A New Mastoid Retractor BY MAX THORNER, A.M., M.D. CINCINNATI, O. PROFESSOR OF CLINICAL LARYNGOLOGY AND OTOLOGY, CINCINNATI COLLEGE OF MEDICINE AND SURGERY (MEDICAL DEPARTMENT OF THE CINCINNATI UNIVERSITY) ; LARYNGOLOGIST AND AURIST TO THE CINCINNATI HOSPITAL, ETC. Reprinted from the Medical Record, July 20, 1895 NEW YORK TROW DIRECTORY, PRINTING AND BOOKBINDING CO. 201-213 East Twelfth Street 1895 Reprinted, from the Medical Record, July 20, 1895. A NEW MASTOID RETRACTOR. By MAX THORNER, A.M., M.D.. CINCINNATI, O. PROFESSOR OF CLINICAL LARYNGOLOGY AND OTOLOGY, CINCINNATI COLLEGE OF MEDICINE AND SURGERY (MEDICAL DEPARTMENT OF THE CINCINNATI UNIVER- SITY) ; LARYNGOLOGIST AND AUKIST TO THE CINCINNATI HOSPITAL, ETC. During a mastoid operation the field of operation must be kept thoroughly clear by having the margins of the wound well drawn apart. After making the in- cision parallel to the insertion of the auricle, and stop- ping the hemorrhage, the bone is denuded by pushing the parts backward and forward with a raspatory. The margins of the wound are then kept separated during the whole operation by strong three- or four-pronged retractors, held by the hands of assistants. This is. however, not only very tiresome dur- ing protracted operations, but the hands, and especially the one holding the posterior retractor, are frequently in the way of the surgeon. To over- come this difficulty several devices have been invented, as, for instance, the self-retaining retractors of Barth, Zarniko, Allport, and Bishop. All of these are constructed on the prin- ciple of two retracting hooks, united at the lower extremities by cross- bars, or by screws ; by which they are also separated and kept so during the operation. For some time I have been using a little device that is so exceedingly simple and has given such universal satisfaction, to me 2 and a number of colleagues, that I think it will readily recommend itself for this and similar operations. The instrument consists of a flat S-shaped piece of steel, about one inch and three-fourths long, and five- eighths of an inch broad. One of the extremities is shaped into a three- or four-pronged hook, while the other extremity forms a blunt, broad retractor, bent in the opposite direction. This instrument is used in the following manner : When the bone is well denuded and the periosteum pushed aside, the prongs of one retractor are well hooked below the periosteum of the posterior margin of the wound, and the prongs of the other retractor below the parts of the anterior margin (/>., the detached 3 auricle). Then a long strip of sterilized gauze, about an inch and a half broad, and preferably doubled, to render it stronger, is folded in its middle over the blunt end of the anterior hook, drawn across the forehead and around the head of the patient, and fas- tened tightly over the blunt hook of the posterior re- tractor. Instead of the strip of gauze one may also use a long rubber ring, as was suggested to me by Dr. Vail, of this city, to whom I am also indebted for the sketch from which the cut has been made. Sometimes the amount of tissue which is to be held back by the anterior retractor is so enormous, comprising the auri- cle and more or less infiltrated tissues deep down into the external auditory canal, that the usual anterior hook, as shown in the cut, cannot sufficiently grasp it, to embrace it well, as it were. For such cases, and their number is not small, I have had constructed, at the suggestion of Professor S. C. Ayres, a special ante- rior hook in which the pronged end is about one inch distant from the flat shaft. With this hook, especially if we have one somewhat (about one-fourth to three-eighths of an inch) broader, and having four instead of three prongs, we can safely hold back the auricle with any amount of infiltrated tissue. J, This is the manner of procedure in which the antrum only is to be opened. In such operations, however, in which the upper and posterior walls of the auditory canal are to be removed, one may 'either apply both hooks in the above-described manner, or one may, as I would prefer in some cases, use only the posterior hook, after having drawn the strip of gauze around the detached auricle between the wall of the osseous and the cutaneous canal, and then back through the auditory canal proper, as has been recommended by Holmes.1 The strip of gauze is then 1 Archives of Otology, 1893, p. 344. 4 tied around the forehead and over the blunt hook of the posterior retractor in the above-described manner. Little changes in the application of the hooks will sug- gest themselves, of course, to the surgeon ; sometimes, for instance, the relative position of the hooks will demand that the strip of gauze be carried across the upper lip, just below the nose, instead of across the forehead. The advantages of this method are obvious. The margins of the wound are kept immovably separated, as the gauze can be fastened tightly or loosely. It can be removed or changed in an instant. One, and some- times two, hands of an assistant are positively spared, and one may do with one assistant less. Neither hands of assistant nor cross-bars of instrument are in the way of the operator. This appliance does not get tired nor relaxed, as the hands of assistants sometimes do in protracted operations. The relative position of the hooks can be readily changed to suit the con- venience of the surgeon. The posterior hook may also serve to hold down the flexible probe, which is in- troduced into the attic from the posterior funnel- shaped opening, after the antrum has been opened. The hooks are readily rendered aseptic, and the gauze is, of course, sterilized before the operation. Those who prefer a blunt retractor instead of a pronged or sharp one, may simply reverse the instrument. The slender S-shaped curve renders it easily adapted to the irregular surfaces with which we have to deal. And, finally, the instrument can be used for any other surgical operations, and is cheap on account of its simple construction.