[Ill.u.s.tration: FIG. 247. EXPOSURE OF THE INTERNAL JUGULAR VEIN HIGH UP.

A, Common facial vein; B, Sterno-hyoid muscle; C, Omo-hyoid muscle; D, Anterior border of the sterno-mastoid muscle retracted outwards. A ligature is placed around the jugular vein just above the common facial vein. When the jugular is ligatured at this spot it is not necessary to tie the facial vein. In actual practice the vein, of course, would be tied and cut between two ligatures, the upper portion of the vein being brought out into the neck.]

When the vein has been identified, a blunt dissector is pa.s.sed between its outer wall and the sheath, so as to separate the two. The sheath is incised upwards and downwards until the vein is freely exposed. If the vein be patent, it will be of a bluish colour, expanding and diminishing in volume with each act of respiration. If it be thrombosed, there is usually accompanying periphlebitis which may make the separation of the sheath from the vein and the surrounding tissues difficult. If there be no periphlebitis, the thrombosed portion may be purplish, or, if the clot be of long standing and breaking down, more of a yellowish colour; the vein stands out as a cord and does not pulsate. If the thrombus be limited to the portion above the entrance of the common facial vein, the upper portion of the jugular may be small and collapsed, only becoming full and pulsating below the point at which the facial joins it.

The next step in the operation is to get well below the point at which the jugular is thrombosed. If the thrombus be practically limited to the jugular fossa the vein may be ligatured above the common facial; if not, as low down the neck as possible. In ligaturing the vein low down in the neck, the skin incision must be extended downwards, and as the lower portion of the neck is reached, the omo-hyoid will have to be pulled aside. The probe should be pa.s.sed all round the vein so as to make certain that it is freed from its sheath, and especially that it is separated from the vagus nerve which lies behind it.

An aneurysm needle threaded with silk is now pa.s.sed around the vein from within outwards. The loop of silk is cut so as to form two ligatures, and the aneurysm needle then withdrawn; the lower ligature is first tied, its ends being cut short. The upper ligature is then tied a short distance above it, but in this case the ends are left long. The vein is raised from its bed by slight traction on this ligature and is cut across between the two, the lower portion being allowed to sink back into the wound. The upper portion is then carefully separated for some distance upwards. Lying behind the vein may be seen the vagus nerve (Fig. 248). Any tributaries are clamped between two forceps, cut across, and ligatured, the upper end of the vein being brought out into the upper angle of the wound. Care must be taken that enough of the vein is dissected out to allow of this being done, especially if the ligature is applied above the level of the common facial; in this case the facial need not be tied.

If there be no periphlebitis, inflammation of the soft tissues, or thrombosis of the vein itself in the neck, the wound may be closed by means of silkworm-gut sutures, excepting at its upper angle through which the open end of the jugular vein projects. If, however, the vein be thrombosed, and especially if there be periphlebitis, the wound should be left open, except perhaps at its lower angle, and should be lightly packed with gauze, as in these cases cellulitis of the neck may afterwards occur.

After completion of the operation in the neck the surgeon turns to the mastoid process. If the ligature of the vein has been the primary step, the mastoid operation is now performed and the lateral sinus is freely exposed for a considerable distance behind the thrombus. If, however, the mastoid operation has been the first stage, and the jugular has been tied as soon as exposure of the sinus showed it to be thrombosed, the operation on the mastoid is now completed and the sinus opened as already described (see p. 444). The next step is to incise the sinus freely from above downwards towards the jugular fossa and curette out the thrombus.

If there be considerable haemorrhage, it means that the thrombus is probably parietal and situated within the jugular bulb, the bleeding presumably coming from the inferior petrosal sinus or other tributaries which enter the bulb or upper portion of the jugular vein. If the bleeding be excessive, the sinus is plugged after a moment or two, by inserting a piece of gauze into its lumen towards the jugular bulb.

[Ill.u.s.tration: FIG. 248. LIGATURE OF THE INTERNAL JUGULAR VEIN LOW DOWN IN THE NECK. The upper portion of the vein is dissected out and brought into the neck. A, A', Cut ends of the ligatured facial vein; E, Descendens noni nerve; F, Carotid sheath and internal carotid artery; G, Vagus nerve; H, Gland; J, Lower end of the internal jugular vein. The hook pulls aside the omo-hyoid muscle.]

In this case the portion of the vein brought into the neck is usually also filled with blood. After isolating it from the deeper tissues by packing strips of gauze round it, the vein is deliberately opened just above the ligature. The bleeding usually stops after a moment or two, but if it cannot be controlled, the lumen of the vein must again be closed by a ligature, the end of the vein being allowed to project on to the neck.

If there be no bleeding from the lower portion of the lateral sinus and jugular bulb, it means that the vessel is completely thrombosed at this point. The clot should now be removed by curetting through the sinus from above downwards towards the jugular bulb, and also from below upwards through the open end of the jugular vein.

[Ill.u.s.tration: FIG. 249. FREE EXPOSURE OF THE LATERAL SINUS, WHICH HAS BEEN INCISED, WITH LIGATURE OF THE INTERNAL JUGULAR VEIN. The lateral sinus is obliterated posteriorly by a plug of gauze pressed in between its outer wall and the underlying bone. The sinus is freely exposed almost down to the jugular fossa. The vein has been ligatured and its upper portion sutured to the skin wound in the neck. The arrow shows the direction along which the sinus and vein are syringed.]

The venous channel is afterwards syringed through from above downwards.

To do this, a piece of rubber tubing is inserted into the opening in the lateral sinus and some warm saline solution is injected through it with a syringe. If the clot be not firmly adherent it can usually be washed out through the opening in the vein. No force should be used. If gentle syringing be not sufficient to expel the clot, the attempt must be given up. The chief objection against syringing is the possibility of particles of the septic thrombus being forced into the veins communicating with the jugular bulb. A small drainage tube is inserted within the sinus.

In order to keep the lumen of the vein in the neck open, it should be st.i.tched to the edge of the wound surface by several catgut sutures (Fig. 250). If the bleeding necessitated plugging of the lower end of the sinus and retention of a ligature on the vein in the first instance, syringing should be postponed until the first dressing; the portion of the vein left protruding through the skin wound in the neck is then cut across, and the edge of the vein sutured to the margin of the wound under cocaine.

The mastoid cavity is lightly plugged with gauze and a dry dressing applied. The wound in the neck is similarly treated.

=After-treatment and progress of the case.= There is frequently considerable shock after the operation, especially if exposure of the jugular bulb has been undertaken, partly owing to the duration of the operation and to haemorrhage. If the patient be very collapsed, a continuous saline injection, to which some brandy may be added, may be given per r.e.c.t.u.m according to Moynihan's method. After the primary shock has pa.s.sed off, the immediate result is usually satisfactory.

_If the jugular vein has not been ligatured_, the first dressing should be performed within forty-eight hours, the gauze packing being removed, the wound syringed out, and afterwards repacked. The plugs of gauze, which were pressed in between the outer wall of the sinus and the overlying bone in order to obliterate the lumen of the latter, should not be interfered with for at least six days. If the case progresses favourably, the temperature becomes normal within a day or two, the patient feels well, and the wound a.s.sumes a healthy appearance. If, on removal of the gauze plugging, haemorrhage takes place, then the plugging must be renewed and not touched again for three or four days. After it is possible to remove these plugs, the wound is treated as has already been described in Schwartze's operation or in the complete operation in which the posterior wound was left open.

_If the jugular vein has been ligatured_, the sinus and vein should be syringed through daily, and this should only be stopped after all secretion has ceased, usually a matter of a week or ten days.

_When the sinus, jugular bulb, and vein have been exposed throughout their length_ the wound is treated as an ordinary surgical one, being packed until it granulates up from the bottom (_vide infra_).

[Ill.u.s.tration: FIG. 250. METHOD OF SUTURING THE OPEN END OF THE INTERNAL JUGULAR VEIN IN THE NECK.]

Apart from intracranial and pyaemic complications, the progress of the case may be delayed owing to the enfeebled and septic condition of the patient, and also from the occurrence of abscesses in the neck, or region of the mastoid itself. These abscesses are the result of septic thrombosis occurring in some tiny vessel. The first sign of their occurrence is an attack of pyrexia, shortly followed by a painful swelling at the affected spot. Any collection of pus should be drained at once. Although it is quite good practice to close the incision in the neck in a clean case, yet there must be no hesitation to open it up on the slightest sign of it becoming septic.

The case may appear to progress favourably for the first week or ten days, and then an intermittent and increasing pyrexia may occur for no obvious reason. This is usually due to extension of the infection along the petrosal sinuses, or perhaps along the transverse sinus.

Symptoms of involvement of the cavernous sinus may arise, perhaps even with formation of a peri-orbital abscess; or, on the other hand, the patient may gradually sink in consequence of septic toxaemia; or the end may come more suddenly with the onset of basal meningitis.

Unfortunately, these cases are almost hopeless from the first, as very little can be done from a surgical point of view owing to the fact that they are not seen soon enough.

_In thrombosis of the cavernous sinus_ the only hope of recovery lies in its exposure and incision of its wall. The sinus may be approached by tracking forwards the superior petrosal sinus--a matter of considerable difficulty, and seldom justifiable. Recently Charles Ballance has suggested the adoption of the Hartley-Krause route for extirpation of the Ga.s.serian ganglion, and says he has found the operation easy and effectual. If pus be evacuated from the sinus he considers it advisable to adopt the recommendation of Voss, who cuts away the zygoma and removes more bone from the basal aspect of the skull so as to get direct drainage (Allb.u.t.t and Rolleston's _System of Medicine_, 1908, vol. iv, Part ii, p. 495).

EXPOSURE OF THE JUGULAR BULB

This may be performed either by following the sinus downwards or through the floor of the auditory ca.n.a.l and tympanic cavity. The former method was first described by Grunert (_Archiv fur Ohrenheilkunde_, 1902, vol.

liii, p. 287); the latter by Piffl (_Archiv fur Ohrenheilkunde_, 1903, vol. lviii, p. 76).

=Indications.= The object of the operation is to remove the septic clot situated within the jugular bulb in the hope of preventing extension of the infection along the veins leading into it, more especially the inferior petrosal sinus. This indeed has been known to occur even after the lateral sinus has been curetted out, the jugular vein ligatured, and the venous channel syringed through.

=Grunert's operation.= After free opening of the mastoid process and exposure of the outer wall of the lateral sinus, the skin incision is extended downwards beyond the tip of the mastoid. The soft tissues are then separated from the bone forwards and backwards so as to expose completely not only the mastoid process, but also the digastric fossa and base of the skull immediately behind it, up to the outer bony margin of the jugular foramen. Unless care is taken, the forcible traction forwards of the soft tissues necessary to expose the field of operation may injure or tear the facial nerve as it emerges from the stylo-mastoid foramen.

The tip of the mastoid process is removed first. The lateral sinus is then freely exposed to its lowest possible limit by removing the overlying bone. In doing this it must be remembered that the sinus becomes horizontal just before it ends in the jugular fossa, so that at this point the skull forms its floor instead of its outer wall.

After having exposed the sinus as freely as possible, the 'bridge' of bone separating it from the outer wall of the jugular foramen is removed in small pieces by nipping it away with narrow biting forceps until the jugular bulb is exposed from its outer surface. The facial nerve should not be injured, as it lies in front and external to the portion of the bone to be removed.

In performing the later stages of the operation, the patient's head should be turned well over to the opposite side in order to get a good view of the parts lying behind and beneath the mastoid process; and in tracking the sinus downwards, the probe should be used carefully in order to try and define the exact position of the jugular fossa.

=Piffl's operation.= Owing to the anatomical difficulty of reaching the jugular bulb by following the sigmoid sinus downwards, especially in those cases in which the sinus lies far forwards and in which, at the same time, there is a very well-developed jugular fossa, Piffl recommends exposure of the jugular bulb from above through the auditory ca.n.a.l. The object of this method is to prevent injury to the facial nerve, which he states is almost certain to occur in Grunert's operation, if carried out in cases such as those just mentioned.

After the complete mastoid operation has been performed, the skin incision is extended downwards and forwards in order that the soft tissues may be freed from the floor and anterior surface of the bony portion of the auditory ca.n.a.l as far forward as the Glaserian fissure.

The soft tissues are pulled forward with a blunt hook to give sufficient room. The lower portion of the tip of the mastoid is removed by means of the gouge, as far as can be done without injuring the facial nerve, which in this operation is pulled backwards with the soft tissues at the posterior inferior margin of the wound. The lower bony margin of the auditory ca.n.a.l, now freely exposed, is removed by means of a pair of fine biting forceps until the floor of the tympanic cavity is reached.

If there be not sufficient room, the bone may be clipped away as far as the styloid process, which also may be removed by bone-forceps after the muscles attached to it have been dissected off.

In freeing the styloid process, its posterior surface must be approached with caution for fear of injuring the facial nerve, which here lies in close connexion with it. In the front of the wound the capsule of the temporo-maxillary joint may be exposed, but must not be interfered with.

After removal of the styloid process, the uppermost portion of the external jugular vein should be seen emerging from the jugular fossa.

This is followed upwards by careful removal of the bone between it and the floor of the auditory ca.n.a.l and tympanic cavity, until the jugular bulb is brought into view. This part of the operation must be proceeded with very cautiously, the bone being nibbled away in small fragments with gouge forceps which are of sufficient strength to nip through the bone without having to wrench it away. The amount of bone to be removed and the difficulty of the operation depend largely on the anatomical condition found.

Whether Grunert's or Piffl's operation has been employed, the operation may be completed either by incising the outer wall of the sinus and jugular bulb, then curetting out the thrombus, and finally washing through the lower portion of the vein from above downwards, or by the more radical method of also exposing the upper portion of the jugular vein throughout its whole length. To do this the post-aural incision is continued downwards until it joins the one previously made in the neck.

To obtain room, the neck must be somewhat extended and the jaw pulled well forward and the sterno-mastoid muscle backwards. The jugular vein is then dissected upwards towards the bulb.

The nearer the jugular fossa is approached the deeper and more difficult becomes the exposure of the vein. Pa.s.sing in front of it may be found the stylo-pharyngeal, stylo-hyoid, and digastric muscles. In Grunert's operation they need not be cut through as the vein will lie posterior to them. In Piffl's operation these muscles probably have been already reflected forward, after removal of the styloid process.

Particular care must be taken not to injure the nerve trunks, which are in such close relationship with the vein. Lying immediately behind the vein is the vagus nerve; the spinal accessory pa.s.ses downwards and outwards behind it, and the glosso-pharyngeal and hypoglossal nerves forwards between the vein and the internal carotid artery.

After the vein, the jugular bulb, and the sigmoid sinus have been exposed throughout their course, their outer wall is cut through with a pair of blunt-pointed scissors along its whole length, so as to convert the venous ca.n.a.l into an open gutter. The thrombus is then curetted out and the dissected portion of the jugular vein cut off as high up as possible. Any bleeding from the inferior petrosal sinus or condyloid veins, which may not be thrombosed, should be arrested by direct pressure of a strip of gauze over the bleeding points. The wound cavity is then washed out with a weak biniodide solution and dried.

The lower portion of the incision in the neck may be closed with sutures and a small drainage tube inserted at its lower angle. The upper portion of the wound, now directly continuous with that of the mastoid cavity, is left open and packed lightly with gauze, which is inserted into the remains of the venous channel.

=Comparison of operations for lateral sinus thrombosis.= Except when the thrombus is limited to the upper part of the sigmoid sinus, it is undoubtedly wiser to tie the jugular vein than to be content with curetting out the clot after obstructing the sinus above and below by means of gauze plugs. Exposure of the jugular bulb is so difficult an operation and requires so much time, especially if the whole length of the upper portion of the jugular vein is also dissected out, that it is seldom advisable to perform it; nor will it often be justifiable owing to the condition of the patient, who is seldom strong enough to undergo such a prolonged operation. The records of this particular operation are so few that it is impossible as yet to determine its value.

If the sinus be exposed as low down as possible, and the jugular vein dissected out and brought out into the neck, and the venous channel afterwards syringed through, the chances of recovery should be almost as good as in the case of free exposure of the jugular bulb.

If the inferior petrosal sinus be already infected before the operation, it does not matter whether the operation performed is that of syringing through the jugular bulb or freely exposing it, as in either case the inferior petrosal sinus cannot be followed out.

Curetting of the lower portion of the sinus without previous ligature of the jugular vein should never be done.

=Difficulties and dangers of the operation.= The chief difficulty in these operations is anatomical; the chief danger is haemorrhage.

If the haemorrhage be due to accidental tearing of the wall of the sinus in the earlier part of the operation, and if it be impossible to obliterate the sinus below this point by pressing in gauze between its wall and the underlying bone, then the jugular vein should be tied before anything else is done.