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