a knife or the galvano-cautery at a white heat, and the
opposing surfaces are then kept apart as described.

All post-operative conditions in the nose and throat will heal more
rapidly and pleasantly if the patient be freely exposed, day and night,
to abundance of fresh air; and while fatigue is generally to be avoided,
the sooner the patient is out of bed and in the fresh air, the better
for him. Our inability to operate under aseptic conditions should make
us more careful to raise the resistance of the individual by general
care, and to protect him from external dangers.


CLEANSING THE NOSE

The simplest and safest method of cleansing the nose is by blowing
it,--one nostril at a time. Sometimes it is required to hawk any
discharge backwards and expel it through the mouth.

Watery lotions are frequently required to assist in cleansing the
nose. Strong antiseptics and astringents must be avoided. All nose
lotions should be alkaline, and isotonic with the blood plasma. These
requirements are met by prescribing one or more alkalis (bicarbonate
of soda, borax, salt, &c.), in the strength of about 5 grains to the
ounce. They may be rendered more pleasant by the addition of white
sugar or glycerine. The addition of a small amount of some mild
antiseptic--menthol, thymol, oil of eucalyptus, carbolic, sanitas,
listerine, &c.--may give a pleasant flavour. But all antiseptics have a
slight irritant action which is disagreeable if there be an intact
mucosa, although they may be more helpful in certain cases of ulceration
or intranasal sepsis. When the Schneiderian membrane is more or less
damaged, when there are foreign bodies, sloughs, necrosis, &c., in the
nasal chambers, these or similar antiseptics can be employed, though
always with an alkaline basis.

All nose lotions should be employed tepid. They may be sniffed,
irrigated, sprayed, or syringed into the nostrils. Crusts, scabs, and
sloughs may have to be removed from the nose with forceps, after its
sensitiveness has been deadened with cocaine; peroxide of hydrogen will
help to detach them.


AFTER-RESULTS

Incomplete operation may be unsatisfactory in many ways. Thus, nasal
obstruction may be unrelieved: foci of suppuration may be left in the
accessory sinuses: portions of adenoid growth or tonsils left behind may
continue to give trouble: malignant growths may not be extirpated freely
enough. On the other hand, operations may fail to relieve, or even
produce a worse state of affairs, if too much tissue be sacrificed. This
is important as regards the nose, owing to the important respiratory and
defensive function of its mucous membrane. It is a good rule to injure
the inferior turbinal as little as possible, otherwise a condition of
crusting rhinitis may be set up, with secondary atrophy in the pharynx
and larynx.[50]

[50] W. H. Stewart, _Proc. Laryngol. Soc. Lond._, March 5, 1898, p. 57.

Much judgment is required in adapting the suitable operation to each
case. While in some instances one or more small interventions are all
that is required, in another a well-planned and more extensive operation
may be indicated. In any case, the advice of Semon should be kept in
mind, viz. that the magnitude of an operation should not exceed the
gravity of the symptoms calling for relief.




CHAPTER II

OPERATIONS FOR INJURIES, DEFORMITIES, FOREIGN BODIES, AND RHINOLITHS:
OPERATIONS UPON THE TURBINALS: OPERATIONS IN SYPHILIS AND LUPUS


OPERATIONS FOR INJURIES TO THE NOSE

The external injuries of the nose belong to general surgery. It might be
well to recollect that the fleshy end of the nose may be completely
detached, and yet, if carefully and promptly replaced, perfect union
will occur.[51]

[51] J. M. Renton, _Brit. Med. Journ._, December 16, 1905.


FRACTURES OF THE NASAL BONES AND SEPTUM

=Setting a recent fracture.= One or both nasal bones may be displaced,
causing a flat bridge with a sharp ridge on either side.

In the septum fracture generally takes place in the quadrilateral
cartilage, or displacement occurs at its junction with the vomer or
superior maxilla. It may be accompanied by a hæmatoma (see p. 612), and
the occurrence of epistaxis shows that it is really a compound fracture.
Care should therefore be taken not to infect the wound in the nose, and
the patient should be warned on the subject.

The application of cocaine and adrenalin may allow of careful inspection
of the septum. But, as the exact condition of things is marked by
swelling, it is nearly always advisable to administer a general
anæsthetic. Crepitus can rarely be made out. A hæmatoma is dealt with as
directed (see p. 612). If there be any displacement of the septum--and
it generally takes place towards the side on which there is already some
convexity or depression of the nasal bones--the parts should be raised
into place by manipulation with the little finger in the nostril. A
flat-bladed forceps, like those of Adams, may be used. One blade in each
nostril will straighten the septum and, at the same time, raise the
whole nose into place. Small pencils of sterilized cotton-wool, smeared
with vaseline (see p. 608), are then carefully packed up into the roof
of the nose and kept there by Meyer’s vulcanite tube (Fig. 284). They
are changed every 24 or 48 hours, for a week or so. The vomer is rarely
fractured, although much callus is often thrown out in the displacements
which occur between it and the cartilage.

Recent cases require no splints. In fact, if the displacement be
promptly reduced--under general anæsthesia--the restored parts will
generally maintain their position.

=Elevating an old fracture.= In neglected cases it may be necessary to
re-fracture the nasal bones, and when these are replaced an external
splint may be necessary. This can be made of plaster of Paris; or the
outside of the nose may be covered with a piece of heavy adhesive
plaster, and outside that a shield of tin, copper, or, preferably,
aluminium.[52]

[52] T. A. de Blois, _Trans. Amer. Laryn. Association_, 1900, p. 12.

[Illustration: FIG. 284. MEYER’S HOLLOW VULCANITE NASAL SPLINT.]

Fracture of the ethmoid is, fortunately, rare. When it occurs it is apt
to run into the cribriform plate, and be associated with the escape of
cerebro-spinal fluid and other indications of fracture of the anterior
fossa of the skull.


OPERATIONS FOR CONGENITAL OCCLUSION OF THE NOSTRILS

=Operation for congenital occlusion of the anterior nares.= _If the web
obstructing the nostril be thin and membranous_, and of low vitality, a
simple and effective method is to destroy it with the galvano-cautery.
It is best to spread the treatment over several sittings, so as to
diminish the local reaction. The application of cocaine may not be
sufficient to numb the pain, as the tissue of the obstructing web is
more allied to skin than to mucous membrane. It should therefore be
punctured quickly in two or three places, with a sharp cautery point
raised nearly to a white heat. If the patient be nervous it may be well
to administer nitrous oxide gas.

After the operation the nasal orifice is kept distended until healing
has taken place by wearing Meyer’s vulcanite tube in it or short lengths
of full-sized rubber drainage tube, well smeared with boric, aristol,
zinc, or similar ointment. These simple nasal dilators are changed once
or twice daily, and the nostril is well cleansed on each occasion.

_If the web obstructing the anterior naris be more fleshy in character_
(and it is more apt to be of this nature when it is incomplete), it may
be necessary to remove it with a knife. So as to leave as much
epithelial tissue as possible, and avoid retraction, the operation is
done as follows, under local or general anæsthesia: A narrow,
sharp-pointed instrument, such as a Graefe’s or other ophthalmic knife,
is used to puncture the web from before backwards, and it is then made
to sweep round the obstructing diaphragm, while gradually cutting its
way towards the central lumen. The tongue of skin thus formed can be
used as a graft to cover most of the raw surface. The restored anterior
naris is kept patent, as already described, till healing takes place.

[Illustration: FIG. 285. KRAUSE’S TROCHAR AND CANULA. For puncturing the
maxillary antrum from the nose.]

[Illustration: FIG. 286. NASAL PUNCH-FORCEPS.]

In some cases the following operation has been shown to be easy and
effective: An incision is made at the junction of the web with the
septum, keeping close to the latter and passing straight down to the
floor of the nose. On the outer side a similar incision is made, but
sloping somewhat outwards. The flap formed between these two incisions
is not cut off, but is bent backwards and fastened to the floor of the
nose by a single horsehair stitch.[53]

[53] G. K. Grimmer, _Proc. Royal Soc. of Med._ (_Laryngol. Section_)
April, 1908.

=Operation for congenital occlusion of the posterior choanæ.= If the
obstruction be not freely and completely removed it tends to re-form. A
general anæsthetic is required. Unless the operator is ambidextrous he
will find it most convenient to stand on the patient’s left hand, and to
introduce his own left forefinger into the post-nasal space. This
enables him to guide any straight, sharp instrument, such as an antrum
drill (Fig. 323), Krause’s trochar (Fig. 285), or a surgical bradawl,
from the front of the nose until it presses against and breaks through
the obstructing diaphragm in two or more points. If preferred, an
electric trephine can be used, and often pressure with the tip of a pair
of nasal punch-forceps will be sufficient. The latter, either straight
or tip-tilted (Fig. 286), are then inserted through the nostril, and,
still guided by the left forefinger in the post-nasal space, are
employed to clip away all the obstruction. To prevent any possibility of
this reforming it is recommended by some surgeons that a small piece
should be nipped out of the posterior margin of the bony septum. This
can be done with the beaked punch-forceps of Grünwald (Fig. 286), passed
through the nose, or with a pair of Loewenberg’s post-nasal forceps
(Fig. 287) introduced through the mouth. In either case their action is
controlled and directed by the operator’s left forefinger in the
post-nasal space.

[Illustration: FIG. 287. POST-NASAL FORCEPS.]

No special after-treatment is required. The patient should be ordered a
tepid alkaline nose lotion, and should be encouraged to make use of the
nasal air-way and acquire the habit of blowing the nose.


REMOVAL OF FOREIGN BODIES FROM THE NOSE

It might be helpful to remember that foreign bodies not only enter the
nasal cavities (1) through the anterior nares, but also (2) through the
posterior choanæ, or (3) by penetration through the walls. They may also
arise (4) _in situ_, as in the case of sequestra and rhinoliths. The
last group will be considered separately.

A foreign body, if small, may form the centre of a rhinolith.

=Operation.= Great care and gentleness are required in the removal of
foreign bodies from the nose. The extraction should never be attempted
blindly, or forcibly, or hurriedly. A little delay to make necessary
arrangements does no harm. If a child will not submit to examination it
is much better to employ a general anæsthetic so as to complete
examination and, if found necessary, extraction at the one sitting. If
the nose be not well illuminated and opened with a nasal speculum,
groping about in the dark will only do further damage and result in
disappointment.

[Illustration: FIG. 288. NASAL DRESSING FORCEPS.]

In adults removal can generally be carried on under cocaine. The nostril
is cleaned with cotton-wool, and if the extremity of the probe used for
detecting the presence of a foreign body be curved to a right angle, it
will also serve for gently levering or displacing it forwards. With a
small pair of nasal dressing forceps (Fig. 288) it can generally be
firmly seized and gently extracted, care being taken not to include any
of the mucosa nor to drag the foreign body out regardless of the
sinuosities of the cavity. Lister’s ear hook is a most useful
instrument. Sometimes a nasal snare will help to extract the substance
or to tilt or drag it into a better position.

Unless coated with solid accretions there is never any need to break up
a foreign body; anything small enough to slip into the nose is small
enough to be extracted entire. If it should be found impossible to
remove the body through the anterior nares, it may be pushed backwards
into the post-nasal space, where the forefinger of the left hand is in
readiness to prevent its falling into the gullet or larynx.

The usual warm alkaline lotion may be used to clear the nose, but liquid
should never be forcibly injected into the nostril with the idea of thus
expelling the foreign body. If the lotion be sent up the nasal chamber
on the same side it will only drive the intruding substance further in;
if injected on the opposite side there is risk of otitis media.

In the case of small children it is sometimes recommended that a piece
of muslin should be placed over the mouth, and that the practitioner
should then apply his lips to those of the patient and by blowing
forcibly through the mouth drive out the foreign body by the blast of
air from the post-nasal space. Or the same principle may be applied by
insufflating the air from a Politzer’s bag through the opposite nostril.
Both plans are alarming and seldom effective.

The _after-treatment_ consists of some simple cleansing lotion and
soothing ointment.


REMOVAL OF RHINOLITHS (NASAL CALCULI, OR CONCRETIONS IN THE NOSE)

These concretions are almost unknown in children, in whom foreign bodies
are met with most frequently. A general anæsthetic is, therefore, not so
often required, otherwise the remarks on the removal of foreign bodies
will be found to apply to the extraction of calculi. With the help of
cocaine and good illumination they can easily be removed with a
strabismus hook, Lister’s ear hook, or a pair of fine probe-pointed
nasal forceps with serrated extremities. In some cases where the
calculus has sent prolongations into the recesses of the meatus, it
might first be necessary to crush it. In that event a general anæsthetic
may be required.

The _after-treatment_ consists in simple cleansing measures. Subsequent
syringing of the nose should be done from the opposite side.


OPERATIONS UPON THE TURBINALS

=Indications.= In many cases of hypertrophic rhinitis it is necessary to
remove portions of redundant turbinal tissue. It is never desirable--and
it can only rarely be necessary--to remove the whole of the inferior
turbinal. ‘Turbinotomy,’ or amputation of the whole inferior turbinal,
was recognized as an operation some years ago. But it was never
generally accepted, as it was always realized that the highly important
physiological functions of the lower spongy bone could not be spared.
Improved technique, particularly in being able to correct deformities of
the septum without the sacrifice of any mucous membrane (see p. 603),
now enables us to rectify nasal stenosis with the sacrifice of much less
turbinal tissue.

The middle turbinal is not of so much importance in the physiology of
the nose, and the whole of this body is not infrequently removed. This
may be done not only because it is diseased, but even a healthy middle
turbinal may require amputation in order to approach the accessory
sinuses or diseases in the deeper regions of the nose. Part of the
healthy inferior turbinal may also require removal--as in the radical
operation on the maxillary sinus.

As these operations will be referred to frequently later on, and as
their performance enters into different groups of operation, they will
be described first.


OPERATIONS UPON THE INFERIOR TURBINAL

=Amputation of the anterior end. Indications.= The amputation may be
required:

(i) On account of polypoid degeneration of the anterior extremity of the
turbinal.

(ii) To allow of access to the antro-nasal wall (see p. 633).

(iii) To avoid operation on the septum by relieving nasal stenosis.

[Illustration: FIG. 289. FIRST STEP IN REMOVING THE ANTERIOR END OF THE
INFERIOR TURBINAL, WHICH IS SEEN TO HAVE UNDERGONE POLYPOID
DEGENERATION.]

=Operation.= The local application of cocaine and adrenalin (see p. 573)
is sufficient.

=Anæsthesia.= With the patient sitting upright in a chair, and the
nostril well illuminated, a pair of nasal scissors (such as Heymann’s,
Walsham’s, or Beckmann’s) are made to grasp as much of the anterior
extremity as it is desired to remove, generally the anterior third (Fig.
289). The scissors are pressed very firmly against the outer nasal wall,
so as to divide the base of the turbinal as close as possible to its
attachment. If the scissors slip off the bone it should be divided with
Grünwald’s punch-forceps. The semi-detached extremity is then surrounded
with a nasal snare, carrying a No. 5 piano wire, and cut through (Fig.
291).

It is well not to seize and twist off the anterior extremity, as this
might lead to the ripping out of a larger portion than was intended.
Besides, it might cause fracture of the base of the remaining piece of
the inferior turbinal bone and this might become displaced inwards so as
to block the air-way more than ever.

[Illustration: FIG. 290. NASAL SCISSORS.]

=After-treatment.= It is well to check the hæmorrhage without the use of
plugging. Some antiseptic powder--europhen, xeroform, formidine,
aristol, &c.--if lightly insufflated over the wounded area, will assist
in the formation of a protective scab. This should not be disturbed for
some days, during which the nose is made comfortable by some menthol and
boric ointment, or a paroleine spray. When the scab begins to break down
its removal is assisted by warm alkaline lotions (see p. 579). The stump
may require a few applications of nitrate of silver or other silver
salt. There is no danger in this operation. Healing, as in other
intranasal operations, takes from three to six weeks.

=Amputation of the lower margin.= =Indications.= This is not
infrequently necessary when there is a general hypertrophy--as in the
compensatory hypertrophy of septal scoliosis (Fig. 310)--or when the
whole lower and outer margin is occupied by papillary hypertrophies
(Fig. 289).

=Operation.= The operation can be carried out under the local
application of cocaine and adrenalin, but is frequently performed as
part of some other operation under a general anæsthesia.

The steps have to be varied according to the degree and extent of the
hypertrophic tissue requiring removal. When this is principally along
the lower border of the turbinal it can be removed with one cut of a
stout pair of nasal scissors (Fig. 290). Under good illumination a blade
is insinuated along the concavity, while the other passes between the
convexity and the septum. Care should be taken that the direction of the
scissors is parallel to the axis of the turbinal body, and that the cut
embraces only that portion of the lower area to be removed. The severed
portion should be quickly seized with a pair of punch-forceps and lifted
out, or the patient, if only under local anæsthesia, may be requested to
blow it forward into a tray. Otherwise it is apt to become obscured in
the outpouring of blood, and, if the patient is unconscious, to be
sucked backwards out of sight. If, as not infrequently happens, the
lower margin remains attached at its posterior extremity, a wire snare
is threaded along over it so as to cut this through. When the papillary
hypertrophy is more diffuse it is apt to be concealed in the concavity
of the turbinal. From this hiding-place it can be partially dislodged
with a probe and then cut off with a snare.

The after-treatment is similar to that for removal of the anterior end.

=Removal of the posterior end.= =Indications.= The posterior extremity
of the inferior turbinal is very subject to a moriform hypertrophy, and
some delicacy and skill are required in removing it.

=Operation.= The interior of the nose on the affected side should be
treated with a weak solution of cocaine and adrenalin. The most
disagreeable part of the operation is the introduction of the operator’s
finger into the post-nasal space. Hence the fauces should be freely
sprayed with a 5% solution of cocaine. This will deaden painful
sensation, but it will not prevent the discomfort nor the nausea often
induced.

It is well to avoid as much as possible the direct application of
cocaine or adrenalin to the moriform hypertrophy itself, for it is an
extremely vascular growth, and if much contracted it is more difficult
to ensnare.

The operation may also be carried out under a general anæsthetic, when
one is given for other surgical measures in the nose. In that case it is
best to defer the removal of the moriform hypertrophy until the
end--practically until the patient is commencing to recover
consciousness--on account of the sharp hæmorrhage which is apt to
accompany it.

The chief difficulty of the operation lies in the fact that the part to
be operated on cannot be kept in view, either directly or indirectly,
and that therefore success depends a good deal on delicacy of touch.

A nasal snare--such as that of Blake, Krause, or Badgerow--is threaded
with No. 5 piano wire, and a loop left out a little larger than
sufficient to grasp the growth. This loop is then bent over smartly
towards the side to be operated on, and a slight kink is given to it.
The loop is then slightly withdrawn within the barrel, and this again
brings it into a straight line. If now the snare be passed along the
floor of the nose until the end of it is opposite the posterior
extremity of the turbinal, and if the looped wire be slightly projected
from the barrel, the loop will tend to curve outwards to the side on
which it was kinked. In this way it will be felt to surround the
moriform growth, which can then be cut off.

[Illustration: FIG. 291. AMPUTATION OF THE POSTERIOR END OF THE INFERIOR
TURBINAL.]

It must be confessed that this is not always successful, that there is
no means of making sure that the snare is applied to the root of the
growth, and that once the bleeding is started posterior rhinoscopy fails
to reveal if any of it still remains. It is better therefore to
introduce the purified forefinger of the left hand into the post-nasal
space, so as to define the growth and guide the loop of the snare over
it. The nail of the same finger then keeps the wire close to the base of
the hypertrophy, while the loop is drawn home (Fig. 291). The patient
may then be relieved of the discomfort of the operator’s finger in his
throat, and may be given time to clear away the collected mucus. A
little delay is advantageous, as it allows coagulation to take place in
the large veins of the moriform growth. Some surgeons recommend that
once the growth is strangled the snare should be left _in situ_ for 10
or more minutes. This is irksome and unnecessary, and bleeding is seldom
excessive if the snare be not employed for cutting off the hypertrophy,
but is used as follows: Once the loop is drawn firmly home so as to
embrace the growth tightly, a few minutes’ rest is given. Then,
steadying the patient’s head with the now disengaged left hand, the
snare is plucked from the nose with a quick movement. This brings away
the mulberry hypertrophy in its grasp, and frequently a strip of mucosa
from the lower margin of the turbinal. No bone is removed in this
operation. The bleeding may be very sharp at first, but generally ceases
under the usual measures (see p. 574). Occasionally it is extremely
troublesome, and as the bleeding surface overhangs the post-nasal space
the only local pressure which is available is that of a post-nasal plug.

=After-treatment.= As secondary hæmorrhage is apt to be met with the
patient should be advised to leave his nose alone, neither blowing nor
clearing it, nor using any cleansing measures for 48 hours. After that
time he can employ the usual warm alkaline nose lotion. He should be
warned against the habit of hawking backwards, as this would tend to a
recurrence of the hypertrophy.

[Illustration: FIG. 292. NASAL SPOKESHAVE.]

=Prognosis.= Great relief can generally be promised within a few days.
There is no danger in the operation. The hæmorrhage may be troublesome,
especially in men. The precautions described in the previous chapter are
well worth observing (see p. 574).

=Complete turbinotomy.= =Indications.= As already remarked it must be
extremely rare for this operation to be required. Papillary hypertrophy
chiefly attacks the lower and posterior parts of the turbinal, and these
can be removed as described above, so that if the entrance of the
nostril is made free by anterior turbinectomy, there will still be left
a sufficient area of functionally active mucosa. If, however, almost the
entire inferior turbinal be degenerated, or if it be replaced by
malignant growth, it can be removed in the following way.

=Operation.= Anæsthesia may be local or general. If no other operative
procedure be required at the same time, the anæsthesia of nitrous oxide
gas or chloride of ethyl will be long enough. Owing to the vascularity
of the part adrenalin should be applied for at least 30 minutes
beforehand.

Removal of the turbinal is easily and quickly carried out with Carmalt
Jones’s or Moure’s spokeshave (Fig. 292). This is introduced, passed as
far as the posterior extremity of the turbinal, and the edge is guided
in place with the operator’s left forefinger in the post-nasal space.
With a sharp pull the spokeshave is then drawn forwards and the detached
body can be lifted out with a pair of punch-forceps. Owing to the slope
of the attached border it is seldom that the whole of the turbinal is
removed. Those who are skilled in the use of this instrument can
manipulate it so as to leave a good part of the attached margin of the
turbinal, and the spokeshave can be used instead of the scissors for
removal of the inferior margin. But its action is apt to be uncertain,
and as it may unexpectedly rip out more than was intended, it is seldom
employed nowadays.

=After-treatment.= After the removal of such a large portion of
secreting surface the nasal secretion may dry into adhering crusts and
scabs for some weeks--possibly for six or even eight. The scabs should
be softened by the use of ointment or oily sprays, and removed by the
fere use of warm alkaline lotions. The even healing of the granulating
surface requires watching; its progress should be inspected from time to
time, as the surface may require touching with a weak nitrate of silver
solution.


OPERATIONS UPON THE MIDDLE TURBINAL

=Indications.= Amputation of the anterior end may be required for (1)
simple hypertrophy, (2) cyst or empyema in the anterior extremity, (3)
to gain access to the ostia of the various accessory sinuses, (4) as a
first step to uncover the ethmoidal cells, and (5) as a first step in
removal of ethmoidal polypi.

=Operation.= Local anæsthesia with cocaine and adrenalin is sufficient,
and the operation can be carried out with the patient sitting in the
examination chair. It frequently forms part of some other intranasal
operation which is performed under a general anæsthetic, but the
preliminary application of cocaine and adrenalin should still be carried
out (see p. 572). If the pieces of gauze soaked in the cocaine-adrenalin
mixture be carefully tucked up on each side of the head of the turbinal,
the part to be removed is generally well exposed. With a pair of
Grünwald’s punch-forceps (Fig. 286) or Panzer’s scissors (Fig. 290), the
anterior attachment to the outer wall is cut through (Fig. 293) so as to
free the end, around which a cold wire snare can be passed and the
extremity removed (Fig. 294.) In cases where it is difficult to
introduce the punch-forceps under the attachment of the middle turbinal
the blades may be applied to the lower margin, about half an inch from
the anterior extremity so as to bite out a wedge. Into this the loop
of the wire snare is inserted and the head of the turbinal can easily be
snared off.

[Illustration: FIG. 293. FIRST STEP IN THE REMOVAL OF THE ANTERIOR END
OF THE MIDDLE TURBINAL.]

[Illustration: FIG. 294. SECOND STEP IN THE REMOVAL OF THE ANTERIOR END
OF THE MIDDLE TURBINAL.]

The snare is generally recommended as being safer than the
punch-forceps. There is certainly a risk attending any slip in
manipulating the latter in this region, more so, indeed, than in the
deeper ethmoidal regions, for in the anterior part of the nasal roof the
cerebral floor dips down lower than it does posteriorly, and the nasal
fossa in the anterior part of the middle meatus is very narrow, so that
if the forceps slipped they might impinge on the cribriform plate.

But when the middle turbinal is softened and broken down by disease it
is as safe, and it is certainly more convenient, to take out a wedge
from its centre, as directed above, and then with a pair of Grünwald’s
or Luc’s forceps to twist out not only the anterior extremity, but also
the posterior half. The latter part can also be removed with a
spokeshave, as directed for the inferior turbinal (see p. 591).

=After-treatment.= There is not the same tendency to crusting as occurs
after operation on the inferior turbinal. Hæmorrhage is also less
troublesome. Plugging is therefore the less likely to be required, and
should always be avoided if possible, since it would interfere with
drainage from the various accessory sinuses, and this operation is
frequently required when their contents are particularly septic. The
best plan is to leave the nose severely alone for 48 hours, and then to
clear it gradually with the help of warm alkaline lotions.


OPERATIONS FOR THE RESULTS OF SYPHILIS

=Sequestrotomy.= The discovery of a syphilitic sequestrum always calls
for active treatment.

=Operation.= If the sequestrum be not loose we must wait until it is
movable. Its detachment will be expedited by mercurial inunctions or
injections, and suitable local cleansing and disinfecting measures. As
soon as any movement can be detected in the dead mass we can proceed,
under cocaine, to detach it. Various forms of polypus forceps and
bone-pliers may be required, and the necrosed bone has to be raised from
its bed by a variety of lever and to-and-fro movements. Several sittings
may be necessary, but this is inevitable, as any violent measures are
soon arrested by hæmorrhage. When the necrosed bone has been mobilized
it may be too large for extraction through the nares; such a mass as the
greater part of the body of the sphenoid has sometimes necrosed _en
bloc_. In such cases the dead bone must be broken up _in situ_ and then
removed piecemeal through either the anterior or posterior nares. Very
rarely Rouge’s operation may be required (see p. 622).

=Operations for post-syphilitic adhesions of the velum.= So long as
there is an adequate passage for nasal respiration it is best to leave
any slight degree of stenosis alone. When there is complete atresia, and
when mouth-breathing, deafness, or other consequences develop, some
effort at relief should be made.

=Operation.= Under chloroform, and with the hanging head, W. G.
Spencer[54] separates the soft palate from its adhesion to the posterior
pharyngeal wall, draws it forwards, and fixes it by two silk sutures to
the muco-periosteum of the hard palate. Tilley carries out the same
principle by threading the soft palate on both sides with strong silver
wire and anchoring it to the incisor teeth. The wires cut out in 10 to
14 days, but by this time considerable healing will have taken place
over the raw surfaces from which the adhesions had been separated.[55]

[54] _Proc. Laryngol. Soc., London_, vol. v, November, 1897, p. 4.

[55] Ibid., vol. x, March 6, 1903, p. 81.

After freeing the soft palate, H. B. Robinson prevents it from again
uniting by the following method: ‘A piece of lead plate is cut the full
breadth of the naso-pharynx and bent so that one arm rests on the dorsal
surface of the soft palate, and the lower one on the buccal surface, the
cut margin being received between the plates and apposed to the bend,
and so kept away from the pharyngeal wall.’ The piece of lead is kept in
place by silk threads attached to the four corners, two passing forward
through the nostrils and two through the mouth. The lead plate is not
removed for a fortnight.[56]

[56] Ibid., vol. xiv, June, 1907, p. 106.

Whatever method is employed to enlarge the stricture, dilatation must be
kept up for some time by the frequent passage of the forefinger, a
palate hook, or a dilatable bag.

=Results.= Stenosis of the passage from the naso-pharynx to the
meso-pharynx, caused by syphilitic adhesions between the soft palate and
the posterior pharyngeal wall, is one of the most difficult affections
in this neighbourhood to operate on with satisfactory results. The cause
of disappointment lies in the low vitality of specific scars and their
well-known tendency to contract.

Surgical measures are sometimes required for the damage left by syphilis
during the healing process.

The saddle-back deformity of the external nose is best corrected by
subcutaneous injection of paraffin (see Vol. I, p. 681).

Perforations in the hard or soft palate may require operation to close
them (see Vol. I, p. 717).


OPERATIONS FOR TUBERCULOSIS

Tuberculosis only occurs in the nose in the mitigated form of lupus.
Surgical interference is frequently called for, generally in the form of
curettage or the application of caustics.

The most satisfactory caustic is the galvano-caustic point, applied
under cocaine, and at repeated sittings.

Curettage is required in more advanced cases. Chloroform is always
required. Not only should all soft and diseased tissue be scraped away
with a Volkmann’s spoon, but the curettage should be carried on
vigorously until a healthy and resistant area has been reached. It is
rare for too much tissue to be removed, whereas recurrences are only too
frequent.




CHAPTER III

OPERATIONS UPON THE NASAL SEPTUM


OPERATIONS FOR DEFORMITIES

REMOVAL OF SPURS

=Indications.= A spur or ledge, uncomplicated with deviation of the
septum, occasionally requires removal. It will generally be found in the
lower meatus, at the junction of the quadrilateral cartilage and ethmoid
with the superior maxillary crest and vomer.

[Illustration: FIG. 295. CRESSWELL BABER’S NASAL SAW.]

=Operation.= The operation can be carried out painlessly and bloodlessly
under cocaine and adrenalin. The galvano-cautery, trephine, and
spokeshave should be avoided. An incision is made from behind forwards
along the summit of the projection, and the muco-perichondrium is turned
upwards and downwards. (For particulars as to reflecting these flaps see
p. 605.) A straight, fairly stout nasal saw (Fig. 295) is inserted below
the projection, and, while the patient’s head is steadied with the left
hand, the saw is carried inwards and upwards with short, swift
movements. During the first of these the cutting edge should be directed
obliquely towards the opposite nostril so that the saw gets a good bite
into the base of the spur. Otherwise, if simply directed vertically the
resistance it meets with is likely to send it obliquely outwards, and
the obstruction will be imperfectly removed. This defect will be the
more apparent later on, when some heaping up of scar tissue is sure to
take place over any trace of projection. In other words, in order to
remove a spur flush with its base it is necessary to cut deeper than the
base. At the same time it is important to avoid buttonholing the septum
by cutting into the opposite nostril.

When the spur lies close along the floor of the nose it may be necessary
to direct the saw from above downwards. The result is not so
satisfactory, and the removal may have to be completed by seizing and
twisting off the semi-detached spur with a pair of polypus forceps, or
stripping it forwards with a spokeshave.

=After-treatment.= The reflected flaps of muco-perichondrium are
replaced and maintained in position for 48 hours with plugs of
cotton-wool. Subsequently a warm alkaline nasal lotion and a little
ointment may be required.

=Perforating the septum.= It will be seen that if a spur is associated
with a convexity of the septum to the same side it will be very
difficult to remove the projecting obstruction adequately without
cutting into the concave side of the septum, and so producing a
perforation. Some surgeons even recommend that this should be done
intentionally, and maintain that the resulting perforation seldom gives
any trouble. This may be true in some cases, and the result is sometimes
fairly good. But we have more completely satisfactory methods at our
disposal; the perforation method does not relieve the majority of cases,
and it interferes with the subsequent performance of more perfect
operation. It can therefore only be approved of when the surgeon has not
acquired the technique of the submucous resection operation (see p.
603).

_Operation._ When it has been decided to produce a perforation it is
carried out with the nasal saw, as described for the removal of spurs
(see p. 595). The saw is introduced so as to embrace as much as possible
of the projection.

_After-treatment._ The drying and scabbing of discharge along the margin
of the perforation is apt to give trouble for some weeks. This
inconvenience is the more marked the nearer the perforation approaches
to the anterior nares. It must be met by careful and repeated cleansing
and lubrication of the nasal chambers. Any scabs should be carefully
softened with hydrogen peroxide, lifted off the edge of the perforation,
and any underlying ulceration treated with applications of nitrate of
silver, argyrol, &c.


OPERATIONS FOR SIMPLE DEVIATION

It is very rare to find a deviation of the nasal septum without some
accompanying spur or ledge. It is still more rare to meet with a
deviation which is entirely limited to the cartilaginous septum; there
is nearly always some bony formation in the deformity, contributed by
the nasal spine of the superior maxilla, the vomer, or the perpendicular
plate of the ethmoid, or by all three. Hence the limited field of
application for the various operations which have been designed for
‘straightening the cartilaginous septum’. In the few cases where the
deformity is almost entirely cartilaginous these operations are only
partially successful in overcoming its resiliency. They will therefore
be only briefly considered.

=Gleason-Watson operation.= For a thorough performance this operation
requires a general anæsthetic. The scheme of the operation is to make a
U-shaped incision around the convexity, leaving it attached above. The
flap of cartilage is then pushed through the U-shaped opening into the
concave side. As its bevelled edge is larger than the button-hole in the
septum it will be to some extent prevented from slipping backwards (Fig.
296). This tendency may also be combated by an attempt to snap through
the base of the flap of cartilage, and by careful packing of the
formerly obstructed nostril. The operation is performed with a nasal
saw, carried from below upwards, and maintained carefully in the
antero-posterior axis of the septum.

[Illustration: FIG. 296. THE GLEASON-WATSON OPERATION FOR DEFORMITY OF
THE SEPTUM. _a_ shows the incision made from the stenosed nostril, and
below the convexity; _b_ represents the septum as pushed into the free
nostril; and _c_ shows the result after subsequent removal of the spur.]

=Asch’s operation.= The resiliency of a deviated cartilaginous septum is
more completely overcome by this method of operating. It requires a
general anæsthetic.

By means of appropriate cutting scissors (Fig. 297) a crucial incision
is made over the summit of the convexity of the deviation, so that we
have four triangular flaps meeting at the point of greatest stenosis. By
means of the finger introduced into the obstructed nostril, or suitable
septal forceps, these four flaps are snapped across at their bases so as
to overcome their tendency to spring back.

Into the formerly obstructed nostril is introduced a Meyer’s vulcanite
hollow splint (Fig. 284), a Lake’s rubber splint (Fig. 298), or a gauze
packing. This should be retained for 48 hours. Afterwards it will
require daily changing and cleansing, possibly for several weeks. In the
opposite nostril a lighter support will serve to keep the ends of the
fragments _in situ_.

=Moure’s operation.= According to its author this operation can be
carried out under local anæsthesia, but it is generally advisable to
employ some such general anæsthetic as nitrous oxide or chloride of
ethyl. By means of suitable scissors one incision is made through the
septum parallel to the bridge of the nose and above the prominence of
the deviation, and by another parallel to the floor of the nose the
septum is divided below the deviation. This is now only fixed at its
anterior and posterior extremities, but has been rendered more movable
from side to side. By means of a specially designed dilator and splint
the septum can be moulded into a good position, and maintained there
until healing takes place.

[Illustration: FIG. 297. ASCH’S CUTTING SCISSORS. Employed in the
operation upon the septum.]

[Illustration: FIG. 298. LAKE’S RUBBER SPLINT.]

The conditions in which any of these operations can prove suitable are
rarely met with. In the worst forms of stenosis from septal deformity
they are useless. At the best they can never completely remove it. In
one of them a perforation is made on purpose, and in the others it not
infrequently is produced unintentionally. The objections to a
perforation have been described (see p. 598). Hæmorrhage, shock, and
prolonged and painful after-treatment are important drawbacks. A dry
scabby condition of the septum may be produced, and the patient may
complain more of this than of his previous nasal stenosis; indeed, he
may find that the stenosis is unrelieved and that a constant source of
irritation has been added to it.

The perforation operation should only be employed when the patient is in
circumstances where a complete submucous resection cannot be carried
out. The Gleason-Watson operation is unsuitable where the deviation
reaches high up. It should be avoided if it is seen that the perforation
will have to be brought close forward to the anterior nares.

Another objection is that any of these operations, particularly the
production of a perforation, will greatly increase the difficulties and
diminish the benefits of the subsequent complementary operations which
are only too often required.

Asch’s operation is easily carried out, and may be practised by those
who have not mastered the technique of submucous resection (see p. 603).
Moure’s operation is easily and quickly performed, and where a
well-marked deviation of the anterior part of the cartilaginous septum
is met with, it will give considerable relief.


OPERATION FOR COMBINED BONY AND CARTILAGINOUS DEFORMITY

_Submucous Resection (Window operation)_

This is the most perfect operation we at present possess for the cure of
deformities of the nasal septum. It has largely supplanted those already
outlined; it is suitable for the most extreme degree of deformity: and
it will secure complete relief to the symptoms produced, whether they
consist of stenosis of the air-way, obstruction to discharge, or reflex
effects.

The design of the operation is to excise all obstructing cartilage and
bone, with any projecting spurs or ledges, while preserving intact the
mucous membrane on each side. It has been brought to its present degree
of perfection chiefly by the work of Killian and Freer.[57]

[57] For bibliography and more detailed description, see StClair
Thomson, _Med.-Chir. Trans._, vol. lxxxix, 1906; _Lancet_, July, 1906;
and _Brit. Med. Journ._, vol. ii, 1906.

=Indications.= The special indications of this operation would appear to
be:--

1. Cases where it is desirable to establish normal nasal respiration and
remove mouth-breathing, with its numerous consequences.

2. Correction of the disfigurement caused by the lower end of the
quadrilateral cartilage projecting into one nostril.

3. Cure of headaches or reflex neuroses of nasal origin.

4. The relief and treatment of Eustachian catarrh.

5. Facility for treating nasal polypi and affections of the accessory
sinuses.

=Objections to the operation.= (_a_) That the excision of a large part
of the septum may lead to flattening or deformity of the nose. This
objection is groundless. A strip of septal cartilage is always left
above, beneath the crest of the nose. Falling in of the bridge of the
nose could only be consequent on entire removal of this ‘bowsprit’ of
cartilage, or from its destruction through the wound becoming septic. No
deformity has occurred in my hands in over 200 operations. On the
contrary, the appearance of the nose is generally much improved.

(_b_) That the operation entails greater risks from any subsequent blows
on the nose. This objection has been met by the experience of Otto Freer
in four cases where severe blows, causing epistaxis and occurring even
within a week of operation, did not result in any damage to the fleshy
septum, nor to the external appearance of the nose.[58]

[58] _Annals of Otology, Rhinology, and Laryngology_, June, 1905.

(_c_) That the operation is long and tedious. The duration of the
operation depends on the nature of the case, the skill of the surgeon,
and the difficulties met with--chiefly in the way of hæmorrhage. A
simple deviation of the cartilaginous septum can be removed by this
method in 10 to 20 minutes. Many beginners are apt to be content with
such a partial removal. More time is required in completely removing
bony deformities. Many cases take 30 minutes, and none need exceed an
hour when once the necessary dexterity has been acquired. More time is
taken up if fresh applications of cocaine or adrenalin have to be made,
if bleeding be troublesome, and if one of the flaps should be punctured.

(_d_) That the operation requires special skill. This is a real
objection to the popularization of the operation. It does not seem
probable that it can ever pass out of the hands of those who are kept in
daily practice in rhinological technique.[59]

[59] ‘As all operators who know it will confess, the Fensterresektion of
the septum belongs to the most extremely difficult intranasal
operations.’ Zarniko, _Die Krankheiten der Nase_, 1905, p. 300.

(_e_) That the operation is unsuitable for children. Owing to the small
size of the nasal chambers the operation presents greater technical
difficulties before the age of sixteen. My own practice formerly was to
await this age, and Killian used to advise that children under twelve
were not fit subjects. But Freer held that the operation is proper for
children at all ages, although with them the deformity tends to recur
unless every vestige of it has been removed. Killian has lately adopted
this view, and agrees that the operation may be performed on children
even as young as four years of age.[60]

[60] _Beiträge zur Anatomie, &c. des Ohres, der Nase, und des Halses_,
Hefte 1-4, 1908.

=Advantages of the operation.= These may be summarized as follows:--

1. A general anæsthetic is not inevitable.

2. Hæmorrhage gives no trouble.

3. Absence of pain and shock.

4. No reaction. The post-operative temperature seldom rises above 99° F.

5. Absence of sepsis, with its possible extension to ears, sinuses, or
cranial cavity.

6. No splints are required, and no plugs after the first 48 hours.

7. Rapid healing, without crust formation.

8. No risk of troublesome adhesions.

9. Short after-treatment.

10. Speedy establishment of nasal respiration.

11. Suitability for every variety of deformity of cartilage or bone in
the septum which may require treatment.

12. No ciliated epithelium is sacrificed.

13. Accuracy of result can be depended on; the prognosis is, therefore,
the more definite.

14. If the external appearance of the nose be altered at all it is in
the way of improvement.

It will be seen that the above advantages cancel most of the drawbacks
which were formerly so annoying in nasal surgery.

=Contra-indications.= 1. Elderly people are so accustomed to their nasal
obstruction, and its secondary consequences are generally so fully
established, that the benefits would be much less marked than earlier in
life.

2. Serious or progressive organic disease. This does not apply to
quiescent or arrested tuberculosis.

3. Active syphilis.

4. Lupus.

5. The operation should be postponed if the patient shows any symptoms
of influenza, or of acute or infectious catarrh.

=Operation.= Submucous resection can be completely carried out under
local anæsthesia, as described on p. 572. Killian and others secure
local anæsthesia by submucous injection of cocaine and adrenalin (see p.
572), but I have found this method alarming to the patient, apt to
produce disagreeable palpitation, and not superior to the method of
superficial application already described, particularly if sufficient
time is allowed for the mixture to act, and if a few cocaine crystals
are allowed to dissolve over the site of incision some minutes before
starting it.

In nervous subjects it is better to administer chloroform, not so much
because of any pain they suffer, but because of the mental strain they
are apt to feel in watching the various manipulations.

[Illustration: FIG. 299. BAYONET KNIFE.]

_Position._ The operation is best done with the patient horizontal on an
operating table, with the head and shoulders well raised. His nose is
then almost on a level with the eye of the surgeon, who is armed with a
frontal search-light or Clar’s mirror (see p. 571), although he can also
operate successfully with an ordinary forehead reflector.

[Illustration: FIG. 300. INCISION FOR SUBMUCOUS RESECTION OF THE SEPTUM.
The incision is made, on the convex side, from B to A. If the free end
of the quadrilateral cartilage is displaced from behind the septum
cutaneum, and presents in one nostril, then the incision is made from
_b_ to _a_.]

_The incision._ This can be made with a narrow scalpel, but a much
shorter instrument mounted on a bayonet handle cutting all round the
point will be found more satisfactory (Fig. 299). The incision is made
from the side of the convexity, just anterior to it, and generally about
half a centimetre behind the junction of the skin and mucous membrane
(Fig. 300). It is started high up in the attic of the nose, and carried
downwards to the floor. Sometimes it curves a little backwards below,
but it is quite unnecessary to convert it into an L-incision by a second
cut backwards. The incision, in its whole extent, divides the mucous
membrane and cartilage at one cut, but without puncturing or wounding
the mucosa of the opposite (concave) side. In doing this the operator’s
forefinger in the opposite nostril serves as a useful guide (Fig. 301).
In those cases where the lower free end of the quadrilateral cartilage
is displaced from behind the septum cutaneum into one nostril--commonly
but erroneously described as ‘dislocation of the septum’--the incision
is made directly over the exposed extremity (Fig. 300, _b-a_).

_Raising the convex flap._ With a small sharp elevator the
muco-perichondrium is raised along the posterior edge of the incision.
Great care must be taken not to pass the raspatory between the mucous
membrane and the closely adhering perichondrium. The dead white,
slightly roughened surface of the bare cartilage should be distinctly
visible, and should not be coated with any soft, smooth, or pinkish
perichondrium. Once the flap is well started a dull-edged detacher (Fig.
302) will readily undermine it by sweeping movements gradually advancing
upwards and backwards. If possible the limits of the convexity should be
passed, but it is well not to attempt to go round sharp projections, as
it is there that perforations are apt to take place. It is easier at a
later stage to strip the flap off crests or spurs.

[Illustration: FIG. 301. MAKING THE INCISION FROM THE CONVEX SIDE IN
SUBMUCOUS RESECTION OF THE SEPTUM. The forefinger of the left hand acts
as a guard in the opposite nostril.]

_Incision through the cartilage._ If the cartilage has not already been
completely cut through at the first incision it is now divided in the
same extent as the cut in the muco-perichondrium, great care being taken
not to button-hole the mucosa of the concavity.

[Illustration: FIG. 302. DULL-EDGED DETACHER.]

_Raising the concave flap._ The sharp elevator, followed by the
dull-edged detacher, is introduced from the incision on the convex side.
The muco-perichondrium of the concavity is now raised in the same way
and with the same precautions already used on the convexity, the sharp
elevator and then the dull-edged detacher being introduced through the
incision in the obstructed orifice, and manœuvred between the cartilage
and the concave flap without puncturing the latter (Fig. 303).

[Illustration: FIG. 303. DENUDATION OF THE SEPTUM IN SUBMUCOUS
RESECTION. The muco-perichondrium has been raised from the convex side
of the septum, and the cartilage has been cut through (from A to B in
Fig. 300). The dull-edged detacher is shown separating the mucous
membrane from the concavity of the deflexion.]

[Illustration: FIG. 304. COMPLETE DENUDATION OF THE DEVIATED SEPTUM.
Semi-diagrammatic drawing of a transverse section of the nose, viewed
from above. The deviated septum has been divided in front, and its
muco-perichondrium has been stripped up on each side. The nasal speculum
is introduced through the convex nostril, and a blade is inserted on
each side of the septum, between it and its mucous covering.]

_Excision of the deviated cartilage._ A long Killian’s nasal speculum
(Fig. 346), or the long Thudichum’s speculum I have had made, is now
introduced through the obstructed nostril, one blade being inserted on
each side of the now denuded septum (Fig. 304). It is easy to see if the
mucous membrane has been sufficiently stripped off. If not, it can be
carried further with a few sweeps of the raspatory. Ballenger’s swivel
septum knife[61] (Fig. 305) is then placed astride the anterior cut
surface of the cartilage, pushed upwards and backwards below the roof of
the nose until it comes in contact with the ethmoid, then downwards and
backwards to the angle between the ethmoid and the vomer, and, finally,
pulled forwards along the upper margin of the vomer (Fig. 306). The
excised cartilage is thus removed _en bloc_, and may measure an inch by
one and a half inches.

[61] _The Laryngoscope_, vol. xv, June, 1905, No. 5, p. 417.

[Illustration: FIG. 305. BALLENGER’S SWIVEL SEPTUM KNIFE.]

The empty pocket between the two separated and flaccid mucous membranes
is wiped out and the two fleshy curtains are allowed to fall together.
With a nasal speculum each nasal chamber is next carefully inspected to
see that the thoroughfare is completely restored. As a rule deeper
obstructions, formerly invisible, will come into view, and the mucosæ
are again separated with a long nasal speculum and more of the septum is
shaved off with Ballenger’s knife or clipped away with Grünwald’s
punch-forceps, which also serve to remove portions of the vomer and of
the perpendicular plate of the ethmoid.

_Excision of bony spurs and ledges._ It has been pointed out that it is
extremely rare to find a deviation limited entirely to the cartilaginous
septum. I have never yet met a case in which it was not desirable to
remove some of the bony septum.

[Illustration: FIG. 306. THE METHOD OF EMPLOYING BALLENGER’S SWIVEL
SEPTUM KNIFE. The knife is shown cutting out the cartilaginous
deviation.]

When the deformity of the septum is principally composed of bone the
operation is started as already described. It is then easier to lay bare
any thickening or deviation of the nasal process of the superior
maxilla, or of the chondro-vomerine suture--the usual sites of bony
obstructions. When the main mass of deviated cartilage has been cut out
with Ballenger’s knife free access is obtained from above to these
deformities, and the fleshy muco-perichondrium can be peeled off on each
side with much less risk of a tear or puncture. Still, much care is
required in working round sharp corners, and, when the spurs lie low,
the flaps frequently require to be reflected right down to the floor of
the nose. Once well exposed, the maxillary spine is attacked with strong
punch-forceps or chisel and hammer, and as pieces of it are prised up
they are twisted off with forceps. Once the obstructing maxillary spine
is cleared away it is easier to deal with any vomerine deformity.

A great deal of the success of an operation depends on the complete
removal of these spurs and ledges, and as they may have to be followed
back nearly to the posterior choanæ this part of the operation may be
the most difficult, as it is the most necessary (Figs. 307-9).

The pocket between the two flaps is again carefully wiped free of
blood-clot and chips of bone and cartilage, and when the two mucous
membranes are allowed to fall together they should hang perfectly plumb
in the middle line and allow of an uninterrupted view through each nasal
chamber, right back to the post-nasal space.

_Stitches._ With a small Trélat’s needle the incision is closed with one
or two catgut stitches.

[Illustration: FIG. 307. SUBMUCOUS RESECTION OF THE SEPTUM. The arrows
indicate the points where the chisel may be applied when exostosis of
the nasal maxillary spine requires removal.]

_Dressing._ Plain sterilized cotton-wool is tightly rolled into pencils
about 3 inches long, and well smeared with sterilized vaseline. These
are carefully packed into each nostril. The nose should not be tightly
plugged, our object being to keep the two mucous membranes in
apposition, but at the same time entirely occluding nasal respiration.

=After-treatment.= The patient remains quiet for the rest of the day.
Ice may be given to suck and an iced cloth laid across the bridge of the
nose. At the end of 48 hours the plugs are removed and will be found to
come away very easily. The patient should be warned against blowing his
nose, but may suck blood-stained mucus backwards and hawk it out through
the mouth. Any discomfort may be soothed by spraying the nostrils with
liquid vaseline, or introducing a piece of menthol and boric ointment
into each nostril morning and evening.

[Illustration: FIG. 308. SUBMUCOUS RESECTION OF THE SEPTUM. The shaded
area indicates the extent of the bony and cartilaginous septum usually
requiring removal.]

[Illustration: FIG. 309. SUBMUCOUS RESECTION OF THE SEPTUM. The shaded
portion indicates the extent of cartilage and bone removed in marked
deformity, when the free end of the quadrilateral cartilage projects
into one nostril.]

The relief to the former state of nasal obstruction may at once be
appreciable. If there be any local reaction it may take 3 or 4 days for
the obstruction to subside. In 7 to 10 days the patient begins to enjoy
the benefit of the operation, but it is only after 3 weeks that the full
advantage of it is established.

=Complementary operations.= As a rule the formerly patent nostril is
found after this operation to be the more obstructed of the two. The
reason of this is readily explained by a reference to Fig. 310. The now
redundant hypertrophy in the formerly good nasal chamber is
removed--according to its degree and extent--by one of the methods
described on p. 587.

From long disuse marked alar collapse may interfere with the good
results of the operation.

=Difficulties.= _Insufficient illumination_ is a difficulty that can
easily be provided against by using a frontal photophore or Clar’s
mirror (see p. 571).

[Illustration: FIG. 310. SEMI-DIAGRAMMATIC TRANSVERSE SECTION OF THE
NOSE. Shows the compensatory hypertrophy of the inferior turbinal in the
unobstructed nostril. Part of this frequently requires removal after the
septum has been straightened.]

_Hæmorrhage_ presents no difficulty if patients are prepared as directed
(see p. 574), unless one happens unexpectedly on a patient with a
hæmophilic tendency. In one such case I had no trouble at the time of
operation, but bleeding gave great annoyance for a fortnight afterwards.

_The incision_ I have described has always proved sufficient. In some
cases this straight incision is unintentionally converted into an
L-shaped one, when the flap is torn over a sharp low-lying spur.
Beginners may find it easier to start with an L-shaped incision, but it
is unnecessary and does not leave so small and clean a wound.

The perichondrium should be raised with great care, for it is more easy
than one would think to leave it adhering to the septum, while
separating only the mucous membrane.

_Previous operations_ always increase the difficulties of the
proceeding. The old-fashioned ‘shaving off’ of spurs often removed the
entire thickness of the cartilage at one part, without perforating the
concave mucosa. The submucous resection (window operation) is not
infrequently not carried far enough. In either of these circumstances
we are confronted with the great difficulty of trying to separate the
two muco-perichondria--now closely united to one another.


OPERATION FOR PERFORATION OF THE NASAL SEPTUM

When a perforation of the nasal septum is situated at some distance
within the nasal orifice it seldom gives any trouble. A perforation may
also be situated close to the anterior nares without even making its
presence known. But in some cases--no matter what the original cause of
the perforation--constant annoyance is given to the patient by the
crusting and bleeding which takes place along its margin. When these
crusts have been carefully removed inspection will show that the cause
of the trouble is the projecting free edge of the cartilage which
prevents the edges of mucous membrane from each nostril from closing
over it. When this circular edge is healed over smoothly, secretions
cease to adhere to it, and the patient is not troubled by the annoying
crust formation.

[Illustration: FIG. 311. OPERATION FOR PERFORATION OF THE SEPTUM. The
muco-perichondrium is reflected for some distance round the opening so
as to allow of the projecting rim of cartilage being removed. The
exposed edge is then covered over by the mucous surfaces falling
together.]

This desirable condition can be brought about in crusting perforations
by means of the following operation designed by Goldstein.[62] After
preparation with cocaine and adrenalin (see p. 573), the
muco-perichondrium is reflected on each side along the whole
circumference of the perforation for a distance of about a quarter of an
inch from the free margin. Over the greater part of the circumference
this can be done with Freer’s sharp elevator, or with the small sharp
elevator employed in submucous resection of the septum. In dissecting
the anterior part of the circumference the same kind of elevator can be
used, but with the operating edge bent forward at an acute angle (Fig.
311). A slit in the elevated mucous membrane, posterior to the
perforation, will relieve tension. With a Ballenger’s single-tine swivel
septum knife a rim of cartilage is then cut away around the perforation,
so that the two mucous surfaces from opposite nostrils can come in
contact and overlap the circular edge of cartilage. This smooth surface
will prevent any further sticking and crusting of discharge. It is kept
_in situ_ for 48 hours by vaselined cotton-wool plugs, similar to those
used in the submucous resection of the septum (p. 608).

[62] _The Laryngoscope_, xvi, 1906, p. 879.


OPERATION FOR ABSCESS

A free incision is made into it, under cocaine or nitrous oxide
anæsthesia. A horizontal cut should extend right across the swelling,
and as low in it as possible, to prevent the pocketing of pus. It is
sufficient to make it on one side, as the pus from the other side can be
pressed across through the defect in the cartilage. Any loose fragments
of cartilage should be probed for and removed. The lips of the incision
are kept apart by loosely tucking in a small piece of ribbon gauze. This
promotes drainage of the lower part, and is changed daily. Afterwards
healing takes place under simple cleansing measures.


OPERATION FOR HÆMATOMA

If the hæmatoma be small and not in a suppurating nose, evaporating
lotions are applied externally and the swelling is left alone, being
carefully inspected daily for early symptoms of suppuration. If the
swelling be large and tense, it is safer to incise it freely as
described above for abscess of the septum.




CHAPTER IV

OPERATIONS FOR REMOVAL OF NASAL GROWTHS THROUGH THE NOSTRILS: OPERATIONS
FOR OBTAINING DIRECT ACCESS TO THE NASAL CAVITIES AND NASO-PHARYNX


OPERATIONS FOR REMOVAL OF NASAL GROWTHS THROUGH THE NOSTRILS

REMOVAL BY SNARE

=Indications.= Operation with the snare is indicated in cases of simple
mucous polypi, if only a few polypi are present, and no sinus
suppuration is suspected. It is a suitable method for the removal of
papilloma, fibroma, and bleeding polypus of the septum. The snare is
also serviceable in the removal of enchondroma, osteoma, and growths, if
of limited size, after they have been detached from their bases or
broken up with a chisel or bone forceps.

[Illustration: FIG. 312. NASAL SNARE.]

=Instruments.= The surgeon will employ the pattern of snare to which he
is accustomed. The simpler models, such as those of Krause, or some
modification of Blake’s instrument, such as that of Badgerow, when
threaded with No. 5 piano wire will be found sufficient in most cases
(Fig. 312). For tougher growths, or those with a thicker pedicle, the
snare of Lack can be recommended. It is threaded with heavier wire, and
by a screw arranged in the handle the loop can be slowly and steadily
contracted.

=Operation.= The nose is carefully prepared with cocaine and adrenalin
(see p. 573), remembering that any growth or polypus is itself
insensitive. The anterior part of the nasal cavity, and particularly the
septum, should be thoroughly anæsthetized.

Under good illumination the snare is introduced with the loop vertical,
and passed alongside the growth,--between it and the septum or to the
outer side, as space permits. It is then swept round a half-circle, so
as to bring any tumour within the loop, and by a to-and-fro movement the
snare is worked upwards towards its base. The attachment of the ordinary
mucous polypus is generally in the region of the middle meatus. The wire
loop is thus threaded on to the growth or polypus. The loop is now
steadily tightened until it is felt that the pedicle is grasped,--it is
seldom visible. By a quick movement of avulsion the tumour is then torn
from its attachment. This will bring away some of the œdematous tissue
on the distal side of the loop, and there will be less tendency to
recurrence than if the root were simply cut across. With the removal of
a first polypus others come into view and they must be treated in the
same manner. The number which can be removed at one sitting will depend
on how well the patient is able to bear the manipulations and how much
bleeding there is. If both nostrils be affected it is well to treat them
on alternate weeks.

When the growth slips, or is pushed backwards, it can be brought forward
into the field of operation by asking the patient to blow down the nose,
with the opposite nostril closed. Or the presenting part of a polypus
may be seized with a pair of toothed catch-forceps and the wire loop
slipped over this.

If the growth be hanging backwards, and presents in the post-nasal
space, as it often does when it originates from the mucosa of the
maxillary antrum, it may be necessary for the surgeon to introduce his
left forefinger behind the palate,--as described on p. 590 (compare Fig.
291),--so as to steady the growth and at the same time slip the wire
loop around it. If there be no space for the latter manipulation, the
left forefinger is used to steady the mass while a pair of polypus
forceps is guided along the floor of the nose until the growth can be
seized between the blades so as to tear it from its attachment and pull
it out through the anterior nares.

=After-treatment.= The bleeding will generally cease spontaneously,
assisted by cold ablutions to the face, or pinching the end of the nose
until a clot forms (see p. 575). If bleeding persists, a piece of gauze,
moistened with peroxide of hydrogen, should be packed in lightly and
removed as soon as the patient can lie down quietly. It is best to avoid
the use of any plug. It was to plugging that Luc attributed the loss of
a patient from meningitis consequent on the removal of polypus.[63]

[63] _Revue hebd. de Laryn._, 1903, xxiv, Nr. 46, November 14, p. 597.

If the entrance to the nose be tender, it may be smeared with a little
menthol and boric ointment; ice-cold cloths may be kept across the
bridge of the nose; and pain or sensitiveness can be relieved by a few
doses of phenacetin or some similar anti-neuralgic.

Insufflations of antiseptic powder are useless, and the nasal cavity
should be left alone for 24 or 48 hours. A nose lotion should then be
used two or three times a day, until the local condition is again
inspected at the end of a week.

Any attempt to destroy the roots of polypi by the galvano-cautery is
useless and dangerous.


REMOVAL BY FORCEPS AND CURETTES

=Indications.= This operation is indicated in all cases of recurring
polypi and extensive caries of the ethmoid, but the plan of operation is
also suitable for the removal of some cases of papilloma, fibroma,
enchondroma, or osteoma.

It can also be employed in certain cases of malignant disease in the
nose. When the growth appears to be limited to the nasal fossæ, and
particularly in cases of sarcoma, the above operation may be indicated.
Even when glands are present this may still be the preferable operation,
as glands can be removed at a separate sitting.

Possibly a better method of deciding the case of malignant intranasal
disease suitable for this operation will be founded on the discovery of
the original attachment of the growth. If located towards the front of
the nose in the anterior part of the middle meatus, removal can be
carried out on the lines described.

=Contra-indications.= If there be any mental symptoms suggesting that
intracranial inflammation has taken place already, the patient should be
carefully examined before operation is embarked on. It is unsuitable for
debilitated and elderly subjects. In patients over 60 with recurrent
polypi it is wiser to secure relief by a series of small operations
under cocaine.

Many neoplasms and inflammatory hypertrophies, such as mucous polypi,
can be removed satisfactorily _per vias naturales_ by the method to be
described. Naturally the details will vary with the situation and extent
of the disease to be removed. The following description applies
particularly to growths or hypertrophies springing from the ethmoidal
region:--

=Operation under cocaine.= The nose is carefully prepared with adrenalin
and cocaine, the strips of moistened ribbon gauze being carefully tucked
in between the septum and the ethmoidal region, as well as between this
latter and the outer wall. The inferior turbinal and the front of the
nasal cavity should be similarly prepared, so as to diminish
vascularity, retract the healthy tissue, and thus increase the space for
operating in, while lessening the risk of wounding the septum and so
causing adhesions. At least one hour should be given for the solution to
act. The operation is done with the patient sitting upright in the
ordinary examination chair, with the body craned forward somewhat, and
the head supported and held in focus by an assistant. Ready to the
surgeon’s hand should be some lengths--about a yard--of 1-inch to 2-inch
ribbon gauze, and a vessel of cold sterilized water into which it is
easy to shake off the growths as they are removed with the forceps.

[Illustration: FIG. 313. LUC’S NASAL FORCEPS.]

If the middle turbinal has not already been removed it may have to be
amputated, as described on p. 592. In many cases of ethmoidal caries it
is easily removed with nasal forceps.

The instrument I recommend is Luc’s forceps[64] (Fig. 313), supplemented
by Grünwald’s punch-forceps (Fig. 286). The former are introduced
vertically, so that one blade passes between the ethmoid and the septum
and the other passes under cover of the middle turbinal. By insinuating
them carefully, and gradually working them upwards and outwards, a large
mass of tissue or carious ethmoid can be grasped, twisted off, and
shaken from the forceps into the vessel of water. Before any marked flow
of blood has taken place it will be possible to make a second or third
introduction of the forceps, and seize the successive masses of growth
which come into view. When the bleeding obscures the field of operation
one of the strips of gauze can be picked up quickly in the forceps and
used for plugging that side of the nose, while a similar operation is
carried out in the opposite nasal chamber, if it is affected.

[64] _La Tribune Médicale_, 1905.

Hæmorrhage may require the plug being left _in situ_ for a few minutes,
so as to get a clear view of the depths of the nose. This is better
secured if the end of the gauze strips are first soaked in either
adrenalin or a 10% solution of hydrogen peroxide. In this way the main
mass of the ethmoid can be completely cleared away, the posterior
ethmoidal cells opened up, and the front wall of the sphenoidal sinus
broken down. Not infrequently the surgeon finds afterwards that this
latter cavity has been quite inadvertently, though successfully, opened.

=Operation under general anæsthesia.= Under a general anæsthetic this
operation can be even more satisfactorily carried out, but the surgeon
has to keep well in view the anatomical relations of the parts, and the
altered relationship to the horizontal position compared with what he is
more accustomed to with the patient sitting in the examination chair.
When chloroform is employed the interior of the nose is prepared in the
same way beforehand with adrenalin and cocaine; the patient is placed
horizontal on an operating table with his head and shoulders slightly
raised; the post-nasal space is plugged with a sponge (see p. 575); and
the tongue is drawn forward with a clip (Fig. 314) so that the
administration of the anæsthetic through the mouth is quite
uninterrupted. This method allows the surgeon to operate deliberately,
generally with the hæmorrhage under easy control, the field of operation
well illuminated, and no anxiety in regard to the anæsthetic.

[Illustration: FIG. 314. TONGUE CLIP. Keeps the tongue drawn forwards to
allow of general anæsthesia, when the post-nasal space is plugged.]

The removal of polypoid ethmoid can thus be completely carried out. With
this method I have removed at one sitting a mass of diseased ethmoid
which weighed four ounces.[65] It also permits the introduction of the
operator’s little finger to some distance, so as to detect polypoid or
carious surfaces.

[65] _Proc. Laryn. Soc. Lond._, 1907, xiv, p. 106.

With a ring-knife any irregular spicules or projections can be smoothed
down. The ring-knife--or a Volkmann’s spoon--is carefully introduced
behind a mass of growth, and then pulled briskly out through the nose
while hugging its outer wall. The nasal roof should be diligently
respected.

When the operation has been completed the post-nasal plug is removed,
and it is well to pass the forefinger of the left hand well up into the
posterior choanæ to detect and push forwards any masses of growth which
may have been driven backwards.

Hæmorrhage generally ceases with the usual remedies (see p. 576). It is
better to avoid all plugs.

=Dangers and complications.= This operation in careless or inexperienced
hands is not free from risks. The chief danger is from injury to the
cribriform plate, as any damage in this area, occurring in the septic
conditions which generally call for operation, is generally followed by
fatal meningitis.

In addition to the usual precautions, particular attention should be
paid while manœuvring in the anterior part of the space between the
septum and the outer nasal wall. Here the punch-forceps are not directed
backwards against the main mass of the sphenoid, but, as the head has to
be extended in order to approach the anterior area, they follow an
obliquely upward direction which brings them into dangerous proximity
with the floor of the cranial fossa--which dips down lower in front than
it does posteriorly. Great care, therefore, is taken to avoid any
thrusting or boring movements with the forceps. They are first made to
press outwards as much as possible the opposing walls of this narrow
region, so that polypoid masses can fall between the blades under good
inspection.

Occasionally the os planum is perforated, resulting in emphysema of the
eyelids or an ecchymosis like a ‘black eye’. An orbital abscess may
follow (Lack).


METHODS OF OBTAINING DIRECT ACCESS TO THE NASAL CAVITIES AND
NASO-PHARYNX

LATERAL RHINOTOMY, OR MOURE’S OPERATION

Direct inspection and treatment of the deeper regions of the nose, the
naso-pharynx, the ethmoidal labyrinth, and the neighbouring area of the
maxillary sinus, is well secured by the following operation, which has
been fully described by Moure of Bordeaux.[66]

[66] Moure, _Revue hebdomadaire de Laryngologie_, October 4, 1902;
Duverger, ibid., September 2, 1905.

=Indications.= This operation is particularly suitable for malignant
growths originating in the upper or inner walls of the maxillary sinus,
the ethmoidal labyrinth, the deeper regions of the nose, the
naso-pharynx, or the sphenoid. It might be required for very vascular
naso-pharyngeal fibromata with extensive prolongations. It is very
suitable for necrosis--generally syphilitic--of the sphenoid when
threatening the base of the brain.

For malignant growths in the regions mentioned, this route is
particularly suitable, if, of course, the limitation of the growth and
the absence of secondary infection justify intervention. The large space
formed by throwing the nose and antrum into one cavity gives a freer
field than removal of the superior maxilla, without the disfigurement
and tendency to recurrence so apt to be associated with this latter
operation, since it seldom includes removal of the ethmoid, which is the
usual seat of origin of the disease. In Moure’s operation the functions
of the eye, and of the nerves and muscles of the face, are not
interfered with, nor are there those difficulties with phonation and
deglutition which are left by removal of the upper jaw.

The interior of the nose is prepared with adrenalin and cocaine (see p.
572), chloroform is administered, and a sponge is packed into the
naso-pharynx (see p. 575).

=Operation.= An incision is made from the inner border of the eyebrow,
along the side of the nose, until it enters the lower margin of the
nasal orifice. A second incision, starting from the same spot above, is
next carried round the lower margin of the orbit and outwards as far as
the malar eminence (Fig. 315).

[Illustration: FIG. 315. INCISIONS FOR LATERAL RHINOTOMY (MOURE’S
OPERATION).]

The lobule of the nose is then detached, so that the fleshy parts of the
nose can be thrown over to the opposite side, while a triangular flap is
turned downwards and outwards. With a raspatory the nasal process of the
frontal bone, the nasal bone, the ascending process of the superior
maxilla, and the canine fossa are next exposed. The lachrymal sac is
carefully defined and retracted. A chisel is first driven through the
superior maxilla, close to its junction with the malar bone, but
avoiding the infra-orbital nerve, and the section is carried downwards
across the canine fossa until it reaches the alveolar border (Fig. 316).
From the lower extremity of this incision--which of course enters the
maxillary sinus--the bone which separates it from the pyriform fossa is
broken through with stout forceps. In this way the antro-nasal wall is
detached close to the floor of the nose, and can be removed together
with the inferior turbinal. The nasal bone itself is next removed,
together with part of the lachrymal bone and the nasal process of the
frontal. Finally the middle turbinal and lateral mass of the ethmoid are
removed with punch-forceps (Grünwald’s or Luc’s), Volkmann’s sharp
spoons, or a ring-knife.

[Illustration: FIG. 316. THE AREA OF BONE REMOVED IN LATERAL RHINOTOMY.
The flaps have been retracted, and the dotted lines show where the bones
are chiselled through.]

A gouge, or Killian’s eye protector (Fig. 342), is then slipped inwards
and downwards at the upper part of this opening until it comes in
contact with the body of the sphenoid. An assistant holds it closely
parallel to the cribriform plate, where it acts as a protector. With a
large sharp spoon, acting from above downwards and forwards, the
ethmoidal labyrinth can be cleared away with any tumour which may have
infiltrated it. The os planum, if not already destroyed, can be removed,
so as to obtain access to the orbit. Direct approach is given to the
sphenoidal sinus. The septum can be readily resected, but an endeavour
should always be made to preserve a strip of cartilage under the bridge
of the nose to prevent any external deformity (see p. 609). It is
needless to say that great care must be taken while working close to the
cribriform plate.

A malignant tumour can then be removed with forceps, sharp spoons, and
the fingers, any prolongations being followed into the naso-pharynx, the
maxillary sinus, the sphenoidal sinus, the lateral mass of the ethmoid,
or even into the pterygo-maxillary fossa. Success largely depends on the
care with which this curettage is carried out. It should be followed by
the application of caustics or Paquelin’s cautery.

[Illustration: FIG. 317. LATERAL RHINOTOMY. The side of the nose has
been removed, and direct access obtained to the upper and deeper nasal
regions.]

Bleeding is generally abundant at first. It can be controlled with
tampons and the use of hydrogen peroxide. When the whole of the
malignant growth has been removed, hæmorrhage generally stops
spontaneously. Firm packing of the wound is therefore unnecessary and is
best avoided. The large cavity is filled with one long strip of 1-inch
ribbon gauze, which is left projecting from the nostril, and the skin
incisions are carefully brought together with silkworm-gut sutures.
Healing takes place by first intention. There may be a little flattening
of the side of the nose, but there is no disfigurement, and a few months
afterwards it is difficult to detect any trace of the operation. The
strip of gauze is removed in 24 to 48 hours, and simple intranasal
cleansing measures are then instituted (see p. 579).


ROUGE’S OPERATION (SUBLABIAL RHINOTOMY)

No special instruments are required for this operation. Full
illumination--with a Clar’s mirror or frontal search-light (see p.
571)--is particularly necessary.

In addition to the usual preparations, the mouth, teeth, and gums should
be purified as much as possible beforehand.

General anæsthesia, preferably with chloroform, is required.

=Indications.= With the progress of rhinology the occasions for invading
the nasal chambers otherwise than by the natural orifices have steadily
diminished. Rouge’s operation was formerly employed in dealing with
deformities of the septum, in the treatment of ozœna, in lupus of the
nose, for the removal of simple mucous polypi, in operations on
naso-pharyngeal fibromata, or as a simple method of exploration. In all
these circumstances it is now uncalled for, as we are possessed of
simpler, safer, and more effective methods.

In more modern times it has been advocated as a route of approach to the
accessory cavities of the nose by some authors, but this proposition has
not met with general support.

The chief indications for Rouge’s operation are as follows:--

1. Very large sequestra. The majority of syphilitic sequestra can be
removed through the natural orifice. In some cases they can be broken up
after being mobilized and then removed through the nostrils. If still
impossible of extraction Rouge’s operation is indicated.

2. Osteomata are sometimes too large to be extracted through the natural
orifice, and as they are much too hard to break up _in situ_, this
operation is clearly indicated.

3. Malignant growths.

=Operation.= Standing behind the head of the patient, an assistant
seizes the extremities of the upper lip between the forefinger and thumb
of each hand, so as to turn it up against the nostrils and present its
mucous surface. A small packet of loose gauze is placed at each corner
of the mouth, to be handy for stanching any bleeding. An incision is
then made across the gum, a little below the gingivo-labial fold, from
the first upper molar on one side to the other (Fig. 318). This is
carried right down to the bone.

With a raspatory the soft parts can be easily and rapidly separated up,
so as to bring the orifice of each nasal chamber into view. With a pair
of scissors curved on the flat the cartilage of the septum is next
detached from the nasal maxillary spine, or the latter can be detached
with a chisel and hammer (Fig. 319). The assistant is now able to pull
the everted lip with the fleshy parts of the nose further up on to the
face, fully exposing the pyriform orifice of the nasal chambers, with
part of the anterior wall of the superior maxilla exposed on each side.

[Illustration: FIG. 318. ROUGE’S OPERATION. _First stage._ The upper lip
is everted and retracted by an assistant standing behind the patient’s
head. The dotted line indicates the line of incision.]

The conditions met with are then dealt with as required. Hæmorrhage
gives little trouble, and can generally be checked by pressure with
strips of gauze, possibly supplemented by the use of peroxide of
hydrogen. When the operation has been completed the everted lip is
turned down, and falls into place, where it can be secured by a few
catgut sutures.

=After-treatment.= Two pads of cotton-wool over the upper lip, to right
and left of the nasal openings, will give relief and secure healing of
the wound by first intention. The mouth should be kept as clean as
possible, and cleansing measures to the nasal chambers will be required
in proportion to the amount of destruction of its self-cleansing mucous
membrane.

=Advantages.= This operation has several advantages:--

(_a_) It is not difficult of execution, and can be carried out with a
scalpel and a raspatory.

[Illustration: FIG. 319. ROUGE’S OPERATION. _Second stage._ The soft
parts are retracted.]

(_b_) It gives a free access to the floor of the nose and the anterior
part of the nasal fossæ. The vestibule, the natural orifice of the nose,
only measures 20 millimetres by 7 to 8 millimetres. Rouge’s operation
exposes an orifice measuring 3-1/2 centimetres by 2 centimetres. The
posterior margin of the septum, instead of being 8 centimetres distant
from the outside, is now brought within a reach of 5 centimetres. The
floor of the nose lies on a lower level than that of the vestibular
entrance, and is wider some distance in than it is at the orifice. By
means of this operation the whole floor comes into clear view, and the
exit from the nasal chambers becomes the widest part of the nose.

(_c_) The bones of the face are not interfered with, and the amount of
traumatism is slight.

(_d_) Bleeding, which is so apt to be troublesome in operations through
the skin of the face, is less and is easily controlled.

(_e_) The patient can be assured that there will not only be no
disfigurement, but not even the slightest scar on the face.

(_f_) The operation can be repeated without any disfiguring scars. In
operations upon the nose through the face the cicatrix becomes more
marked with each intervention.


COMBINATION OF MOURE’S AND ROUGE’S OPERATIONS

The two methods above described can be combined if necessary. This would
be called for particularly in growths so large that they could not be
attacked through the narrow vestibule of the nose, and for those in
which the attachment is evidently in the ethmoidal region. This
combination might be called for in any large innocent or malignant
growth.


EXTENSION OF ROUGE’S OPERATION TO ALLOW OF ACCESS TO THE MAXILLARY
ANTRUM

When the growth involves both the nasal cavity and the maxillary sinus
Rouge’s operation can be extended so as to form part of the Caldwell-Luc
operation (see p. 631).

The latter operation is modified as suggested by Denker (Fig. 332),
_i.e._ the opening through the canine fossa is extended forwards until
the nasal cavity is opened through the pyriform opening. This will give
free access to the large cavity formed by throwing the antrum and the
nasal chamber on the same side into one easily inspected space (Fig.
332). Hæmorrhage gives no cause for anxiety, there is no disfigurement,
the original root of the implantation can be eradicated, and, if
necessary, the operation can be repeated without difficulty. If the
growth extends upwards and inwards to the ethmoidal region this
infralabial opening can be combined with Moure’s operation.

=Indications.= This operation is suitable for any form of growth
invading both the antrum and nasal cavities, and is therefore generally
called for in malignant growths.


OTHER METHODS

The other methods for obtaining access to the nasal cavity through the
face--described as the methods of Hippocrates, Syme, Dupuytren,
Langenbeck, Lawrence, Ollier, &c.--are now only of historical interest.
They all leave a scar on the face; bleeding is troublesome; they do not
give a greatly enlarged field; and most of them do not bring the seat of
disease any closer. With the advances made by rhinology the necessity
for intervention through the face has become more infrequent.




CHAPTER V

OPERATIONS UPON THE ACCESSORY NASAL SINUSES


OPERATIONS UPON THE MAXILLARY SINUS

CATHETERIZING THE MAXILLARY SINUS

It is rarely possible to enter the antrum through its natural ostium.
The attempt may be made after the local use of cocaine and adrenalin
(Fig. 320).

[Illustration: FIG. 320. CATHETERIZING THE MAXILLARY SINUS.]


PUNCTURING THE MAXILLARY SINUS FROM THE NOSE

=Indications.= It is chiefly employed as a diagnostic test. As a
curative measure it is seldom successful except in comparatively recent
infection. If the case be uncomplicated by suppuration in other
cavities, if the teeth in the upper jaw on the same side be intact, and
if the patient be anxious to avoid more severe measures and be willing
to undergo the discomfort of a daily puncture, lavage has been reported
as successful when repeated 27 times, even in a case with a history of
17 years’ duration.[67] But under the circumstances just mentioned it
is wiser to recommend the establishment of an antro-nasal communication
(see p. 637).

[67] Koenig. _Soc. paris. de Laryn._, 1905, 30 juin.

[Illustration: FIG. 321. LICHTWITZ’S AND MORITZ SCHMIDT’S ANTRUM
NEEDLES.]

[Illustration: FIG. 322. PUNCTURING THE MAXILLARY SINUS. The dotted part
represents the portion of the exploring needle which passes under cover
of the inferior turbinal.]

=Operation.= This is done under local anæsthesia from the inferior
meatus. One pledget of cotton-wool, soaked in cocaine and adrenalin, is
carefully tucked under the inferior turbinal on the affected side, and
another is applied to the septum. At the end of 20 minutes a straight
Lichtwitz’s or curved Moritz Schmidt’s (Fig. 321) hollow needle is
passed under the inferior turbinal and introduced upwards and outwards
as near as possible to the centre of its attachment. The handle of the
needle is tilted against the cartilaginous septum, while the point is
directed towards the malar eminence. When it is felt to encounter the
thin, membranous part of the antro-nasal wall it is easily thrust
through (Fig. 322).

While the nasal cavity is kept under inspection, air is blown through
the needle, and any secretion can be observed escaping from under the
centre of the middle turbinal. This douche of air is then followed by an
irrigation of warm normal saline solution. In an acute case this lavage
can be repeated daily until the symptoms of tension are relieved, or
until the secretion begins to escape spontaneously.[68]

[68] Logan Turner, _Edinburgh Medical Journal_, August, 1906, p. 152.

Puncturing the maxillary sinus from the middle meatus incurs a greater
risk of striking the orbit and is not so likely to reveal a small amount
of thick secretion on the floor of the cavity.

[Illustration: FIG. 323. ANTRUM DRILLS.]

[Illustration: FIG. 324. SOLID RUBBER OBTURATORS. Used in alveolar
drainage of the maxillary sinus.]

[Illustration: FIG. 325. ANTRUM NOZZLE.]


PUNCTURING THE MAXILLARY SINUS FROM THE ALVEOLAR MARGIN

This is one of the oldest methods of drainage. It is less frequently
employed nowadays, partly because carious teeth and empty sockets are
not so commonly met with, and partly because the results have not proved
very satisfactory.

=Indications.= The operation is useful as a diagnostic or palliative
measure. In cases of unilateral multi-sinusitis, if a suitable tooth
socket be available, the alveolar operation serves both to determine the
condition of the maxillary sinus and to establish drainage, while the
other cavities are being investigated or treated. In patients who are
too old or feeble to endure more radical measures, or who decline them,
the obturator may be left in indefinitely. In that case, if the
neighbouring teeth be intact, a solid gold plug should be fitted to the
denture bearing the false first molar. During the night this is
exchanged for the soft rubber plug. If several teeth be missing it is
more comfortable to have the obturator and denture separate--the latter
being made with a setting to receive the flange.

An anæsthetic should always be given. Nitrous oxide gas or chloride of
ethyl are generally recommended for this short operation, but in cases
that present any difficulty it is better to follow the nitrous oxide
with ether, or the chloride of ethyl with chloroform.

=Operation.= The most suitable tooth socket is that of the first molar,
but if this be not available, that of the second bicuspid or second
molar may be employed. If a tooth in one of those situations be carious,
or be suspected as the cause of the sinusitis, its extraction and the
drilling of the alveolus may be carried out under the same anæsthetic.
The patient can be recumbent on an operating table, or lying back in a
dentist’s chair. A small antrum drill (Fig. 323) is grasped in the hand
as a bradawl is held, with the forefinger lying along it to within 1 to
1-1/2 inches from the end, where it acts as a stop to prevent the
instrument from plunging too deeply into the sinus. The drill is held
vertically against the alveolar border, and with a few quick, rotatory
thrusts is pushed into the cavity. The inner of the tooth sockets is
selected. If required, the hole can be enlarged by a similar instrument
of a larger bore. A plug, which fits firmly into the opening, is
introduced, and nothing further is required for that day. A solid
vulcanite obturator is recommended. It should be left _in situ_ for two
or three days, when it is removed to allow of the cavity being syringed
through, and is then replaced by a solid, soft rubber plug, of a
somewhat smaller diameter (Fig. 324). The vulcanite obturator is better
for establishing the canal; if removed too soon it may be difficult to
replace it, and manipulation may set up severe neuralgia. A small
size--No. 6 or 7--is quite sufficient.

[Illustration: FIG. 326. WASHING OUT THE MAXILLARY SINUS FROM AN
ALVEOLAR OPENING.]

At the end of two or three days lavage of the cavity is gradually
instituted. A pint of warm sterile normal saline solution is sent
through the cavity by a Higginson’s syringe, fitted with a suitable
nozzle (Fig. 325). As the stream issues from the nose it is received in
a black vulcanite tray, which readily demonstrates the colour, quality,
and quantity of antral secretion (Fig. 326). When the pint of liquid is
finished, air is blown through, so as to leave the sinus as dry as
possible. The patient should be advised to replace the rubber obturator,
properly cleaned and purified, as soon as possible. If this be
neglected--for even as short a time as 5 minutes--the soft tissues may
obstruct the channel so as to render the reintroduction painful and
perhaps impossible. Another useful warning is not to wear a plug so long
as to allow of the flanges being worn away, and so risk the penetration
of the rubber tube into the cavity.

The syringing should at first be daily, even twice a day if necessary,
and then gradually diminished in frequency, until after the lapse of a
week it is found that the maxillary sinus is quite free of any pus or
flocculent mucus. By changing the obturator daily the patient can
readily tell whether a washing out is required. When three to six months
have passed without any trace of secretion, the empyema may be
considered cured. This is the more likely if a formerly obscure sinus
becomes translucent, and if the patient passes through a ‘cold’ without
suppuration beginning in it again. A trifling amount of discharge is
sometimes kept up by the mere presence of the obturator.

If the saline solution fails to arrest the discharge permanently, I have
rarely found that any other lotion is more effective. Strong antiseptic
solutions are too irritating; milder ones, like boric lotion,
permanganate of potash, weak mercurial lotions, &c., are without effect.
If the discharge remain thick and offensive, peroxide of hydrogen may be
added to the salt solution in the proportion of 2 vols. %. As an
astringent, sulphate or chloride of zinc may be tried, in the proportion
of 1 grain to the ounce; or the cavity may occasionally be washed out
with a 2% solution of argyrol or nitrate of silver.

In cases where a cure has been obtained, the obturator is first
discontinued during the night and is then exchanged for one of smaller
size. The opening in nearly all cases will close spontaneously.
Occasionally the track may be stimulated with nitrate of silver, pure
carbolic acid, or a small curette.

=Results.= This method of treatment is only curative in uncomplicated
cases limited strictly to the maxillary sinus. If all suppuration has
not disappeared before the end of three months, a complete cure is not
to be expected by persevering longer.


OPERATION THROUGH THE CANINE FOSSA ONLY

_Desault’s operation._ Previously to the introduction of the
Caldwell-Luc operation it was customary to make an opening into the
maxillary sinus from the canine fossa, and to curette, drain, pack, and
carry out all subsequent treatment through the buccal orifice. The
reinfection of the cavity from the mouth was, of course, inevitable: the
treatment was prolonged and unpleasant: and the results were so
unsatisfactory that the method has now been abandoned in favour of one
or other of the operations to be described.


THE CALDWELL-LUC RADICAL OPERATION

=Indications.= This is the favourite operation in well-marked chronic
empyema of the antrum.

The mouth, teeth, and gums are purified as thoroughly as possible. The
face, with any moustache or beard, should also be well cleansed. The
nose on the affected side is prepared with cocaine and adrenalin (see p.
572).

[Illustration: FIG. 327. THE INCISION IN THE CALDWELL-LUC OPERATION UPON
THE MAXILLARY SINUS.]

On the Continent this operation is sometimes carried out under local
anæsthesia, but chloroform is generally employed. When the patient is
unconscious, a sponge is packed in the post-nasal space (see p. 575),
the tongue is drawn forward with a tongue clip (Fig. 314), and the
chloroform administered from a Junker’s apparatus.

=Operation.= The surgeon, armed as usual with a forehead electric
search-light or Clar’s mirror (Figs. 282, 283), stands on the affected
side. In addition to the post-nasal sponge, another is inserted far
back between the molars on the side to be operated. This cheek sponge
prevents any blood from running down into the pharynx and requires
changing frequently.

The cheek being well retracted by an assistant, an incision is made half
a centimetre below the gingivo-labial fold, extending from the first
molar to the canine tooth (Fig. 327). It is carried down to the bone, so
that the muco-periosteum can quickly be separated upwards, exposing the
canine fossa. With hammer and chisel a circular piece of the wall is
then cut through, measuring about half an inch across, and the opening
is enlarged with bone-forceps or burr sufficiently to admit the
surgeon’s little finger.

[Illustration: FIG. 328. THE CALDWELL-LUC OPERATION UPON THE MAXILLARY
SINUS. Breaking through the antro-nasal wall below the level of
attachment of the inferior turbinal. The opening has been purposely
represented coming too far forward in order to include the view of the
antro-nasal wall.]

The first opening of the sinus is frequently accompanied by free
bleeding. This soon ceases, particularly if the cavity is packed for a
little while with a strip of 2-inch ribbon gauze. During the operation,
pieces of this gauze, 1 to 1-1/2 yards long, prove very useful in
checking any oozing and allowing a clear inspection of the walls of the
sinus. They may be dipped in adrenalin, or, if the bleeding is sharp, in
a 10% solution of peroxide of hydrogen, and left in place for a few
minutes, while iced water is freely applied to the face and neck. As
soon as the bony wall has been removed, the diseased mucous membrane
presents in the opening in irregular, polypoid, bluish-greyish masses,
bathed in pus which may be highly fœtid. The diseased mucous membrane
should be carefully plucked out of the cavity with a pair of Grünwald’s
forceps, supplemented by the use of a small ring curette, and guided by
the eye and the touch of the operator’s little finger. Some surgeons
recommend that the whole mucous lining of the sinus be carefully and
completely removed, and the walls scraped down until they are white and
bare. Unless the whole mucosa is diseased, this hardly seems necessary,
particularly if a free opening be made into the nose. Polypoid masses
and degenerate mucous membrane are chiefly met with on the floor of the
antrum (in the crevices between the cusps of the teeth), on the inner
wall in the neighbourhood of the ethmoid, and in the recess in the malar
region, and it is to these areas that attention should be directed.

[Illustration: FIG. 329. OPENING THE MAXILLARY SINUS FROM THE NOSE. This
is done with a Krause’s trochar and canula, after removal of the
anterior end of the inferior turbinal.]

The next step is the making of a free communication with the nose. If
the inferior turbinal is hypertrophied on the affected side, or comes so
low as to obstruct any access to the antro-nasal wall, its anterior
extremity should first be removed (see p. 587 and Fig. 289). It is
better to have done this a few weeks previously under cocaine. The
antro-nasal wall lying below the attachment of the inferior turbinal is
next attacked with a chisel, hammer, and punch-forceps (Fig. 330). This
can be done from the antral aspect, but I have always found it useful to
break it through first from the nose with Krause’s curved trochar and
canula. When the end of this makes its appearance in the sinus, it forms
a useful landmark (Fig. 329).

This antro-nasal opening should be made as large as possible, particular
care being taken to bring it well forward and to smooth down the
remains of the ridge separating the nose from the sinus. The opening
should allow of the surgeon’s little finger passing freely from the
antrum into the floor of the nose, and _vice versa_ (Fig. 328).

Whenever the ethmoid is diseased, as it often is in maxillary sinusitis,
that part of it which bounds the inner antral walls should be punched
away. The middle turbinal, in that case, will probably have been already
removed.

[Illustration: FIG. 330. CARWARDINE’S PUNCH-FORCEPS. Used in breaking
down the lower antro-nasal wall.]

Some surgeons recommend that the infected corners of the antrum be now
wiped out with a solution of chloride of zinc (40 grains to ℥j), and the
cavity packed with a strip of gauze which is led out through the
nostril, whence it is removed at the end of 24 to 48 hours. The use of
this irritant seems inadvisable. The sinus may be syringed out with warm
saline solution, and temporarily packed with a long strip of iodoform
gauze, while the operation is being completed. The wound in the cheek
can be closed with a couple of catgut sutures; but if there has been no
destruction of the bony alveolus, this is unnecessary: the soft parts
will fall into natural and complete apposition. The post-nasal sponge is
removed, the iodoform ribbon gauze is withdrawn through the nostril, and
the patient is put back to bed with the affected side uppermost.

=After-treatment.= A large pad of cotton-wool, bound firmly to the cheek
over the region of the canine fossa, will relieve pain and help to keep
the edges of the wound together. Nourishment should be fluid for the
first three days, and taken from a feeding-cup from the opposite corner
of the mouth. As a rule, there is no reaction, and the temperature
seldom rises above 100° F. A little puffiness below the orbit will soon
subside, and pain is relieved by a few doses of phenacetin, aspirin,
pyramidon, or some similar anti-neuralgic. The patient is frequently up
and out in a few days.

As a rule, the less the local after-treatment the better. The nose may
require to be cleansed with the usual alkaline lotion (see p. 579). If
secretion hangs about the antro-nasal opening, or collects in the
cavity, the latter should be washed out once or twice daily until it
ceases. A short length (4-1/2 in.), but large bore, silver Eustachian
catheter is passed from the nose into the maxillary sinus, and a pint of
warm saline solution is sent through it with a Higginson’s syringe. The
patient soon learns to do this for himself, and it may have to be
continued for a few weeks. If the discharge persists, the cavity may be
painted over with a solution of nitrate of silver, or a strip of ribbon
gauze can be moistened with argyrol solution (25%) and passed through
the antro-nasal opening into the sinus, where it is left for a few
hours.

[Illustration: FIG. 331. THE OPENING INTO THE MAXILLARY SINUS FROM THE
INFERIOR MEATUS OF THE NOSE. The anterior extremity of the inferior
turbinal has been amputated. The opening can be extended backwards,
level with the floor of the nose, and under cover of the inferior
turbinal.]

=Results.= In cases of chronic empyema of the maxillary sinus this
operation is very successful. Failure may be due to overlooking stumps
of teeth within the cavity, and from leaving detached pieces of the
carious wall within it. If the pyogenic polypoid mucous membrane be not
carefully removed, suppuration may persist. The corner which is
difficult to reach is the acute anterior one. At the same time, an
unnecessary denudation of the cavity will delay healing, and the scar
tissue which more or less occupies the sinus will then tend to be
irregular and dry, instead of being smooth and moist. Removal of too
much of the inferior turbinal is apt to induce a scabby condition.

But persistence of nasal suppuration after this operation is generally
found to be due to overlooked disease in some other sinus. The ethmoid
is so frequently affected that it should always be carefully explored,
and treated either before or at the time of the operation upon the
maxillary sinus. Any suspicious-looking cells can be cleared away under
cocaine during convalescence. Suppuration in the frontal sinus will have
generally been excluded beforehand. It is perhaps more common for
reinfection from the sphenoidal sinus to be overlooked.

[Illustration: FIG. 332. DENKER’S OPERATION. This is an operation for
gaining access to the maxillary antrum and the lower part of the nasal
cavity on the same side. The incision through the mucous membrane, and
the steps of the operation, are a combination of the operations of Rouge
and Caldwell-Luc.]

=Dangers.= Operation upon this sinus is generally regarded as quite free
from the risk of cerebral infection. This undeniably is so, when the
antral empyema is uncomplicated by suppuration in other cavities, but
the operation is not free from risk if they are also infected. An
operation upon one maxillary sinus has been known, even in the most
skilful hands, to cause death by meningitis or diffuse septic
osteomyelitis of the cranium. _Post-mortem_ examinations show that this
disaster was due to infection spreading upwards from an infected
ethmoid, frontal, or sphenoidal sinus, when local resistance had been
diminished, or the virulence of the organisms has been increased by the
surgical traumatism of the maxillary sinus.

Such risks are best avoided by determining the condition of all the
sinuses before commencing treatment of nasal suppuration. If a tooth
socket be available, the maxillary sinus should first be drained through
it, so as to diminish the septic intensity of the affection. The ethmoid
region, if diseased, is next treated (see p. 615). The sphenoidal
orifice should be enlarged if that cavity be diseased, and the frontal
sinus, if suppurating, should be operated on before the maxillary. If no
tooth socket be available, both frontal and maxillary sinuses can be
operated upon at the same sitting. Plugs are best avoided; communication
should be made as free as possible; stitches need not be employed; and
everything should be done to avoid retention and secure free drainage.

=Modification.= In the above operation the region which generally
requires to be denuded of mucous membrane is the rough floor--the
irregular surface lying over the cusps of the teeth. The ridge of the
antro-nasal opening is a situation in which secretion is apt to lodge
and dry into scabs. To overcome this drawback it has been suggested by
Bönninghaus that the muco-perichondrium of the outer part of the nasal
floor and the interior surface of the antro-nasal wall should be
carefully preserved in the form of a flap which is then laid down over
this bare area, and fixed there by a stitch and packing.

Another drawback of the Caldwell-Luc operation is that, although
inspection and treatment of the greater part of the maxillary sinus is
secured, still there are two corners which are not well exposed. They
are both on the floor of the antrum, the round posterior corner and the
narrow acute corner in front. The antro-nasal wall corresponding to
these two situations is not removed, and hence the corners are apt to
escape inspection at the time of the operation and free drainage
afterwards.

To avoid this Denker has proposed that the opening in the canine fossa
should be carried forward into the nose, and the opening in the
antro-nasal wall extended forwards to meet it. This allows of much more
complete inspection and treatment of the sinus cavity, and abolishes the
anterior angle. The flap of muco-perichondrium proposed by Bönninghaus
can also be much more easily manipulated. It is said that there is no
fear of disfigurement from the cheek falling in (Fig. 332).


DRAINAGE THROUGH THE NASAL WALL ONLY

It was long ago proposed by John Hunter, and later by Mikulicz and
Krause, that an opening should be made into the maxillary sinus from the
nose. This operation has latterly been developed by Claoué and Réthi,
and now has many supporters.

=Operation.= On the Continent it is frequently carried out under local
anæsthesia, but chloroform is generally required. If the inferior
turbinal comes down close to the floor of the nose, the anterior third
or half should be removed (see p. 587 and Fig. 289). The antro-nasal
wall lying below the attachment of the inferior turbinal is then broken
through with chisel and hammer, or a Krause’s trochar (Fig. 285), and
the opening enlarged with punch-forceps (Fig. 286). For the anterior
margin of the opening--the one most difficult to remove--special forceps
which cut forwards have been designed (Fig. 330).

The opening is large enough to allow the introduction of curettes and of
the application of treatment from the nose. The patient soon learns to
wash out the sinus for himself, with a silver Eustachian catheter and
Higginson’s syringe, as after the Caldwell-Luc operation.

=Results.= The advantages claimed for this operation are that it is
simple, quicker, and as effective as the one with the opening from the
canine fossa. But, of course, it does not allow any inspection, and only
a partial removal, of the diseased contents of the sinus.

Still the results obtained are so satisfactory,[69] that it seems
advisable to try it in the majority of cases as a necessary first step,
even if the Caldwell-Luc operation has to be completed later. But where
the case has a long history; marked obscurity on transillumination; a
foreign body in the sinus; or where the _Streptococcus pyogenes_ is the
virulent organism, or where the streptococcus is associated with the
presence of squamous epithelium and lymphocytes,[70] it adds little to
the gravity or complexity of the procedure if the canine fossa be opened
at the same time, the diseased cavity inspected, and everything
completed under the one anæsthesia.

[69] C. A. Parker, _Brit. Med. Journ._, October 10, 1908, p. 1099.

[70] Logan Turner, ibid., p. 1096.


OPERATIONS UPON THE FRONTAL SINUS

CATHETERIZING AND WASHING OUT THE FRONTAL SINUS

=Indications.= This method is indicated--

(i) As a first step in diagnosis and treatment.

(ii) To diminish the risk of retention and decrease virulence in those
patients where an external operation is not indicated or is declined.

(iii) It is rarely required for acute frontal sinusitis, although it
might be used in acute exacerbation of a chronic suppuration.

=Operation.= It is very seldom that it is possible to sound a frontal
sinus, unless the anterior ethmoidal cells have been broken down by
disease. When this has occurred--or when the anterior extremity of the
middle turbinal has been removed, as described on p. 592--the anterior
region of the middle meatus is well anæsthetized. Under good
illumination a thin silver canula is then introduced until it reaches
the middle meatus with its beak lying below and in front of the bulla
ethmoidalis. By depressing the hand the point of the instrument is then
directed upwards, forwards, and slightly outwards, until it slips into
the frontal cavity (Fig. 333). No force should be employed. The end of
the catheter is bent to suit the conditions met with. A bead of pus
exuding from the hiatus semilunaris will often serve as a useful guide.
If there be any uncertainty as to the catheter having entered the
frontal sinus, its exact situation can be determined by the Röntgen rays
(Figs. 334, 335).

[Illustration: FIG. 333. CATHETERIZING THE FRONTAL SINUS. The anterior
end of the middle turbinal has been removed.]

A Politzer’s inflation bag is now connected with the end of the frontal
canula, and air is blown through it. This will be heard gurgling through
the sinus, and if the anterior region of the middle meatus is at the
same time kept under observation, thick mucus or pus will be seen to be
driven out by it. The Politzer’s bag is then replaced by a syringe, and
a pint of warm sterile normal saline solution (ʒj to Oj) [Transcriber’s
note: Oj = one pint] is sent into the sinus, and as it returns is
received in a black vulcanite tray. The latter readily shows up the
presence of any flakes of mucus or pellets of pus. If successful, the
above proceeding can be repeated twice daily.

When the cavity can be catheterized from the nose it should be washed
out daily with liquids similar to those indicated for suppuration in the
maxillary antrum (see p. 630).

[Illustration: FIG. 334. RADIOGRAPH TO SHOW THE VALUE OF THE RÖNTGEN
RAYS. The canula might be thought to have entered the frontal sinus,
whereas the X-rays show that its point has only penetrated an ethmoidal
cell. Compare with the following figure.]

=Results.= I am very doubtful if a permanent cure is ever effected by
this treatment in a case of established chronic suppuration. In a case
in which I was certain that the suppuration was not of more than four
months’ duration intranasal treatment was a failure, although carried
out most carefully on 44 successive days.[71]

[71] _Proc. Royal Soc. Med._, 1907, December.

[Illustration: FIG. 335. RADIOGRAPH SHOWING CANULA IN THE FRONTAL
SINUS.]

The cause is very apparent whenever these sinuses come to be opened; the
cavity itself is generally stuffed with fungating mucosa, and the
fronto-ethmoidal cells--where the lavage never penetrates--are affected
in the same way.


OPENING THE FRONTAL SINUS IN ACUTE SUPPURATION

It is rare for this to be necessary. The contents of the cavity
generally make their way through the natural ostium, before any of the
bony walls give way. Still, the posterior (cerebral) wall may yield,
giving rise to meningitis or cerebral abscess. The treatment of this
complication is given on p. 650. The orbital wall may be penetrated,
with the formation of an orbital abscess which should be evacuated. It
is most uncommon of all for the anterior wall to give way. When this
does occur the abscess should be opened through an incision designed on
the principle given later on for chronic empyema (see p. 652).


KILLIAN’S OPERATION

At the present time the Killian operation is the one most generally
employed.

=Indications.= The indications for this operation are thus given by
Killian himself:--

1. Failure of other operations.

2. Presence of fistula or abscess, or indications of necrosis.

3. Symptoms of intracranial complications.

4. When in a case of chronic purulent frontal sinusitis there is pain
and fever with a fœtid discharge.

5. Persistent headache, particularly when associated with discomfort in
the region of the eye, and not relieved by intranasal treatment.

6. When the discharge from the sinus remains foul, in spite of repeated
irrigations.

7. When recurring groups of polypi are produced by the suppuration in
the frontal and ethmoidal cells.

8. When a simple purulent discharge is not relieved by careful
intranasal treatment, and the patient desires permanent relief by
radical operation.

A radiograph is taken and is an extremely useful help to indicate the
size and extent of the frontal sinus, and to prepare the surgeon for
meeting with troublesome orbito-ethmoidal cells.

As the ethmoid is diseased in nearly all cases it should be cleared away
at previous sittings, under cocaine or chloroform (see p. 615). Even
when healthy, the anterior extremity of the middle turbinal should be
amputated (see p. 592). If the antrum be also suppurating and a
suitable tooth socket be available, the alveolus will have been drilled
at one of these preliminary treatments. If the sphenoidal sinus be
suppurating, its orifice will have been enlarged.

One hour before the operation the strips of ribbon gauze, soaked in
adrenalin with the addition of 5% cocaine, are carefully laid all over
the mucous membrane of the nose on the affected side. The face,
moustache, and beard are well purified. When the patient is under
chloroform three pencils of tightly rolled cotton-wool are introduced
into the nose; one along the middle meatus, a second in front of the
inferior turbinal upwards towards the bridge of the nose, and the third
in the inferior meatus. The first two pledgets are useful afterwards for
anatomical definition, and the third keeps them in place. A sponge is
inserted in the post-nasal space (see p. 575).

[Illustration: FIG. 336. KILLIAN’S OPERATION UPON THE FRONTAL SINUS.
Shows the skin incision, with the transverse scratches made to ensure
correct coaptation of the flaps.]

=Operation.= There is no advantage in shaving off the eyebrow. It can be
thoroughly purified and helps to locate the skin incision; if removed,
it takes some time to grow again, and is apt not to correspond in size
with the eyebrow of the opposite side. The skin incision is first
defined by scratching through the cutis with the tip of the knife. It
starts at the outer end of the eyebrow, passes inwards along the very
centre of the eyebrow itself, and then sweeps downwards and outwards
over the side of the nose, to end on the cheek (Fig. 336). When the
whole extent has been marked out three or four cross scratches are
made. The object of this is to ensure correct coaptation of the flaps,
and to avoid any risk of disfigurement. Returning to the outer extremity
of the incision, it is now carried down through all the soft tissues
till it meets the periosteum. The flaps are retracted a little upwards
and downwards, while the free hæmorrhage is met with pressure forceps.
The periosteum incisions are now carefully planned. Starting again from
the outer corner the knife is drawn inwards parallel to, and slightly
above, the upper margin of the supra-orbital arch; but, instead of
curving round the inner end of the orbit, in the track of the skin
incision, it is kept straight along under the upper flap to end over the
glabella. The periosteum can now be reflected from the front of the
sinus, and pushed upwards with the skin on to the forehead. The lower
skin flap is detached and retracted downwards, until the inner third of
the supra-orbital arch is defined. The periosteal covering is next cut
through by carrying the knife along the lower border, but instead of
passing inwards parallel to the first periosteal incision this second
one sweeps down on to the side of the nose, in the track formed by the
skin incision (Fig. 337).

[Illustration: FIG. 337. KILLIAN’S OPERATION UPON THE FRONTAL SINUS. The
thick lines indicate the incisions through the periosteum.]

The periosteum is carefully peeled off the nasal process of the superior
maxilla, and turned down from the inner third of the supra-orbital
arch, exposing a triangular area of bone. The periosteum must be
carefully preserved over the inner part, to avoid the risk of necrosis
of the arch, which is converted into a bridge, the ‘Killian bridge’, by
the opening in bone below and above it.

The upper flap of soft parts, with the periosteum, is well retracted up
on to the forehead. The radiograph will have given an idea of the extent
to which the front wall of the sinus must be laid bare. With a chisel
and hammer the sinus is opened at its inner extremity. A good plan is to
employ Killian’s triangular curved chisel (Fig. 339) and to cut a trench
in the bone along the upper margin of the bridge. This trench is
gradually deepened at the inner end until the sinus is entered. The
entry is generally announced by the bulging upwards of the blue,
polypoid, pyogenic membrane into which the thin white delicate mucosa of
the cavity has been converted. The anterior wall is now completely
removed with hammer, chisel, and forceps. Those of Lombard, Horsley,
Hajek (Fig. 341), Jansen, Citelli (Fig. 340), or similar models enable
us to bevel down the margins of the cavity carefully as it slopes up on
to the forehead.

[Illustration: FIG. 338. PERIOSTEAL ELEVATORS.]

[Illustration: FIG. 339. KILLIAN’S TRIANGULAR CURVED CHISEL.]

The pyogenic membrane is now carefully plucked away with a pair of
Grünwald’s forceps. I never find it necessary to curette the cavity,
which must always be a risky proceeding. Small pledgets of ribbon gauze,
if gently rubbed along the surface and into the corners, will detach
every scrap of diseased mucosa.

The septum separating the two frontal sinuses may be found to be
defective. The opening through the eyebrow on one side may open into a
cavity which communicates only with the nasal cavity of the opposite
side--one sinus being very large and extending far beyond the middle
line, while the other is quite small. Or only one frontal cavity may be
present. An extensive acquaintance with the surgical anatomy of the
region is required to prepare the surgeon for encountering these and
other irregularities, and the systematic use of radiography will prevent
him from being taken by surprise.

[Illustration: FIG. 340. CITELLI’S BONE-FORCEPS.]

[Illustration: FIG. 341. HAJEK’S BONE-FORCEPS.]

The next step is to make the opening below the bridge. The exposed
surface of the nasal process of the superior maxilla is cut through with
the triangular chisel. The opening is enlarged with bone-forceps until
free access is obtained to the anterior ethmoidal cells. The pledgets of
cotton-wool placed in the nose at the beginning of the operation now
come in to help as guides. The periosteum is further elevated from the
lachrymal bone above its groove, from the orbital plate of the ethmoid
as far back as the anterior ethmoidal vessels, and from the orbital
plate of the frontal bone below the bridge and extending outwards to the
trochlear attachment and the supra-orbital notch. During this proceeding
the contents of the orbit are protected from pressure by several folds
of gauze, and are carefully retracted outwards by Killian’s protector.
The area of bone which can now be clipped away comprises parts of the
lachrymal, of the lamina papyracea, and of the floor of the frontal
sinus. The whole of the floor of the sinus must be removed, either from
above the bridge or from below. If this cannot be done without anxiety
as regards the attachment of the pulley of the superior oblique, it is
better to risk this than to leave pus-secreting pockets of
orbito-ethmoidal cells cut off from drainage in the roof of the orbit.
But the pulley of the superior oblique should never be divided from its
attachment to the rim of the orbit. It is much safer to reflect the
periosteum further outwards and downwards from the lower border of the
Killian bridge. In doing this the pulley of the superior oblique is
detached with it; any diplopia, most noticeable on looking downwards and
outwards, is generally temporary; and as a rule it will disappear when
the swelling subsides and the periosteum gets back to its anchorage
(Fig. 342).

[Illustration: FIG. 342. KILLIAN’S OPERATION UPON THE FRONTAL SINUS. The
periosteum has been preserved on the bridge. Above this the frontal
sinus is exposed: at its inner (nasal) extremity the frontal bulla is
indicated, mounting up into the cavity; at the outer extremity an arrow
indicates the orifice of a fronto-orbital cell which should be opened
up. The periosteum lying above the bridge has been retracted up with the
soft parts on to the forehead. Below the bridge is the opening to the
ethmoidal region. The curved retractor is protecting the eyeball.]

It is this part of the operation which is the most delicate, tedious,
and important. It is very common to meet with irregularities. The
orbital recess of the frontal sinus itself may run back in the roof of
the orbit nearly as far as the foramen opticum. One or two galleries may
be met with in the roof of the orbit--prolongations of orbito-ethmoidal
cells--passing outwards as far as the temporal end of the eyebrow. Their
presence can only be revealed after removal of the floor of the frontal
sinus proper, and in this way two or three bony dissepiments may have to
be removed before the orbital fat arises, as it should do, to occupy the
lower part of the exposed frontal sinus. In this part of the operation
much help is obtained by the careful use of a probe, by frequently
securing a field free from bleeding by pressure with adrenalin or
peroxide, and by the knowledge previously gained by skiagraphy.

If the Röntgen rays have shown that the frontal sinus does not extend
above the level of the bridge, or if radiography be not available and
there is any uncertainty as to the extent of the cavity, this lower
opening should be made first.

In the inner part of the large orifice which has been made below the
bridge the deeper ethmoid cells can be treated, and the sphenoidal
ostium is much nearer than when viewed from the introitus narium, so
that it is easy to enlarge it and deal with the contents.

Now, as throughout the operation, great care must be taken to shield the
eyeball with gauze pads and the protector. The hanging pressure forceps
are apt to be pushed against the globe.

The whole area of operation is next carefully cleaned with warm normal
saline solution. Any projecting corners or loose spicules of bone are
removed. If any point of pus should show up it must be carefully
followed to its source. The cotton-wool pledgets are removed from the
nose. The pressure forceps are twisted off, and any vessels that require
it are ligatured. A strip of ribbon gauze is loosely packed in the lower
part of the enlarged fronto-ethmoidal space, and the end is led down to
the nasal orifice. The flaps are brought together, and care is taken
that the reflected periosteum is pulled back with them. Formerly Killian
in the majority of cases used to sew up the whole wound at once. He now
agrees that it is safer to leave the external angle with a small
drainage tube running inwards and downwards to the area of the
fronto-ethmoidal cells. The inner part of the incision in the eyebrow,
and all the part lying below the bridge, can be closed. Killian employs
aluminium-bronze wire, and a metal suture seems preferable, as the
contamination of the wound edges makes stitch-abscess not uncommon.

Secondary suture--on the second or third day--is reserved by Killian for
cases when (1) the history or appearance of the mucosa indicates a
recent exacerbation, (2) there is a history of erysipelas, (3) the pus
is very fœtid, (4) there is any history of a tendency to wound
complications, or (5) there is marked invasion of the diploë in the
frontal bone.

Double cyanide gauze, rung out of boric lotion and covered with a good
supporting pad of cotton-wool, is then put on. But when there is any
question of intracranial complication, when the pus is fœtid or there is
any necrosis, and when the surgeon is forced to operate during an acute
exacerbation, it is better to apply warm boric fomentations and leave
the upper and outer supra-orbital part of the incision freely open.

=After-treatment.= The patient is put to bed on the sound side, so as to
assist drainage. He is advised not to blow the nose, but to hawk as much
of the secretion as possible backwards and then expectorate it. The
gauze drain is removed from the nose at the end of twenty-four hours,
and is not renewed. The drainage tube at the temporal end of the
incision is changed at the end of forty-eight hours, and afterwards is
removed and cleansed daily. The dressing is also changed daily, after
the first forty-eight hours, so as to keep a careful watch for any
retention. On the fifth day the sutures can be removed, and soon
afterwards the dressing can be discontinued and the eye left uncovered.
Intranasal treatment should be avoided for a while. But after two or
three weeks the granulating surface behind the bridge is painted
occasionally with a 2 to 3% solution of nitrate of silver. Any crusts
are removed after soaking with peroxide of hydrogen.

=Complications and dangers.= The operation is not free from danger.
Latent cerebral trouble connected with the sinus may be roused into
activity by the local traumatism, however skilfully effected. The shock,
or the lowered local resistance, may stimulate a latent infection in
neighbouring sinuses, and also weaken the lines of defence protecting
the cranial cavity.

In 1905 Logan Turner collected the record of twenty-four deaths which
had occurred after operation on the frontal sinus.[72] This number has
been exceeded by the fatalities since published and the much greater
number which have never been recorded.[73] The chief dangers are (1) a
spreading septic osteomyelitis, (2) meningitis, and (3) abscess in the
frontal cerebral lobe.

[72] Logan Turner, _Edinburgh Medical Journal_, 1905, March.

[73] _Die Komplikationen der Stirnhöhlenentzündungen_, von P. H. Gerber,
Berlin: S. Karger, 1908.

_Infection of the bone_ is indicated chiefly by a puffy, tender swelling
on the forehead or temple, adjoining the upper flap. There may be
little or no rise of temperature, and little complaint on the part of
the patient. But no time should be lost in laying the wound freely open,
searching for any shut-off focus of pus, and applying hot boric
fomentations diligently. Once infection is established in the bone it
may be impossible to stay its progress, even by the most thorough
removal of diseased tissue: but the effort should be made.[74]

[74] H. Tilley, _Lancet_, 1899, August 19, p. 534, and _Edinburgh
Medical Journal_, 1905, March, in paper of Logan Turner’s.

_Meningitis_ is an equally dangerous complication. It may arise without
direct injury to the cerebral wall of the sinus. If, during removal, the
anterior end of the middle turbinal be damaged too high up, the lymph
channels around the olfactory nerve may be opened so freely that
infection spreads along them to the meninges. Or the cerebral wall may
sometimes be broken through without a serious result, if the dura mater
be left intact behind it. But if there be any damage done to the wall in
the neighbourhood of the crista galli or cribriform plate, the dura
mater is almost inevitably injured at the same time, and a rapid and
fatal meningitis may be expected. The infection is generally
streptococcal, and surgery is powerless to stop its progress.

_Abscess in the frontal cerebral lobe_ may arise from operation on the
frontal sinus. In my experience it is more apt to occur independently of
interference with the sinus, to remain latent, and then to be simply
roused into activity by the local traumatism. The symptoms are,
unfortunately, very vague. Rise of temperature, headache, irritability,
drowsiness, and optic neuritis may be present. On the occurrence of
these symptoms the sinus should be freely reopened, and the posterior
(cerebral) wall carefully inspected for any necrosing area. In any case
it should be removed and the frontal lobe explored in all
directions.[75]

[75] A successful case is reported, _Proc. Roy. Soc. of Med., Lond._,
1908, June meeting, by L. V. Cargill, William Turner, and the writer.

These dangerous complications, in many cases, were no doubt due to a
failure to recognize that the complicated group of ethmoidal cells were
involved in all cases of chronic frontal suppuration, and that previous
to the introduction of the Killian operation our operative methods were
very apt to dam up suppuration in dangerous corners. Finally, it was
only when rhinologists first began to investigate frontal sinusitis that
it was recognized what a dangerous region this is. To be convinced of
this it is only necessary to compare the anxiety inspired by our regard
for the cerebral wall of the frontal sinus with the calmness with which
we regard an opening into the middle fossa, or through the dura mater,
in mastoid operations.

We are not yet in possession of definite evidence in regard to the
proportionate number of deaths which are due directly or indirectly to
pus in the frontal sinus. Some observers hold that more deaths have
occurred from operation than from neglected cases. Molinié has followed
the history of fifteen private patients with frontal sinusitis, and not
operated on, for ten years. Only one has died, and that was from another
cause.[76] In any case we may still accept Lermoyez’s dictum: ‘Avoir une
sinusite chronique est chose moins grave qu’on ne croit: opérer une
sinusite frontale est chose plus sérieuse qu’on ne le dit.’[77]

[76] _Annales des Maladies de l’Oreille_, 1905, juillet, ii. 72.

[77] Ibid., 1904, XXX. vi. 579.

Doubtless the dangers have been diminished since the more general
adoption of the Killian operation, but accidents may occur in the most
skilful hands. This must be kept in mind when drawing up the indications
for interference.

=Results.= In uncomplicated cases, successfully operated on, the results
are most satisfactory. The preservation of the Killian bridge quite
prevents any really unpleasant disfigurement. The depression which may
form above it is proportionate to the size and depth of the cavity. No
man need decline the operation on account of the scar left. In women we
are able, with the help of a radiograph, to form an idea beforehand as
to the degree of depression which may be left. This, if required, can be
remedied by the injection of paraffin (see Vol. I), but, fortunately,
the frontal sinus in women is not, as a rule, so deep as in men.

As regards cessation of purulent discharge the result will depend on the
extent of the sinus, the presence of complicated orbito-ethmoidal cells,
and the skill of the operator. If the ethmoidal labyrinth has not been
completely dealt with, one or two cells may continue to secrete. It may
be wiser to leave them alone. In very deep sinuses a ‘dead space’
between the back of the Killian bridge and the posterior (cerebral) wall
of the sinus remains open, and may continue to secrete if not cicatrized
over evenly.

But secretion is no longer pent up in the fronto-ethmoidal group of
cells, and the patient is relieved of headache, depression, and other
symptoms of septic absorption.


THE OGSTON-LUC OPERATION

This operation was first described by Ogston,[78] but was independently
conceived by Luc.[79] Its principle is to make a fairly free opening
into the frontal sinus, and then establish a large communication with
the nasal cavity. The inner part of the supra-orbital rim is sometimes
destroyed. But the operation does not provide for the treatment of
orbito-ethmoidal cells, the anterior ethmoidal region and the
sp[h]enoidal wall are not exposed, and if there be a large orbital
recess to the frontal sinus it cannot be satisfactorily dealt with.

[78] Ogston, _The Medical Chronicle_, 1884, December.

[79] Luc, _Société Française d’Otologie_, Paris, 1896, mai.

=Indications.= But the Ogston-Luc procedure, or some modification of it,
is still suitable in (1) exploratory openings of the frontal sinus, (2)
when the sinus requires opening for a recent and acute infection[80],
and (3) for mucoceles and suppurating mucoceles.[81]

[80] StClair Thomson, _The Practitioner_, 1906, July.

[81] Logan Turner, _Edinburgh Medical Journal_, 1907, November and
December.

=Operation.= A general anæsthetic is required. It is not necessary to
shave the eyebrow, but the surrounding skin should be well purified. A
curved incision is made through the eyebrow down to the bone along the
inner third of the supra-orbital ridge, reaching from the supra-orbital
notch to opposite the inner canthus. In the latter direction it can be
extended if the ethmoidal region is chiefly affected, and if the ethmoid
only requires exposing the incision is placed lower down.

With a raspatory the soft parts are turned upwards and downwards so as
to expose the anterior wall of the sinus, which is opened with chisel
and hammer. A probe will indicate its depth and direction. The opening
is enlarged with bone-forceps sufficiently to allow inspection of the
interior of the cavity, and permit of the passage into the nose being
enlarged with forceps, curettes, or burrs. The polypoid mucosa occupying
the sinus and the fronto-ethmoidal cells along the passage to the nose
are carefully plucked away. A drainage tube or wick of gauze is inserted
from the sinus down into the cavity of the nose, so that it can be
withdrawn from the anterior nares at the end of twenty-four hours. The
drainage tube is replaced by some surgeons. The frontal wound is
sometimes closed at the time of the operation, and sometimes left open.

=Results.= These are variously given by different observers. Thus one
author states that it will effect a cure in 85% of cases,[82] while
another operated by this method in eleven cases, of which two died and
not one was completely cured.[83]

[82] Lermoyez, _Annales des Maladies de l’Oreille_, 1902, novembre.

[83] H. L. Lack, _Edinburgh Medical Journal_, 1902, June, p. 542.

The subject does not require further discussion, as most operators have
now given this operation up in favour of the improvements wrought in it
by Killian. Luc himself has abandoned it in favour of the Killian
operation. The latter is undoubtedly to be preferred in all cases of
well established chronic purulent sinusitis with fungating mucosa and
involvement of the ethmoidal cells.


KUHNT’S OPERATION

In this operation the entire anterior wall of the frontal sinus is
chiselled away, so as to allow of the soft parts covering it being
pressed down into the cavity until they are applied to the posterior
wall. This, naturally, effects a complete obliteration of the cavity,
but in order to secure it the orbital ridge has frequently to be removed
to such an extent that a frog-like prominence is given to the eye, and
the resulting disfigurement is very marked. Besides, this operation does
not deal with the orbital recess of the sinus, or the orbito-ethmoidal
cells--the most important part of the operation. In fact, the only
advantage of this operation--complete obliteration of the sinus--is
secured by Killian’s operation, which also allows these regions to be
dealt with, permits free drainage into the nose, and avoids
disfigurement.


OPERATIONS UPON THE SPHENOIDAL SINUS

=Surgical Anatomy.= In operating on this sinus there are many anatomical
and pathological points which it is desirable to remember. Only a few of
them can be recalled.

The cavity is seldom absent, although it may be quite small. Its size
and conformation may be irregular. Thus in one instance it may extend
far out into the wing of the sphenoid, while in another it may be even
smaller than a posterior ethmoidal cell invading the body of the
sphenoid bone and lying above it.

While the sphenoidal sinus on one side is very small the opposite one
may be so large that it comes in relation with the optic groove of the
opposite side.

The anterior wall of the sphenoidal sinus can be opened with safety. The
roof comes into close relation with the structures round the sella
turc[ic]a. The outer wall is close to many large blood-vessels which
might cause troublesome hæmorrhage if wounded. The upper outer wall may
be as thin as paper.

There may be deficiencies present in the bony walls, so that, for
instance, the mucous membrane of the sinus and the dura mater may be in
direct contact.

The Röntgen rays give such valuable information as to the size and
relations of the cavity, as well as to diseases in its cavity or walls,
that a radiograph should be taken in all cases (Figs. 343 and 344).


SOUNDING AND WASHING OUT THE SPHENOIDAL SINUS

=Indications.= Lavage alone may be sufficient for acute or recent cases,
but in chronic forms of suppuration a larger and permanently patent
ostium must be established, both to allow of more effective drainage and
of treatment of the interior of the cavity.

When the interior of the nasal chamber is in a normal condition it is
only possible to catheterize this cavity in a limited number of cases.
The region of the middle turbinal and olfactory cleft is carefully
prepared with cocaine and adrenalin. A pledget soaked in the mixture is
inserted between the middle turbinal and the septum, and pushed
backwards until it reaches the anterior wall of the sinus.

[Illustration: FIG. 343. RADIOGRAPH OF THE SPHENOIDAL SINUS. The beak of
a punch-forceps is seen in a posterior ethmoidal cell (which has been
opened) and pressing against the anterior wall of the sphenoidal
cavity.]

A canula is then inserted in a sloping direction inwards and upwards
diagonally across the plane of the middle turbinal until it impinges on
the nasal surface of the sphenoid, in the neighbourhood of the ostium
(Fig. 345). The latter is found by feeling with the tip of the catheter.
The opening is never visible in health. It may lie a little external to
the direction of the olfactory cleft--about 5 millimetres from the
middle line.

[Illustration: FIG. 344. RADIOGRAPH OF THE SPHENOIDAL SINUS. This is a
sequel to the preceding illustration. The front wall of the sinus has
been broken through, and the beak of the forceps is now shown inside the
sphenoidal cavity.]

If this plan be not successful, the ostium sphenoidale can more
certainly be discovered in the following way. A more complete and
prolonged application of cocaine is carried out, particularly in the
neighbourhood of the olfactory cleft and the spheno-ethmoidal recess.
Killian’s long nasal speculum (Fig. 346), sterilized and warmed, is
inserted between the middle turbinal and the septum. By separating the
blades of the speculum the passage is dilated, so that the instrument
can be slipped further in, and so, by alternating movements of expansion
and advance, the front wall of the sinus is brought into view. During
this procedure the middle turbinal is crowded outwards, and no alarm
need be caused if a slight cracking sound shows that its attachment has
been fractured.

The mouth of the sphenoidal sinus is often indicated by the muco-pus
oozing from it or pulsating in harmony with the pulse. If discharge be
not escaping the ostium may be only a potential and not an actual
orifice--like that of the meatus urinarius--and has then to be more
carefully sought for and detected with a probe. If there be difficulty
in finding the ostium, the front wall should not be broken through until
the presence and size of the sinus has been demonstrated by means of a
radiograph (Figs. 343 and 344). The sinus is washed out, as described
for the frontal and maxillary cavities.

[Illustration: FIG. 345. CATHETERIZING THE SPHENOIDAL SINUS.]


OPENING THE SPHENOIDAL SINUS

=Indications.= Profuse purulent post-nasal catarrh, persistent headache,
orbital or ocular or intracranial symptoms, call at once for relief. Not
infrequently suppuration in other cavities will not cease, even though
operated on, until the sphenoidal sinus has been treated.

=Operation.= Unless long-standing suppuration or ozœna have produced
such atrophy of the middle turbinal that the front wall of the
sphenoidal sinus is easily inspected from the front, it will be
necessary to remove the greater portion of the middle turbinal. If the
anterior end has had the typical amputation performed (see p. 592), then
the rest can be removed with the punch-forceps of Grünwald, the wire
snare, or, under nitrous oxide anæsthesia, the spokeshave.

This will bring the anterior wall of the sinus with its ostium into
view. Killian’s long nasal speculum (Fig. 346) may still be necessary.
With the help of cocaine the ostium can then be enlarged with various
instruments. Hajek’s hook can be inserted into the orifice and the front
wall torn away. I have not found this satisfactory. It is much simpler
to insert the beak of a small Grünwald’s forceps into it, or a small
ring-knife, and by a series of boring and screwing motions to render the
ostium patent. It is then easy to introduce a beaked Grünwald’s or some
such punch-forceps as those of Cordes (Fig. 348) and cut away as much of
the front wall as may be required. This can be done freely in an inward
and downward direction, and an opening as large as the tip of the little
finger, and sufficient for drainage and treatment, is thus established.

When describing the removal of posterior ethmoidal cells (see p. 616) it
was pointed out that the tip of the forceps not uncommonly breaks
through the thin portion of the anterior sphenoidal wall.

If the natural ostium sphenoidale be not visible it would be risky to
make an artificial opening without first determining by radiography the
presence and size of the sinus. When this has been ascertained,
palpation with a pair of sinus-forceps or a Lichtwitz’s trochar and
canula will generally detect a thin spot where firm pressure is
sufficient to penetrate into the cavity. The opening is then enlarged as
described.

[Illustration: FIG. 346. KILLIAN’S LONG NASAL SPECULUM.]

In all these procedures care must be taken that the instrument does not
burst suddenly through the front wall with such force that it impinges
on and damages the posterior wall.

The opened sinus must be dealt with according to the conditions met
with. Necrosed portions of bone may require to be removed, but they
rarely occur, except in syphilitic cases. Polypoid masses of mucous
membrane, obscuring the opening, may be carefully lifted out with
forceps or curette, so as to facilitate drainage; but it is never
necessary to think of curetting the interior generally, and particular
regard should be paid to the posterior wall.

=After-treatment.= Profuse hæmorrhage has sometimes occurred after
opening the sinus. In a case of Gleitsmann’s the bleeding did not take
place until seven days after the operation,[84] and in one of C. R.
Myles’s cases profuse hæmorrhage occurred on the ninth day and required
ligature of the external carotid.[85] It is possible that the bleeding
in such cases may come from a branch of the internal maxillary artery,
or even from the cavernous sinus. It can be met by firm plugging with a
long strip of 1-inch ribbon gauze, of which the end is soaked in
adrenalin or peroxide of hydrogen. Hæmorrhage is not a complication that
I have ever met with, after having opened a large number of sphenoidal
cavities, and I do not think it is to be dreaded if the opening be made
as directed.

[84] _Transactions of the American Laryngological Association_, 1895, p.
91.

[85] Ibid., 1903, p. 241.

[Illustration: FIG. 347. RADIOGRAPH SHOWING A PROBE IN THE SPHENOIDAL
SINUS. An india-rubber obturator is in the maxillary antrum.]

The sinus is washed out with a warm normal saline solution. The addition
of peroxide of hydrogen may be useful. The condition of the mucous
membrane may be improved by cleansing the sinus with iodoform emulsion,
or plugging it for twelve or twenty-four hours with iodoform ribbon
gauze. Any pigment can be kept in contact with the walls for some time
by dipping the end of a piece of ribbon gauze into a solution of argyrol
(25%) or nitrate of silver (2%) and packing it into the cavity. The
other end of the strip is left just within the vestibule of the nose, so
that the patient can withdraw it himself.

But if a sufficient opening has been made into the cavity to allow of
natural ventilation and drainage, it is well to abstain from too much
local medication--particularly if there be neither polypus, necrosis,
nor foreign body in the sinus, and if it be not subject to reinfection
from the suppuration in the posterior ethmoidal cells. It is remarkable
how, under such conditions, suppuration will cease in a sphenoidal sinus
if left alone, when, if frequently treated, secretion will continue
indefinitely. In my experience the sphenoidal sinus is one of the most
satisfactory of the accessory sinuses to treat.[86]

[86] _Proceed. Royal Society of Medicine_, Meeting of June, 1908.

[Illustration: FIG. 348. SPHENOIDAL PUNCH-FORCEPS.]

=Other methods.= The sphenoidal sinus can also be opened and treated
during Killian’s operation on the frontal sinus (see p. 648).

It has been proposed to approach the sphenoidal sinus by first
traversing the maxillary antrum. Such a complicated route, involving
extensive destruction of tissue, has no advantage over the direct and
simple method described. Attempts to reach the sphenoidal sinus from the
naso-pharynx are not practical. This is easily seen by observing the
thickness of the floor of the cavity depicted in Fig. 345.


OPERATION IN MULTIPLE SINUS SUPPURATION

Before starting treatment in a case of multi-sinusitis a complete
examination should be formulated. The importance of making the
differential diagnosis as complete as possible cannot be overestimated.

In initiating treatment attention should be directed first to the
ethmoidal region. The ethmoid should be attended to in all cases of
suppuration in the frontal sinus. It is generally necessary, in any
case, to clear it away to gain access to the sphenoidal orifice. It is
well to remove it before or during operation on the maxillary sinus. The
sphenoidal sinus should be catheterized, and, if infected, the orifice
will require enlarging and the cavity treating. A frontal sinus should
be washed out several times before deciding on a radical operation. It
not uncommonly ceases to secrete after the ethmoid has been cleared.

The radical operation on the frontal sinus should not be embarked on
until the ethmoid and sphenoid have been attended to. A radical frontal
operation should take precedence of the maxillary, unless both cavities
are operated on at the same time.




CHAPTER VI

OPERATIONS INVOLVING THE NASO-PHARYNX: OPERATIONS FOR RETROPHARYNGEAL
ABSCESS: OPERATIONS FOR NASO-PHARYNGEAL ADENOIDS


METHODS OF OBTAINING ACCESS TO THE NASO-PHARYNX THROUGH THE NOSE

Many growths in the naso-pharynx, whether originating in the space or
descending into it from the posterior choanæ, can be removed by the
following method.

=Indications.= This operation is indicated for the ordinary mucous
polypus of the nose when presenting in the post-nasal space. Polypoid
masses of the ethmoid may project through the posterior cavity and are
removed in the same way. A naso-pharyngeal polypus (also called choanal
polypus, post-nasal polypus, or benign pharyngeal polypus) is easily
removed by this procedure. Innocent tumours of the post-nasal space,
such as papilloma, adenoma, fibroma, and cysts, can be removed by the
same method.

=Under cocaine.= Cocaine and adrenalin (see p. 572) should be carefully
applied to the septum and turbinals, as it is the passage of the
instrument from the front which is often the most painful part of the
proceeding. The pharynx should be lightly sprayed with a 5% solution of
cocaine so as to check reflex action.

While the patient is seated in the ordinary examination chair the
surgeon stands at his left hand and introduces a looped snare (Fig. 312,
p. 613) through the nostril most suitable for approaching the root of
the growth. When the snare has reached the post-nasal space, the surgeon
introduces the purified forefinger of the left hand through the mouth
and up behind the soft palate, as in Fig. 291. Here it serves to
manipulate the loop over the growth, and holds it close to the root of
the pedicle while the snare is pulled home.

A few minutes should be allowed to elapse to permit the patient to
recover from the unpleasant manipulation, and also to allow of
coagulation of the strangulated blood-vessels. The growth should not be
cut through, as it is wiser to pluck it from its attachment by a quick
movement of avulsion.

The growth may come away with the snare through the nostril, or may fall
into the pharynx and be expectorated.

In fairly roomy nostrils a stout polypus forceps can be used instead of
the snare.

=Under chloroform.= In nervous subjects the same method should be
carried out under a general anæsthetic, care being taken that the growth
does not cause embarrassment by occluding the larynx.

Under chloroform, of course, more extensive operations can be carried
out on the post-nasal space. The pedicle can be attacked with a pair of
scissors with long handles, short blades, and slightly curved on the
flat. These are introduced through that nostril which appears to be in
most direct line with the pedicle, to act as a raspatory, and then cut
through the base of the growth. In some cases an instrument such as
Langenbeck’s elevator (Fig. 338) will prove useful if introduced through
the nostril. The growth is then removed through the mouth by a twisting
movement with a strong volsella.


OPERATIONS FOR OBTAINING ACCESS TO THE NASO-PHARYNX THROUGH THE MOUTH

Many growths in the naso-pharynx can be removed through the mouth,
without preliminary operations through the face or through the hard or
soft palate.

=Indications.= The following method of access to the naso-pharynx is
chiefly called for in true fibroma of the naso-pharynx, otherwise called
naso-pharyngeal polypus, fibroid tumour of the base of the skull,
fibroid tumour of the naso-pharynx, retro-maxillary polypus, or juvenile
sarcoma of the naso-pharynx.

It is also a plan of procedure which may be called for in any very
large, innocent tumours of the naso-pharynx, particularly in cases where
nasal stenosis prevents access from the nostrils. It would be a suitable
method in any operable cases of malignant disease of the post-nasal
space.

=Operation.= The patient is chloroformed and placed in the position of
Rose (hanging head). The mouth being propped open, and the tongue drawn
forward, the tumour is first explored with the forefinger, to detect and
detach any secondary adhesions. A raspatory which works laterally is
next passed from one side of the naso-pharynx to the other above the
growth. A rugine which works in a sagittal plane is then introduced
below the tumour and made to pass upwards behind it--the reverse
movement of Gottstein’s curette in the removal of adenoids (Fig. 350).
This movement is facilitated by securely gripping the tumour and
dragging it forwards with a stout pair of alligator or volsella forceps.
The tumour can thus be so liberated that, with some twisting movements,
it can sometimes be extracted entire--often dragging down with it
through the naso-pharynx any prolongations thrown forward into the nose.

It is useless to attack such growths as true fibroma of the naso-pharynx
with an ordinary wire snare, or such an instrument as a pair of adenoid
forceps. For these firm tumours, specially powerful forceps have been
designed by Doyen and Escat.

_Hæmorrhage_ is apt to be sudden and copious, but the more rapidly and
completely the growth is removed the sooner will bleeding cease--even
spontaneously. After complete removal firm pressure with a marine sponge
will generally check it. A post-nasal plug should be avoided, and is not
usually required. Incomplete operations not only start hæmorrhage but
may start septic absorption.

=Modifications.= (_a_) _Preliminary laryngotomy._ A preliminary
laryngotomy, strongly recommended by J. W. Bond and extensively adopted
by Butlin, adds nothing to the dangers of the case. It allows of the
laryngo-pharynx being packed, so that there is no anxiety in regard to
the descent of blood into the lungs, and it permits the steady
administration of the anæsthetic through the laryngotomy canula. The
surgeon is thus relieved of two great anxieties, and can devote himself
without embarrassment to more deliberate operation.

The laryngotomy tube can be removed as soon as the patient recovers
consciousness and all hæmorrhage has ceased.

(_b_) _Division of the soft palate._ In addition to the operation of
laryngotomy, the following procedure will allow of more deliberate
removal.

The soft palate and uvula are carefully divided in the middle line, and
a silk ligature is placed through each lateral half so that they can be
held forward out of the way. This gives more direct access to the
post-nasal tumour, and if then found to crowd the cavity too closely to
allow of manipulation, the posterior part of the hard palate can be
chiselled away in the middle line. At the conclusion of the operation
the divided palate is carefully united in the middle line (see Vol. II).

=Selection of method.= In some cases operation through the mouth may
have to be combined with a second operation from the front--such as the
method of Moure (see p. 619) or that of Rouge (see p. 622).

Rapidity of operation is important, as, once the pedicle has been cut
through, or the body of the tumour removed, the hæmorrhage tends to
subside spontaneously, or is quickly controlled by packing.

The hanging head (Rose) or the Trendelenburg position is generally
recommended.

The preliminary laryngotomy seems desirable in all cases. The division
of the palate should be avoided if possible. It may not always unite,
and is less likely to do so if subsequent operations are required. The
soft palate is very elastic, and in some cases it can be tied out of the
way by means of a soft rubber catheter passed along the floor of the
nose, and out through the mouth.

Ligature of the external carotid, strongly recommended by Chevalier
Jackson[87], is not necessary unless the patient is very anæmic or weak
from former hæmorrhages. It should then be only a temporary ligature
(see Vol. I, p. 383).

[87] _The Laryngoscope_, xiv, 1904, p. 267.

Hæmorrhage, as already remarked, is chiefly guarded against by rapid and
complete operation. The preliminary use of adrenalin and cocaine, the
administration of lactate of calcium, and the other methods recommended
for the prevention of bleeding (see p. 574) should be carefully attended
to. But in every case preparation should be made beforehand for ligature
of the external carotids and for saline infusion.


OPERATION FOR RETROPHARYNGEAL ABSCESS

=Indications.= The disease is serious, and when not diagnosed almost
inevitably ends in death. Before the abscess bursts death may result
from spasm of the glottis, laryngeal œdema, or asphyxia. The affection
runs its course in 5 to 10 days, and if the abscess opens spontaneously
death almost inevitably results--either from suffocation, or septic
pneumonia, or cardiac failure.

=Operation.= When the diagnosis is settled intervention should be
prompt. It is not necessary to wait for distinct fluctuation. The pus
focus may be so difficult of manipulation in an infant, and the
pharyngeal muscle may be so thick and indurated, that it is practically
impossible, even in the later stages of retropharyngeal abscess, to
detect the presence of pus by palpation.[88]

[88] M. A. Goldstein, ibid., xviii, January, 1908, p. 46.

_The evacuation of the abscess through the mouth_ was formerly looked
upon as dangerous, owing to the difficulty of drainage, the fear of pus
burrowing behind the œsophagus, and the risk of flooding the larynx with
pus. The more difficult plan of opening it from the neck was generally
recommended. The majority of cases can be opened through the mouth with
perfect safety.

No general or local anæsthetic is administered, but everything necessary
for an immediate tracheotomy should be ready at hand. No gag should be
employed, a tongue depressor or the operator’s left forefinger being
sufficient both to keep the mouth open and act as a guide. The infant is
swaddled in a shawl so as to completely control the movements of the
extremities and is then laid on its side on a low pillow, and held by a
trustworthy assistant. The sinus-forceps used for opening a
peritonsillar abscess are thrust into the most prominent part of the
swelling, and the opening enlarged by separating the blades as they are
withdrawn. A slender sharp-pointed bistoury, guarded and guided by the
index-finger, may be used instead of the forceps. The pus will pour out
through the nose and mouth. The incision of the pharynx should be free,
deep and long, and directed against the posterior wall of the pharynx
and as close to the median line as possible, so as to avoid any chance
of wounding the internal carotid.

The surgeon may feel more security if, with the same precautions and
with the patient in the same position, he first aspirates the pus
cavity.

If more accustomed to it, he may also prefer to have the child flat on
its back, with the head overhanging the edge of the table.

Suffocation may be so imminent when the patient is first seen that a
preliminary tracheotomy is required.

_The external operation_, which leaves a certain scar, is reserved for
some rare cases--as when the abscess is too low to be easily reached
through the mouth, when the spasm of the masseters cannot be overcome,
when a large pulsating vessel is noticed in front of the abscess, and
when the abscess points towards the neck. It is also the suitable one
for the chronic and generally tubercular form of abscess more commonly
met with in older patients.[89]

[89] George E. Waugh, _The Lancet_, September 29, 1906.

The external operation is made through an incision along the posterior
border of the sterno-mastoid muscle, and the dissection is carried
behind the large vessels of the neck and in front of the prevertebral
muscles.

=After-treatment.= The after-care of the patient will require
consideration, since the disease is generally met with in the feeble and
ill nourished.

If the abscess be opened in good time the patient is at once relieved
and begins to recover rapidly.


REMOVAL OF NASO-PHARYNGEAL ADENOIDS

=Indications.= The removal of naso-pharyngeal adenoids is not called for
simply because they are accidentally discovered to be present, nor does
the need of operation depend solely on the size of the growths or the
nasal obstruction they produce. Adenoids require removal whenever the
symptoms attributable to them call for relief. These symptoms may be
arranged in three groups, according as they are those (i) of nasal
stenosis, (ii) of secondary septic infection, or (iii) of reflex
effects.

(i) Amongst the first are mouth-breathing and all the numerous sequelæ,
including facial, buccal, dental, and thoracic deformities. It must not
be forgotten that mouth-breathing may never be present, and yet
deformities of the chest or septic or reflex results can be produced by
a small amount of growth in the post-nasal space.

(ii) Amongst secondary septic infections are catarrhal conditions of the
Eustachian tube and otitis media, and catarrhal infection of any part of
the air-passages. Cervical glands and so-called ‘glandular fever’ occur
in this group, as do septic gastritis and other conditions caused by the
conveyance of sepsis to more distant parts.

(iii) Various reflex effects are sometimes attributable to
naso-pharyngeal adenoids. Laryngismus stridulus, reflex cough, chorea,
convulsions, night-terrors, enuresis nocturna, and aprosexia are some of
the ailments which may justify operation on Luschka’s tonsil.

As it is chiefly in children that this operation is required it is
important to see that they are free from indication of infectious
fevers. The operation should be postponed until any acute catarrh has
subsided. If there be otorrhœa the ears should receive suitable
cleansing treatment for a week or two beforehand. The condition of the
teeth requires attention.

The operation is so frequently carried out in private houses that it is
well to make inquiries into the health of the members of the household,
recent illness, and sanitation. When possible, a large, airy room with a
south aspect should be chosen.

=Operation.= In adults it is possible to carry out the operation under
cocaine. On the Continent, particularly in hospital practice, it is
often done without any anæsthetic at all. In this country general
anæsthesia is almost the universal custom. Opinion is divided as to
which is the safest and most suitable anæsthetic to employ.

When the removal of tonsils or other operation is not carried out at the
same time, an anæsthesia of less than a minute is sufficient. In adults,
and in children over 10 years of age, nitrous oxide does excellently.
Younger children are apt to be alarmed by the face-piece and apparatus
necessary for nitrous oxide, and this gas does not seem so suitable for
them as for adults. In younger children chloride of ethyl is extensively
employed on the Continent, but has not met with general favour here.

When the tonsils require removal, or any other operation on the upper
air-passages is carried out at the same time, and in young children
generally, an anæsthesia allowing of more deliberation is desirable.
For this, some operators employ ether,--preceded or not by nitrous
oxide. But the well-known objections to pure ether in the surgery of the
air-passages have caused the preference to be given to chloroform, or to
one of the mixtures of chloroform and ether.

The patient should lie quite flat on the operating table, with only a
low pillow or folded towel under the head. The anæsthetist, who takes
charge of the gag and flexes or rotates the head as directed, stands at
the end of the table. At the patient’s right hand stands the surgeon,
and within easy reach are his instruments, sponges, and iced water.
Standing on the same side and behind him is the nurse. Her duty is to
soothe the patient while passing into unconsciousness, and later on to
roll him well over on to his right side as the operation finishes.

The operation can be carried out more correctly, rapidly, safely, and
comfortably if the surgeon be armed with an electric forehead
search-light (see p. 571). Failing this, the table should be brought
close up and parallel to a window, with the patient’s right hand next
the light.

Surgeons differ as to the degree of anæsthesia desirable. Some like it
to be quite light, so that the patient is all the time in the struggling
stage and requires his hands to be controlled by the nurse. I think this
is quite as dangerous as when the anæsthesia is pushed until the patient
is relaxed, with the corneal reflex just abolished, and the swallowing
and coughing reflexes still present.

When the anæsthetic is administered steadily, with plenty of air, a
degree of unconsciousness is generally secured which will allow of an
operation lasting two or three minutes without any further
adminis[t]ration. Should the patient show signs of recovering
consciousness more chloroform can be given from a Junker’s apparatus.

The anæsthetist then opens the mouth with a suitable gag, such as
Doyen’s or Mason’s, and maintains the patient’s head exactly in the
middle line of the body. Directing the electric search-light into the
pharynx, the surgeon depresses the tongue with a spatula in the left
hand, while with the right he holds the adenoid curette--some
modification of the original Gottstein model (Fig. 349). This is best
seized firmly dagger-wise (Fig. 351). It is then introduced along the
tongue and slipped up into the post-nasal space. Once safely behind the
soft palate and kept straight in the middle line, no harm can be done.
Dropping the tongue depressor, the surgeon depresses the handle of his
instrument until the beak of it is felt in contact with the posterior
free margin of the septum. Pressing the cutting blade firmly and
steadily along this it is swept upwards, backwards, and downwards along
the vault of the naso-pharynx, while the curette revolves around an
imaginary centre in its shaft (Fig. 350). As the instrument is withdrawn
from the pharynx, its cage will be found to contain the adenoid growth,
removed _en bloc_ and generally complete (Fig. 351). Should the growth
slip from the cage, or remain semi-detached from the posterior
pharyngeal wall, it can be seized and lifted from the throat with a pair
of post-nasal forceps (Fig. 287).

[Illustration: FIG. 349. ADENOID CURETTE. StClair Thomson’s
modification.]

The rush of blood which now takes place is met by rolling the patient
well over to his right side, with his face over the edge of the table,
so that the blood can run into the right cheek and so out through the
mouth. With the patient on his side there is no anxiety of asphyxia from
descent of blood or fragments of growth into the trachea, and the
surgeon can more deliberately explore the post-nasal space and, with a
simple adenoid curette, remove any lateral remains of growth which may
have escaped the caged curette.

[Illustration: FIG. 350. THE REMOVAL OF NASO-PHARYNGEAL ADENOIDS.
Semi-diagrammatic illustration to show how the curette revolves around
an axis which moves from _a_, through _b_ and _c_, to _d_. The growth is
pressed into the fenestra of the instrument in the _a'_ position, and
when the sweeping movement has brought it to _d'_, it is detached and
caught in the cage.]

Sponges are merely used to cleanse the mouth and pharynx in order to
make sure that no semi-detached fragments are left behind. If present,
tonsils can be conveniently removed at this stage.

Bleeding, which may be very free for a minute or two without any cause
for anxiety, is promptly arrested by freely sluicing the patient’s face
and neck with ice-cold water.

=After-treatment.= The patient is put back to bed, lying well over to
one side. He should not be allowed to lie on his back, or left
unattended, until consciousness has returned. Collapse may occur at this
time, generally as a precursor of vomiting, or blood may be vomited and
then, owing to the patient’s semi-conscious condition, may be drawn into
the trachea.

[Illustration: FIG. 351. REMOVAL OF NASO-PHARYNGEAL ADENOIDS. The growth
is shown as partially removed from its attachment, and bulging into the
cage of the instrument which opens to receive it.]

Ice may be sucked. After a few hours, if there be no vomiting, barley
water, lemonade, tea, thin beef-tea, or beef jelly can be given. Milk
and milky food should be avoided. An aperient should be given the same
evening, as any foul breath or feverish condition is more likely to be
due to blood and mucus in the stomach than to local sepsis. The mouth is
kept cleansed with the tooth-brush and an alkaline wash.

It is best to avoid local treatment for the nose. At the end of a few
hours the patient is encouraged to clean the nose, and if he be
supplied with abundance of fresh air through freely opened windows, the
wound in the post-nasal space will heal promptly without any local or
general reaction. Occasionally an alkaline nose lotion is required if
there has been much secondary rhinitis, or if the child be kept in
vitiated air.

One day in bed is generally sufficient, and a child may be allowed out
in two or three days, though fatigue should be avoided for a week.
Suitable after-treatment in the way of breathing exercises, gymnastics,
speech correction, and tonics is often needed. Relief of nasal stenosis
may require completion by attention to the condition of the turbinals
and septum.

The operation in adults is performed under nitrous oxide. This can be
carried out in exactly the same way as that already described, but some
surgeons prefer to have the patient sitting up in a dentist’s chair. In
that case, after the removal of the mass of growth, the patient’s head
is thrown forward between his knees.

=Difficulties and dangers.= It may be said that the operation itself,
carried out with usual care and in a patient who is not a hæmophilic, is
free from danger. The chief anxiety is from the anæsthetic, and no
inconsiderable number of deaths from this cause have been reported. When
possible, it is well to secure the services of an expert anæsthetist who
is well used to laryngological work, and accustomed to the operator’s
particular methods.

_Hæmorrhage_ may be brisk, even profuse, for a few minutes, but as a
rule it promptly ceases if the operation be completed, the patient well
rolled to one side, the air thoroughfare left clear so as to allow free
breathing and avoid congestion, and the gag removed to permit swallowing
and diminish pharyngeal reflexes. The more rapidly and completely the
operation is executed, the less will be the bleeding. It not
infrequently originates from semi-detached fragments of growth. Even
when the hæmorrhage is profuse it is better to push on and complete the
removal of growth before attempting to check it. The value of free
applications of ice-cold water cannot be exaggerated (see p. 574). In
many cases bleeding is maintained by the surgeon’s anxious efforts to
stop it with sponging, pressure, or the application of styptics. The
greatest danger arises in the case of hæmophilics. If this diathesis be
undoubtedly present, the operation should be avoided. If only suspected,
more care than usual should be taken in preparing the patient for
operation, and lactate of calcium in 15 to 30 grain doses twice a day
might be given for two or three days beforehand.

When bleeding persists it is met by keeping the patient very quiet and
free from alarm, in a cool and well-ventilated room, and only lightly
covered with clothes. Ice is given to suck and applied on each side of
the neck, while iced cloths are applied to the face and forehead. Clots
are blown out of the nose so as to permit the access of fresh cold air
to the post-nasal space. With a pipette, or a pledget of cotton-wool, a
few drops of adrenalin can be trickled into the nostril and allowed to
run backward. If these measures fail--as they rarely do--the post-nasal
space must be plugged (see p. 575). When hæmorrhage takes place after
the removal of adenoids and tonsils, it will generally be found that the
source of it is in the tonsillar area.

_The uvula_ may retract strongly at the moment of introducing the
curette and then get crushed against the posterior pharyngeal wall: or
it may be seized by mistake with the post-nasal forceps and be torn
away. The same instrument has sometimes been responsible for fracturing
the posterior margin of the septum, injuring the Eustachian cushion, and
tearing off strips of mucosa from the pharynx. These complications are
avoided by using a frontal search-light, operating deliberately, and
abandoning the forceps in favour of the curette. This latter instrument
can be manipulated without these risks if it be first guided safely
behind the uvula and then used more like a carpenter’s adze than a
curette. The stroke with the caged curette should be carried through in
one movement and exactly in the middle line of the body, but always on
the posterior wall. There is no need to attempt removal of adenoid
tissue on the lateral walls. This atrophies if the main mass is removed,
and the fossa of Rosenmüller can be cleared out with the forefinger.

_Local sepsis_ rarely follows if the precautions described be observed,
and local douching is avoided. Any local fœtor--if not arising from the
stomach--is generally traceable to some semi-detached fragment which can
be removed from the posterior wall with a wire snare (Fig. 312) or a
pair of forceps (Fig. 287).

_Deafness_, _earache_, and _otitis media_ will sometimes follow the
operation, even when the use of a nasal douche has been carefully
avoided. They are best met by warm applications, disinfection of the ear
with carbolic lotion (5%), and early incision of the drum under nitrous
oxide gas.

=Other methods of operation.= Removal through the nasal chambers--the
route originally used by Meyer for his ring-knife--is not to be
recommended.

Treatment of the growth with the galvano-cautery, introduced through the
mouth, is difficult, risky, and unsatisfactory.

The use of Loewenberg’s forceps, or some modification (Fig. 287), is
generally abandoned by any one who has become accustomed to the
Gottstein’s curette. A small pair of forceps is, however, very
serviceable in quite young children in whom the post-nasal space may be
so small as to prevent the manœuvring of any form of curette.

The position with the extended head over the end of the table--Rose’s
position--increases the congestion and hæmorrhage, and by throwing
forward the cervical vertebræ makes the approach to the roof of the
naso-pharynx more difficult.




INDEX


OPERATIONS UPON THE FEMALE GENITAL ORGANS

  ABDOMINAL
    gynæcological operations, 1
      after-treatment of, 93
      complications following, 95
    hysterectomy, 36
      risks of, 45
    myomectomy, 46

  ABSCESS OF BARTHOLIN’S GLANDS
    incision of, 142

  ADENOMYOMA OF UTERUS, 56

  ADHESIONS IN OVARIOTOMY, 12

  ANÆSTHETIC FOR CŒLIOTOMY, 6

  ANTERIOR COLPOTOMY, 145

  ATRESIA OF HYMEN AND VAGINA
    operations for, 143

  AUVARD’S SPECULUM, 136

  AVELING’S SIGMOID REPOSITOR, 151


  BARTHOLIN’S GLANDS
    operations upon, 142

  BED-SORES AFTER CŒLIOTOMY, 95

  BELATED OVARIES
    fate of, 56

  BLADDER
    injuries during hysterectomy, 111
    operations upon, 134

  BROAD-LIGAMENT CYSTS
    removal of, 14


  CÆSAREAN SECTION, 69

  CANCER
    of body of uterus, abdominal hysterectomy for, 63
                       vaginal hysterectomy for, 168
                       and fibroids, 52
       cervix with pregnancy, 82
       cicatrix after cœliotomy, 121
       Fallopian tube, operation for, 26
       ovary, ovariotomy for, 15
       uterus after bilateral ovariotomy, 55

  CAPSULES
    spurious, in ovariotomy, 15

  CARCINOMA (_see_ Cancer)

  CARUNCLE, URETHRAL
    extirpation of, 134

  CERVIX
    cancer of, in pregnancy, 82
    dilatation of, rapid, 156
                   gradual, 159
    fibroids, hysterectomy for, 42
    hypertrophy of, operations for, 160

  CHRONIC UTERINE INVERSION
    reposition of, 151

  CICATRIX
    after cœliotomy, 120
    cancer of, 121

  CŒLIOTOMY, 3

  COLPOTOMY, 144
    anterior, 145
    posterior, 147

  COMPLETE LACERATION OF PERINEUM, 127

  COMPOUND PREGNANCY, 33

  CURETTAGE, 152

  CYST
    of Bartholin’s glands, removal of, 142
       broad ligament, 14

  CYSTOCELE
    operations for, 140


  DABS FOR CŒLIOTOMY, 5

  DÉDOUBLEMENT
    Walcher’s, 137

  DILATATION
    of cervix, 156
       vulval orifice, 143

  DILATORS, HEGAR’S, 153

  DUDLEY
    operation upon perineum, 134

  DÜHRSSEN
    trachelorrhaphy, 163


  EMBOLISM, PULMONARY
    after abdominal section, 101

  EMMETT’S
    hook, 136
    scissors, 162
    trachelorrhaphy, 161

  ENUCLEATION OF FIBROIDS, 46

  EXTIRPATION OF URETHRAL CARUNCLE, 134

  EXTRA-UTERINE GESTATION
    operation for, 29
    results of operation, 34


  FALLOPIAN TUBE
    operation for cancer of, 26

  FIBROIDS
    abdominal hysterectomy for, 61
    cancer of uterus and, 52
    cervix, hysterectomy for, 42
    enucleation of, 46
    hysterectomy for, 61, 173
    interstitial, vaginal removal of, 167
    pedunculated, vaginal removal of, 165
    and pregnancy, 77
    red degeneration of, 78
    sessile, vaginal removal of, 166
    vaginal hysterectomy for, 173

  FISTULA
    juxta-cervical, operation for, 139
    recto-vaginal, operation for, 139
    vesico-utero-vaginal, operation for, 139

  FOREIGN BODIES LEFT IN ABDOMEN, 105


  GALABIN’S
    broad-ligament needle, 169

  GASTRIC ULCER
    perforating after cœliotomy, 111

  GESTATION, EXTRA-UTERINE
    operations for, 29

  GLANDS, BARTHOLIN’S
    operations upon, 142

  GYNÆCOLOGICAL
    operations, abdominal, 1
                vaginal, 125
    uterine injuries, operations for, 86


  HÆMORRHAGE AFTER CŒLIOTOMY, 97

  HEGAR’S
    dilators, 153
    operation for hypertrophy of cervix, 160

  HYMEN
    operation for atresia of, 143

  HYPERTROPHY OF CERVIX
    operations for, 160

  HYSTERECTOMY, ABDOMINAL, 46
    subtotal, 36
    total, 40
    in bifid uterus, 44
    after bilateral ovariotomy, 17
    for adenomyoma, 56
    for cancer of body of uterus, 63
                  cervix, 61
    for fibroids, 61
    Wertheim’s operation, 62

  HYSTERECTOMY, VAGINAL
    for cancer, 168
        fibroids, 173

  HYSTEROPEXY
    abdominal, 66
    vaginal, 164

  HYSTEROTOMY, 46


  INCISION OF ABSCESS OF BARTHOLIN’S GLANDS, 142

  INCONTINENCE OF URINE FOLLOWING LABOUR
    operations for, 134

  INJURIES OF UTERUS
    operations for, 86

  INJURY
   to bladder during pelvic operations, 111
      gravid uterus during abdominal operations, 89
      intestines during gynæcological operations, 109
      ureter during pelvic operations, 112

  INTERSTITIAL UTERINE FIBROIDS
    vaginal removal of, 167

  INTESTINAL OBSTRUCTION
    after pelvic operations, 110

  INTESTINES
    injuries to during gynæcological operations, 109

  INTRAPELVIC HÆMORRHAGE
    after cœliotomy, 98


  JESSETT’S
    broad-ligament needle, 169

  JUXTA-CERVICAL FISTULA
    operations for, 139


  KRAUROSIS, POST-OPERATIVE, 120


  LACERATIONS
    of pelvic floor, repair of, 132
       perineum, repair of, 127

  LATERAL COLPOTOMY, 148

  LIGAMENT, BROAD (_see_ Broad ligament)

  LIGATURES
    fate of, in pelvic operations, 117


  MACKENRODT
    vesico-vaginal fistula operation, 138

  MARCKWALDT
    operation for hypertrophy of cervix, 160

  MARTIN’S
    trochar, 147
    vesico-vaginal fistula operation, 137

  MENSTRUATION AND PELVIC OPERATIONS, 4

  METROSTAXIS
    after gynæcological operations, 95

  MYOMECTOMY
    abdominal, 46
    vaginal, 167


  OBSTETRIC UTERINE INJURIES
    operations for, 87

  OÖPHORECTOMY, 21
    hysterectomy after bilateral, 25

  OPERATING TABLES, 6

  OVARIAN TUMOURS
    and pregnancy, 74
    removal of (_see_ Ovariotomy)

  OVARIES, BELATED
    fate and value of, 56

  OVARIOTOMY, 10
    adhesions in, 12
    anomalous, 16
    for cancer of ovary, 15
    at extremes of life, 18
    incomplete, 16
    in infants, 18
    during labour, 75
    mortality of, 19
    pregnancy after, 17
    during puerperium, 76
    repeated, 17
    spurious capsules in, 15

  OVARY, REMOVAL OF (_see_ Oöphorectomy)


  PARALYSIS, POST-ANÆSTHETIC, 95

  PARAVAGINAL SECTION, 148

  PAROTITIS
    following abdominal operations, 99

  PASSAGE OF UTERINE SOUND, 149

  PÉAN’S RETRACTOR, 145

  PEDICLE IN OVARIOTOMY
    treatment of, 12

  PELVIC FLOOR
    repair of laceration of, 132

  PELVIC OPERATIONS
    complications during, 111

  PELVIC TUMOURS
    during pregnancy, 83

  PERINEUM
    repair of lacerations of, 127

  PNEUMONIA
    after abdominal operations, 99

  POST-ANÆSTHETIC PARALYSIS, 95

  POSTERIOR COLPOTOMY, 147

  POZZI’S RETRACTOR, 145

  PREGNANCY
    after bilateral ovariotomy, 17
    bullet wounds of uterus during, 90
    with cancer of cervix, 82
    compound, operations for, 82
    and fibroids, 79
    injury to uterus during, 89
    operations upon uterus during, 69
    and ovarian tumours, 74
    and pelvic tumours, 83

  PREPARATIONS FOR VAGINAL OPERATIONS, 125

  PUERPERAL SEPSIS
    operations for, 83

  PUERPERIUM
    ovariotomy during, 76

  PULMONARY EMBOLISM
    after abdominal operations, 101


  RECTO-VAGINAL FISTULA
    repair of, 139

  RED DEGENERATION IN FIBROIDS, 78

  REPOSITION OF CHRONIC UTERINE INVERSION, 151

  RETRACTOR
    Péan’s, 145
    Pozzi’s, 145

  RICARD
    uretero-neo-cystostomy, 114


  SARCOMA OF UTERUS
    hysterectomy for, 53

  SEPSIS, PUERPERAL
    operations for, 83

  SIGMOID REPOSITOR, AVELING’S, 151

  SIMS’S
    speculum, 136
    vaginal rest, 144

  SOUND, UTERINE
    passage of, 149

  SPECULUM
    Auvard’s, 136
    Sims’s, 136

  SPURIOUS CAPSULES IN OVARIOTOMY, 15

  STABS OF PREGNANT UTERUS, 91

  STERILIZATION
    after Cæsarean section, 71

  STOLTZ
    cystocele operation, 140

  SUBTOTAL HYSTERECTOMY, 36
    relative value of, 50

  SUTURES FOR CŒLIOTOMY, 5

  SWAFFIELD
    closure of wounds, 9


  TAIT, LAWSON
    oöphorectomy, 21
    operation for extra-uterine gestation, 29

  TENTS
    dilatation of cervix by, 160

  TETANUS
    after gynæcological operations, 107

  THROMBOSIS
    after abdominal section, 101

  TOTAL HYSTERECTOMY, 40
    relative value of, 50

  TRACHELORRAPHY
    Emmett’s, 161
    Dührrsen’s, 163

  TUMOURS
    ovarian, during pregnancy, 74
    pelvic, during pregnancy, 83


  ULCER
    gastric perforating, after cœliotomy, 111

  URETER
    injury to during pelvic operations, 112

  URETERO-NEO-CYSTOSTOMY, 114

  URETHRA, FEMALE
    operations upon, 134

  URETHRAL CARUNCLE
    extirpation of, 134

  UTERINE SOUND
    passage of, 149

  UTERUS
    operations upon (_see_ individual operations)
    adenomyoma of, 86
    bullet wounds of pregnant, 90
    cancer of body with fibroids, 52
                   after ovariotomy, 55
    chronic inversion of, reposition of, 151
    compound pregnancy, 82
    fibroids and pregnancy, 77
    fibro-myomata, operations for, 46, 165
    gynæcological injuries to, 86
    pregnant, injuries to, 91
    wounds of, 89, 91


  VAGINA
    atresia of, operations for, 143
    operations upon, 142

  VAGINAL
    cœliotomy, 144
    gynæcological operations, 125
    hysterectomy, for cancer, 168
                      fibroids, 173
    hysteropexy, 164
    myomectomy, 167
    rest, Sims’s, 136

  VENTRO-FIXATION OF UTERUS, 67

  VENTRO-SUSPENSION OF UTERUS, 66

  VESICO-UTERO-VAGINAL FISTULA
    repair of, 139

  VESICO-VAGINAL FISTULA
    repair of, 135

  VISCERA, MISPLACED
    in cœliotomy, 8

  VULVA
    operations upon, 142
    dilatation of, 143


  WALCHER
    dédoublement, 137

  WERTHEIM
    hysterectomy, 62

  WOUNDS OF PREGNANT UTERUS, 90


OPHTHALMIC OPERATIONS

  ABSCESS
    lachrymal, incision of, 297
    orbital, 301

  ACTIVE (CICATRICIAL) ECTROPION
    operations for, 284

  ADRENALIN
    in ophthalmic operations, 178

  ADVANCEMENT
    of levator palpebræ, 272
       ocular muscles, 251

  AFTER-TREATMENT OF OPERATIONS IN GENERAL, 180

  ANÆSTHETICS, 177

  ANKYLOBLEPHARON
    operations for, 264

  ANTERIOR
    chamber, evacuation of, 194
             paracentesis of, 233
    sclerotomy, 228
    synechiæ, division of, 227

  APERTURE, PALPEBRAL
    operations upon, 265

  ARGYLL ROBERTSON
    ectropion operation, 282

  ARLT
    entropion operation, 278

  ATTACHMENT
    of lid to occipito-frontalis, 268


  BANDAGES, EYE, 186

  BRUDENELL CARTER
    iridectomy, 217

  BUROW
    entropion operation, 276


  CALCAREOUS FILMS
    scraping, 243

  CANAL, LACHRYMAL
    operations upon, 290

  CANALICULI
    dilatation of, 290
    incision of, 291
    obliteration of, 294

  CANTHOPLASTY, 265

  CANTHORRHAPHY, 265

  CAPSULE OF LENS
    evulsion of, 195

  CAPSULOTOMY, 192

  CATARACT
    needling of, 189
    secondary, operations for, 192

  CAUTERIZATION OF CORNEA, 240

  CHAMBER, ANTERIOR (_see_ Anterior chamber)

  CICATRICIAL ECTROPION
    operations for, 284

  COCAINE
    sterilization of, 182

  CONGENITAL GLAUCOMA
    iridectomy for, 219

  CONICAL CORNEA
    operations for, 241

  CONJUNCTIVA
    expression of, 245
    removal of foreign bodies from, 244

  CONJUNCTIVOPLASTY, 245

  CONTRACTED SOCKET
    operations for, 260

  CORNEA
    cauterization of, 240
    conical, operations for, 241
    operations upon, 240
    removal of foreign bodies from, 240
    tattooing the, 243
    tumours, removal of, 243

  CORNEAL TUMOURS
    removal of, 243

  COUCHING, 209

  CYCLO-DIALYSIS, 229

  CYSTOID SCAR
    after iridectomy, 184

  CYSTS, TARSAL
    removal of, 246


  DE VINCENTIIS’ OPERATION, 287

  DENONVILLIERS
    ectropion operation, 285

  DIEFFENBACH’S OPERATION, 288

  DILATATION OF CANALICULI, 290

  DISCISSION OF THE LENS, 189

  DIVISION
    of anterior synechiæ, 227
       tarsal cartilage for entropion, 276

  DUCT, LACHRYMAL
    probing and syringing, 292


  ECTROPION OPERATIONS, 279

  ELECTRO-CAUTERY OPERATION FOR CONICAL CORNEA, 242

  ELECTROLYSIS FOR TRICHIASIS, 275

  ELECTRO-MAGNET OPERATIONS, 237

  ENTROPION OPERATIONS, 275

  ENUCLEATION
    of the globe, 255

  EVACUATION
    of the anterior chamber, 194

  EVISCERATION
    of the globe, 257
           orbit, 301

  EVULSION
    of the lens capsule, 195

  EXCISION
    of apex of conical cornea, 241
               lachrymal sac, 294

  EXPLORATION
    of the orbit (Krönlein’s), 299

  EXPRESSION
    of the conjunctiva, 245

  EXTRACTION
    of foreign bodies from conjunctiva, 244
                      from cornea, 240
                           globe, 237
       lens, 195

  EXTRA-OCULAR MUSCLES
    operations upon, 247

  EYELIDS
    operations upon, 263

  EYE-SOCKET
    contracted, operations upon, 261
    paraffin injections into, 260


  FERGUS
    ectropion operation, 281
    plastic operation upon eyelid, 267

  FILMS
    calcareous, scraping, 243

  FIXATION FORCEPS, 190

  FLAPS
    transplantation of for ectropion, 284

  FOREIGN BODIES
    in conjunctiva, 244
       cornea, 240
       globe, 237

  FRICKE
    plastic eyelid operation, 285

  FROST’S OPERATION, 259


  GIANT ELECTRO-MAGNET OPERATIONS, 238

  GLAND, LACHRYMAL
    excision of, 298

  GLAUCOMA
    iridectomy for, 217

  GLOBE
    direction of incisions in, 183
    enucleation of, 255
    evisceration of, 257
    Frost’s operation upon, 259
    Mules’s operation upon, 259
    operations for penetrating wounds of, 234
    wounds in, 182

  GRAFTING SUPERIOR RECTUS INTO LID, 273


  HANDS
    sterilization of, 182

  HARMAN
    ptosis operation, 269

  HEINE
    cyclo-dialysis, 229

  HESS
    ptosis operation, 268


  INCISION
    of the canaliculi, 291
    into the globe, 183

  INJECTION
    of paraffin into eye-socket, 260

  INSERTION OF STYLES, 293

  INSTRUMENTS
    sterilization of, 183

  IRIDECTOMY, 214
    for glaucoma, 217
        growths of iris, 225
    optical, 214
            Brudenell Carter’s, 217
    for prolapse of iris, 225

  IRIDOTOMY, 211
    Kuhnt’s, 212
    Ziegler’s, 213

  IRIS
    iridectomy for growths of, 225
    operations upon, 211
    prolapse of, iridectomy for, 225
    transfixion of, 226

  IRRIGATION
    delivery of lens by, 203


  KRÖNLEIN
    exploration of orbit, 299

  KUHNT
    ectropion operation, 281
    iridotomy, 299


  LACHRYMAL
    abscess, opening of, 297
    canals, obliteration of, 294
            operations upon, 290
    duct, probing, 292
          syringing, 292
    gland, operations upon, 298
    sac, excision of, 294

  LANG’S SPECULUM, 181

  LASH-BEARING AREA
    transplantation of, 278

  LENS
    capsule, evulsion of, 195
    delivery of, by irrigation, 203
    discission of, 189
    extraction of, 195
    operations upon, 187
    surgical anatomy of, 187

  LEVATOR PALPEBRÆ
    advancement of, 272

  LID MARGIN
    suture of wounds of, 264

  LIDS
    operations upon, 263

  LOCAL PREPARATION OF PATIENT FOR OPERATION, 180


  MCKEOWN
    removal of lens, 203

  MAGNET, ELECTRO-, OPERATIONS, 237

  MAXWELL
    contracted socket operation, 261

  MOTAIS
    ptosis operation, 273

  MULES’S OPERATION, 259

  MUSCLES, EXTRA-OCULAR
    operations upon, 247

  MYOPIA
    discission of lens in, 190


  NEEDLING OF THE LENS, 189


  OBLITERATION
    of the canaliculi, 294
           lachrymal canals, 294

  OCULAR MUSCLES
    advancement of, 251
    tenotomy of, 248

  OPERATING
    tables, 180
    theatres, 179

  OPERATIONS
    general preliminaries, 177

  OPTICAL IRIDECTOMY, 214

  ORBIT
    abscess of, 301
    evisceration of, 301
    exploration of, 299
    operations upon, 299
    plastic operations upon, 260

  ORBITAL
    abscess, opening, 301
    portion of lachrymal gland, removal of, 299


  PAGENSTECHER’S SPOON, 196

  PALPEBRAL
    aperture, operations, upon, 265
    portion of lachrymal gland, removal of, 298

  PANAS
    ptosis operation, 271

  PARACENTESIS
    of anterior chamber, 233

  PARAFFIN INJECTIONS
    into eye-socket, 260

  PASSIVE ECTROPION
    operations for, 280

  PENETRATING WOUNDS
    of the globe, 234

  PLASTIC OPERATIONS
    upon the eyelids, 287
             orbit, 260

  POSTERIOR SCLEROTOMY, 232

  PREPARATIONS FOR EYE OPERATIONS, 177

  PRIMARY GLAUCOMA
    iridectomy for, 218

  PROBING LACHRYMAL DUCT, 292

  PROLAPSE OF IRIS
    iridectomy for, 225

  PTERYGIUM
    operations for, 244

  PTOSIS OPERATIONS, 267

  PURIFICATION OF EYE, 181


  RECTIFICATION
    of faulty curve of tarsus, 276

  REMOVAL
    of eye, operations upon socket after, 260
       foreign bodies from conjunctiva, 244
                      from cornea, 240
                           globe, 236


  SAC, LACHRYMAL
    excision of, 294

  SCLERECTOMY, 231

  SCLEROTOMY
    anterior, 228
    posterior, 232

  SCRAPING CALCAREOUS FILMS, 243

  SECONDARY
    cataract, operations for, 192
    glaucoma, iridectomy for, 219

  SEPSIS
    after intra-ocular operations, 181

  SKIN-GRAFTING
    for contracted socket, 261
        ectropion, 287

  SKIN AND MUSCLE ENTROPION OPERATION, 275

  SNELLEN’S SUTURES, 280

  SOCKET, CONTRACTED
    operation for, 261
    operations upon after removal of eye, 260

  SPECULUM, LANG’S, 181

  SQUINT OPERATIONS, 247

  STREATFIELD’S OPERATION, 277

  STERILIZATION
    of cocaine, 182
       instruments, 183

  STYLES
    insertion of, 293

  SURGICAL ANATOMY
    of glaucoma, 217
       lens, 187

  SUTURE OF WOUNDS OF LIDS, 263

  SUTURES, SNELLEN’S, 280

  SYNECHIÆ, ANTERIOR
    division of, 227

  SYMBLEPHARON OPERATIONS, 264

  SYRINGING
    lachrymal duct, 292


  TARSAL CARTILAGE
    division of, for entropion, 276

  TARSAL CYSTS
    removal of, 246

  TARSORRHAPHY, 266

  TATTOOING THE CORNEA, 243

  TENOTOMY
    of ocular muscles, 248

  THEATRES, OPHTHALMIC, 179

  THIERSCH
    skin-grafting for ectropion, 287

  TRANSFIXION
    of the iris, 226

  TRANSPLANTATION
    of the lash-bearing area, 278

  TRICHIASIS
    operations for, 275

  TUMOURS
    corneal, removal of, 243


  UNDINE, 182


  VECTIS, 196

  VY OPERATION FOR ECTROPION, 284


  WHARTON JONES
    ectropion operation, 284

  WOUNDS
    of eyelids, suture of, 263
       globe, 234


  ZIEGLER
    iridotomy, 213


OPERATIONS UPON THE EAR

  ABSCESS
    extra-dural, operations for, 431
    Bezold’s mastoid, operations for, 389
    cerebellar, opening of, 467
    cerebral, opening of, 459
    intracranial, operations for, 459
    subperiosteal mastoid, operation for, 389
    temporo-sphenoidal, opening of, 463

  ADHESIONS, INTRATYMPANIC
    division of, 342

  ANÆSTHESIA
    in aural operations, 310

  ANÆSTHETIC SOLUTIONS
    Neumann’s, 311

  ANATOMY
    of the labyrinth, 420
           mastoid area, 373

  ATRESIA
    of the external auditory canal, operations for, 330

  ATTIC
    syringing out of the, 308

  AUDITORY CANAL, EXTERNAL
    operations upon, 314
               for atresia, 330
                   stenosis, 328
    removal of exostoses from, 316
               foreign bodies from, 322
               polypi from, 331

  AURAL
    instrument, Burkhardt-Merian’s, 315
    mirror, 305
    polypus, removal of, 333
    specula, 306


  BEZOLD’S MASTOID ABSCESS
    operation for, 389

  BOUGIE, EUSTACHIAN
    passage of, 369

  BULB
    jugular, exposure of, 454

  BURKHARDT-MERIAN’S AURAL INSTRUMENT, 315


  CANAL, AUDITORY (_see_ Auditory canal)

  CANULA
    Hartmann’s, 308
    Milligan’s, 308

  CATH[ET]ERIZATION
    of Eustachian tube, 364

  CAUTERIZATION
    of granulations in tympanum, 348

  CEREBELLAR OTITIC ABSCESS
    opening of, 467

  CEREBRAL OTITIC ABSCESS
    opening of, 459

  CLAR’S LAMP, 305

  CLEANSING OF EAR, 307

  COCHLEA
    removal of, 424

  COMPLETE MASTOID OPERATION, 391

  CURETTING
    of aural polypi, 334
       labyrinth, 421
       tympanic granulations, 348


  DILATATION
    of external meatus, 328

  DIVISION
    of anterior tympanic ligament, 341
       intratympanic adhesions, 342
       posterior tympanic fold, 341


  EAR
    cleansing of, 307

  EUSTACHIAN BOUGIE
    passage of, 369

  EUSTACHIAN TUBE
    catheterization of, 364
    lavage of tympanum through, 372

  EXAMINATION OF EAR
    methods of, 305

  EXCISION
    of stricture of external meatus, 329

  EXOSTOSES
    removal of from external meatus, 316

  EXPOSURE
    of the jugular bulb, 454
                   vein, 448
           lateral sinus, 440

  EXTERNAL AUDITORY CANAL (_see_ Auditory canal, external)

  EXTERNAL MEATUS
    operations for stenosis of, 328
    removal of exostoses from, 316

  EXTIRPATION OF LABYRINTH, 425

  EXTRA-DURAL ABSCESS
    operations for, 431


  FOREIGN BODIES
    in ear, removal of, 322

  FURUNCULOSIS
    of ear, operations for, 314


  GALVANO-CAUTERY PERFORATION
    of tympanic membrane, 340

  GENERAL ANÆSTHESIA
    in aural operations, 310

  GRANULATIONS
    in tympanum, removal of, 348

  GRUNERT
    operation on the jugular bulb, 454


  HARTMANN’S CANULA, 308


  ILLUMINATION
    in aural examinations, 305

  INCISION
    of external auditory meatus, 328
    Wilde’s mastoid, 377

  INCUS
    removal of, 351

  INTRACRANIAL OTITIC ABSCESS
    operations for, 459
    after-treatment of, 469
    complications of, 469
    prognosis and results in, 470
    recurrence of symptoms after, 471

  INTRATYMPANIC OPERATIONS, 342


  JUGULAR BULB
    exposure of, 454

  JUGULAR VEIN
    ligature of, 446


  KNIFE
    paracentesis, 340

  KÖRNER
    post-meatal flaps, 402

  KÜSTER-BERGMANN
    mastoid operation, 393


  LABYRINTH
    operations upon, 417
    curetting, 421
    extirpation of, 425
    surgical anatomy of, 420

  LABYRINTHITIS
    non-suppurative, operation for, 417

  LAMP, CLAR’S, 305

  LATERAL SINUS THROMBOSIS
    operations for, 439
    comparison of operations, 457
    complications following, 458
    difficulties and dangers in, 457
    exposure of jugular bulb, 454
    exposure of sinus, 440
    Grunert’s operation for, 454
    ligature of jugular vein for, 446
    Piffl’s operation for, 455
    opening of sinus, 442
    prognosis in, 458

  LAVAGE OF TYMPANUM, 372

  LIGAMENT, ANTERIOR TYMPANIC
    division of, 341

  LIGATURE
    of aural polypus, 333
       jugular vein, 446

  LOCAL ANÆSTHESIA, 310


  MALLEUS
    direct massage of, 349
    and incus, removal of, 351

  MASSAGE
    direct, of malleus, 349
               stapes, 350

  MASTOID
    abscess, Bezold’s, 389
             subperiosteal, 389
    area, anatomy of, 373
    necrosis of, operation for, 390
    operation, the complete, 391
               closure of the wound after, 404
               history of the, 375
               in an infant, 389
               Küster-Bergmann method, 393
               post-meatal flaps, use of, 401
               preservation of ossicles and tympanic membrane after, 399
               for removal of foreign bodies from ear, 327
               Schwartze’s method, 378
               skin-grafting after, 405
               Stacke’s method, 397
               for stenosis of external auditory canal, 330
               for subperiosteal abscess, 389
               Wilde’s incision in, 377
               Wolf’s method, 396
    process, operations upon, 373
             osteomyelitis of, 390

  MEATUS, EXTERNAL (_see_ External meatus)

  MEMBRANE, TYMPANIC (_see_ Tympanic membrane)

  MENINGITIS, OTITIC
    operations for, 433
    after-treatment of, 436
    prognosis and results, 438

  MILLIGAN’S CANULA, 308

  MIRROR, AURAL, 305

  MOBILIZATION OF THE OSSICLES, 349


  NECROSIS
    of mastoid, operation for, 390

  NEUMANN’S
    anæsthetic solutions, 311
    method of opening vestibule, 424
    syringe, 311


  OPENING OF LATERAL SINUS, 442

  OSSICLES
    operations upon the, 349
    massage of the, 349, 356
    mobilization of the, 349
    preservation of the, after mastoid operation, 399
    removal of the, 351, 361

  OSTEOMYELITIS OF MASTOID
    operation for, 390


  PANSE
    post-meatal flaps, 402

  PARACENTESIS TYMPANI, 336
    knife for, 340

  PIFFL
    operation upon the jugular bulb, 454

  POLITZER
    division of anterior tympanic ligament, 341

  POLYPUS, AURAL
    operations for, 331

  POST-AURAL OPERATION (_see_ Mastoid operation)

  POST-MEATAL FLAPS, 401


  REMOVAL
    of the cochlea, 424
           ossicles, 351, 361
       foreign bodies from the ear, 322


  SCHWARTZE
    mastoid operation, 378

  SINUS, LATERAL (_see_ Lateral sinus)

  SKIN FLAPS
    post-meatal, 401

  SKIN-GRAFTING
    after mastoid operation, 405

  SNARE, WILDE’S, 332

  SPECULA, AURAL, 306

  STACKE
    mastoid operation, 397
    post-meatal flaps, 402

  STAPEDIUS
    tenotomy of, 347

  STAPES
    massage of, 350

  STENOSIS OF EXTERNAL MEATUS
    operations for, 328

  SUBPERIOSTEAL MASTOID ABSCESS
    operations for, 389

  SURFACE ANATOMY
    of mastoid process, 375

  SURGICAL
    anatomy of labyrinth, 420
               mastoid area, 373
               tympanic cavity, 335
    toilet of ear, 309

  SYRINGING
    out of attic, 308
           ear, 308
    for removal of foreign bodies, 322


  TEMPORO-SPHENOIDAL ABSCESS
    opening, 463

  TENOTOMY
    of tensor tympani, 346
       stapedius, 347

  TENSOR TYMPANI
    tenotomy of, 346

  THROMBOSIS OF LATERAL SINUS
    operations for (_see_ Lateral sinus thrombosis)

  TOD’S POST-MEATAL FLAPS, 401

  TREPHINING
    for otitic cranial abscess, 462

  TUBE, EUSTACHIAN (_see_ Eustachian tube)

  TYMPANIC CAVITY
    lavage of, 372
    operations within, 335
    surgical anatomy of, 335

  TYMPANIC FOLD
    posterior, division of, 341

  TYMPANIC GRANULATIONS
    curetting of, 348

  TYMPANIC MEMBRANE
    artificial perforation of, 340
    division of anterior ligament of, 341
                post. tympanic fold, 341
    paracentesis of, 336
    preservation of after mastoid operation, 399
    surgical anatomy of, 335

  TYMPANUM (_see_ Tympanic cavity)


  VEIN, JUGULAR (_see_ Jugular vein)

  VESTIBULE
    opening the, 422


  WILDE
    mastoid incision, 377
    snare, 332

  WOLF
    complete mastoid operation, 396


OPERATIONS UPON THE THROAT

  ANÆSTHESIA
    for direct laryngoscopy, 482
        laryngotomy, 512
        thyrotomy, 489
        tracheotomy, 544

  ANATOMY
    of laryngeal lymphatics, 496
       the trachea, 523


  BRONCHOSCOPY
    lower, 562
    upper, 562

  BUTLIN
    after-treatment in thyrotomy, 494
    laryngectomy operations, 507


  CHIARI
    total laryngectomy, 502

  CRICO-TRACHEOTOMY, 529

  CUNEO
    anatomy of laryngeal lymphatics, 496

  CURES AFTER THYROTOMY, 505


  DIPHTHERIA
    tracheotomy for, 517, 526

  DIRECT LARYNGOSCOPY
    Killian’s method, 479


  ENDOLARYNGEAL
    operations, 475
    removal of multiple papillomata, 485

  EXTRA-LARYNGEAL OPERATIONS, 487


  FEEDING AFTER THYROTOMY, 494

  FÖDERL
    total laryngectomy, 502


  GLUCK
    total laryngectomy, 500


  HANDLEY
    total laryngectomy, 502

  HEMI-LARYNGECTOMY, 495
    mortality after, 506
    recurrence after, 506

  HIGH TRACHEOTOMY, 530


  INDIRECT LARYNGOSCOPY, 477

  INFRATHYREOID LARYNGOTOMY, 510

  INTUBATION, 549
    of the larynx, 549
    _v._ tracheotomy in diphtheria, 549


  KILLIAN
    direct laryngoscopy, 479


  LAMP
    for direct laryngoscopy, 480

  LARYNGEAL LYMPHATICS
    anatomy of, 496

  LARYNGEAL STENOSIS
    after tracheotomy, 538

  LARYNGECTOMY, TOTAL, 498
    Butlin’s cases, 507
    Chiari’s cases, 502
    Föderl’s cases, 502
    Gluck’s operation, 500
    Handley’s cases, 502
    Le Bec’s cases, 502
    mortality after, 506
    recurrence after, 507
    swallowing after, 509
    voice after, 508

  LARYNGO-FISSURE
    for removal of multiple papillomata, 485

  LARYNGOSCOPY
    direct, 479
    indirect, 477

  LARYNGOTOMY
    infrathyreoid, 510

  LARYNX
    intubation of, 549

  LE BEC
    total laryngectomy, 502

  LOW TRACHEOTOMY, 532

  LOWER BRONCHOSCOPY, 562

  LYMPHATICS, LARYNGEAL
    anatomy of, 496


  MEDIAN TRACHEOTOMY, 532

  MORTALITY
    after hemi-laryngectomy, 506
          total laryngectomy, 506
          thyrotomy, 504


  PAPILLOMATA, MULTIPLE
    removal of, 484

  PRELIMINARY TRACHEOTOMY, 523


  RECURRENCE
    after hemi-laryngectomy, 506
          total laryngectomy, 507
          thyrotomy, 505

  REMOVAL OF TUBE AFTER TRACHEOTOMY, 535

  RESECTION OF TRACHEA, 547


  SKIAGRAPHY
    in endolaryngeal operations, 476

  STENOSIS
    after tracheotomy, 538

  SWALLOWING
    after total laryngectomy, 509


  THYROTOMY, 487
    complications in, 494
    cures after, 505
    feeding after, 494
    mortality after, 504
    recurrence after, 505

  TOTAL LARYNGECTOMY, 498

  TRACHEA
    anatomy of, 523
    operations upon, 517
    resection of, 547

  TRACHEO-FISSURE, 547

  TRACHEOSCOPY
    indications for, 558

  TRACHEOTOMY, 517
    accidents during, 533
    after-treatment of, 534
    complications of, 536
    for diphtheria, 517, 526
    high, 530
    intubation _v._, 549
    local anæsthesia for, 544
    low, 532
    median, 532
    preliminary, 523
    for removal of multiple papillomata, 485
    stenosis after, 538

  TUBE SPATULÆ
    for direct laryngoscopy, 480

  TUBE, TRACHEOTOMY
    removal of, 535

  TUMOURS, ENDOLARYNGEAL, 475


  UPPER BRONCHOSCOPY, 562


  VOICE AFTER TOTAL LARYNGECTOMY, 508


OPERATIONS UPON THE NOSE AND NASO-PHARYNX

  ABSCESS
    retropharyngeal, 864
    of septum, operation for, 612

  ADENOIDS
    removal of, 665

  ADRENALIN
    in nasal operations, 573

  AFTER-RESULTS OF OPERATIONS, 580

  AIR-PASSAGES, LOWER
    protection of during operations, 576

  AMPUTATION
    of anterior end of inferior turbinal, 587
       lower margin of inferior turbinal, 588
       posterior end of inferior turbinal, 589

  ANÆSTHESIA
    for complete turbinotomy, 591
    local, 572
    for removal of posterior end of inferior turbinal, 589

  ANTRUM, MAXILLARY (_see_ Maxillary sinus)

  ASCH
    operation upon the septum, 599

  ASEPSIS, NASAL, 578


  BLEEDING
    control of, 574

  BÖNNINGHAUS
    operation upon the maxillary sinus, 637

  BOND
    preliminary laryngotomy in naso-pharyngeal operations, 663

  BUTLIN
    preliminary laryngotomy in naso-pharyngeal operations, 663


  CALDWELL-LUC
    operation upon the maxillary sinus, 631

  CANINE FOSSA
    operation through, 631

  CATHETERIZING
    frontal sinus, 638
    maxillary sinus, 626

  CHOANA, POSTERIOR
    congenital occlusion of, 583

  CLAR’S LAMP, 570

  CLEANSING THE NOSE, 579

  COCAINE
    submucous injection of, 572
    substitutes for, 573

  COMPLETE TURBINOTOMY, 591

  COMPLICATIONS FOLLOWING OPERATIONS, 577

  CONGENITAL OCCLUSION
    of nostrils, 582
       posterior choana, 583


  DEFORMITIES OF SEPTUM
    operations for, 597

  DENKER
    operation upon the maxillary sinus, 625, 637

  DESAULT
    operation upon the maxillary sinus, 631

  DEVIATION, SIMPLE, OF NASAL SEPTUM
    operations for, 598

  DIVISION OF THE SOFT PALATE
    for removal of naso-pharyngeal growths, 663


  ELEVATING OLD NASAL FRACTURES, 582

  EUCAINE ANÆSTHESIA, 573

  EXAMINATION OF NOSE
    methods of, 569


  FOREIGN BODIES
    removal of, 584

  FOSSA, CANINE (_see_ Canine fossa)

  FRACTURES, NASAL
    operations for, 582

  FRONTAL SINUS
    catheterizing and washing out, 638
    Killian’s external operation, 642
    Kuhnt’s external operation, 653
    Ogston-Luc external operation, 651
    operation for suppuration in, 638


  GLEASON-WATSON
    operation upon the septum, 599

  GROWTHS, NASAL
    removal of, 616


  HÆMATOMA OF SEPTUM
    operation for, 612

  HÆMORRHAGE
    control of in nasal operations, 574


  ILLUMINATION
    for nasal operations, 569

  INJURIES, NASAL
    operations for, 581

  ISCHÆMIA, LOCAL, 573


  KILLIAN
    frontal sinus operation, 642

  KUHNT
    frontal sinus operation, 653


  LAMP, CLAR’S, 570

  LARYNGOTOMY, PRELIMINARY
    in naso-pharyngeal operations, 663

  LATERAL RHINOTOMY (_see_ Rhinotomy, lateral)

  LOCAL
    anæsthesia, 572
    ischæmia, 573


  MAXILLARY ANTRUM (_see_ Maxillary sinus)

  MAXILLARY SINUS
    operations upon, 626
    Bönninghaus’s operation upon, 637
    Caldwell-Luc operation upon, 637
    canine fossa, operation through, 631
    catheterizing, 626
    Denker’s operation upon, 625, 637
    Desault’s operation upon, 631
    operation through nasal wall, 637
    puncturing, 626
    radical operation upon, 631

  MIDDLE TURBINAL
    operations upon, 592

  MOURE
    lateral rhinotomy, 618
    operation upon the septum, 599


  NARES, ANTERIOR
    congenital occlusion of, 582

  NASAL BONES
    operations for fracture of, 582

  NASAL GROWTHS
    removal of, 613

  NASAL SEPTUM
    abscess of, 612
    deformities of, 597
    hæmatoma of, operation for, 612
    operations upon, 597
      Asch’s operation, 599
      Gleason-Watson’s operation, 599
      Moure’s operation, 599
    perforating the, 598
    perforation of, operation for, 611
    removal of spurs from, 597
    simple deviation, operations for, 598
    submucous resection of, 601

  NASAL SYPHILIS
    operations for the results of, 594

  NASO-PHARYNX
    adenoids, removal of, 665
    examination of, 569
    operations for direct access to, 618, 661
    post-syphilitic affections of, 595
    sequestrotomy in, 594

  NOSE
    methods of examining, 569

  NOSTRILS
    congenital occlusion of, 582

  NOVOCAINE ANÆSTHESIA, 573


  OCCLUSION OF NOSTRILS
    congenital, 582

  OGSTON-LUC
    frontal sinus operation, 651

  OPENING SPHENOIDAL SINUS, 656


  PALATE, SOFT (_see_ Soft palate)

  PERFORATING THE SEPTUM, 598

  PERFORATION OF THE SEPTUM
    operation for, 611

  POST-SYPHILITIC AFFECTIONS OF NOSE AND NASO-PHARYNX, 595

  PROTECTION OF AIR-PASSAGES DURING OPERATIONS, 576

  PUNCTURING
    the maxillary sinus, 626


  RADICAL OPERATION UPON THE MAXILLARY SINUS, 631

  REMOVAL
    of foreign bodies from nose, 584
       nasal growths, 613
       rhinoliths, 586
       spurs from the nasal septum, 597

  RESECTION OF THE SEPTUM
    submucous, 601

  RETROPHARYNGEAL ABSCESS, 664

  RHINOLITHS
    removal of, 586

  RHINOTOMY
    combined lateral and sublabial, 625
    lateral, Moure’s, 618
    sublabial, Rouge’s, 622

  ROBINSON
    operation for post-syphilitic affections of nose, 595


  SEPSIS AFTER NASAL OPERATIONS, 577

  SEPTUM (_see_ Nasal septum)

  SEQUESTROTOMY IN NOSE AND NASO-PHARYNX, 594

  SHOCK DURING OPERATIONS, 577

  SINUS, FRONTAL (_see_ Frontal sinus)

  SINUS, SPHENOIDAL (_see_ Sphenoidal sinus)

  SOFT PALATE
    division of, for removal of naso-pharyngeal growths, 663

  SOUNDING SPHENOIDAL SINUS, 653

  SPENCER
    operation for post-syphilitic affections of nose, 595

  SPHENOIDAL SINUS
    opening, 656
    sounding and washing out, 653

  SPURS OF SEPTUM
    operations for, 597

  SUBLABIAL RHINOTOMY
    Rouge’s, 622

  SUBMUCOUS
    injection of cocaine, 572
    resection of the septum, 601

  SUPPURATION IN FRONTAL SINUS
    operation for, 638

  SYPHILIS, NASAL
    operations for results of, 594


  TILLEY
    operation for post-syphilitic affections of nose, 595

  TUBERCULOSIS OF THE NOSE, 596

  TURBINALS
    operations upon, 586
    inferior, amputation of inferior end, 587
                            lower margin, 588
              removal of posterior end, 589
    middle, operations upon, 592

  TURBINOTOMY, COMPLETE, 591




OXFORD: HORACE HART

PRINTER TO THE UNIVERSITY