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).

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.

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.

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