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Title: A System of Operative Surgery, Volume IV (of 4)

Author: Various

Editor: Frederick Francis Burghard

Release Date: December 26, 2012 [EBook #41710]

Language: English

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OXFORD MEDICAL PUBLICATIONS

A SYSTEM OF
OPERATIVE SURGERY



OXFORD: HORACE HART
PRINTER TO THE UNIVERSITY



OXFORD MEDICAL PUBLICATIONS

A
SYSTEM
OF
OPERATIVE SURGERY


BY VARIOUS AUTHORS

EDITED BY

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



IN FOUR VOLUMES


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




LONDON
HENRY FROWDEHODDER & STOUGHTON
Oxford University PressWarwick Square, E.C.
1909

EDITOR’S PREFACE

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

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

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

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

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

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

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


PREFACE TO VOLUME IV

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

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

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

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

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

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


CONTRIBUTORS TO THIS VOLUME

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

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

Abdominal Gynæcological Operations


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

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

Vaginal Gynæcological Operations


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

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

Ophthalmic Operations


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

Aural Surgeon to the London Hospital

Operations upon the Ear


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

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

Operations upon the Larynx and Trachea


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

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

Operations upon the Nose and its Accessory Cavities


CONTENTS

SECTION I

OPERATIONS UPON THE FEMALE GENITAL ORGANS

PART I

ABDOMINAL GYNÆCOLOGICAL OPERATIONS

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

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

CHAPTER I

PAGES

CŒLIOTOMY
Preparation of Patient, 3. Basins, Dishes, and Instruments, 4. Suture and Ligature Material, 5. Dabs, 5. Gloves, Operating Table, Anæsthesia, 6. The Incision, 7. Misplaced Viscera, 8. Closure of Wound, 839

CHAPTER II

OVARIOTOMY
The Operation, 10. Cysts of the Broad Ligaments, 14. Spurious Capsules, 15. For Carcinoma of Ovary, 15. Incomplete Ovariotomy, 16. Anomalous Ovariotomy, 16. Ovariotomy followed by Hysterectomy, 17. Repeated Ovariotomy, 17. Pregnancy after Bilateral Ovariotomy, 17. Ovariotomy at Extremes of Life, 18. Ovariotomy in Old Age, 19. Mortality, 191020

CHAPTER III

OÖPHORECTOMY
Operation, 22. Abdominal Hysterectomy after Bilateral Oöphorectomy and Ovariotomy, 25. Mortality, 25. Operation for Primary Cancer of the Fallopian Tube, 262128

CHAPTER IV

OPERATIONS FOR EXTRA-UTERINE GESTATION
Indications, 29. Operation, 29. Concurrent Intra- and Extra-uterine Pregnancy, 33. Results of Operative Treatment, 342935

CHAPTER V

HYSTERECTOMY AND MYOMECTOMY
Indications, 36. Subtotal Hysterectomy, 36. Total Hysterectomy, 40. Mortality, 44. Risks of Abdominal Hysterectomy, 45. Abdominal Myomectomy, 463649

CHAPTER VI

ON THE RELATIVE VALUE OF TOTAL AND SUBTOTAL
HYSTERECTOMY
Cancer of the Body of the Uterus and Fibroids, 52. Sarcoma, 53. Cancer of the Uterus after Bilateral Ovariotomy, 55. Adenomyoma of the Uterus, 56. Fate and Value of Belated Ovaries, 565060

CHAPTER VII

HYSTERECTOMY FOR PRIMARY CARCINOMA OF THE UTERUS
For Cancer of the Cervix, 61. For Cancer of the Body of the Uterus, 636165

CHAPTER VIII

OPERATIONS FOR DISPLACEMENT OF THE UTERUS
Ventro-suspension for Retroflexion of the Uterus, 66. Ventro-fixation for Prolapse of the Uterus, 676668

CHAPTER IX

OPERATIONS UPON THE UTERUS DURING PREGNANCY,
PARTURIENCY, AND PUERPERY
Cæsarean Section, 69; Immediately after the Death of the Mother, 72. Ovariotomy and Hysterectomy during Pregnancy and in Labour, 73. Ovariotomy during the Puerperium, 76. Fibroids and Pregnancy, 77. Pregnancy with Cancer of the Cervix, 82. Concurrent Uterine and Tubal Pregnancy, 82. Pregnancy with Tumours growing from the Pelvic Walls, 83. Operations for Puerperal Sepsis, 836985

CHAPTER X

OPERATIONS FOR INJURIES OF THE UTERUS
Gynæcological, 86. Obstetric, 87; to the Pregnant Uterus, 89; to the Gravid Uterus in the course of an Abdominal Operation, 89. Bullet Wounds of the Pregnant Uterus, 90. Stab-wounds of the Pregnant Uterus, 918692

CHAPTER XI

THE AFTER-TREATMENT, RISKS, AND SEQUELÆ OF ABDOMINAL
GYNÆCOLOGICAL OPERATIONS
After-treatment of Abdominal Operations, 93. Complications of Abdominal Gynæcological Operations—Metrostaxis, 95; Bed-sores, 95; Post-anæsthetic Paralysis, 95; Giving way of the Wound, 96; Hæmorrhage, 97; Intrapelvic Hæmorrhage, 98; Pneumonia, 99; Parotitis, 99; Thrombosis, 101; Pulmonary Embolism, 101; Foreign Bodies left in the Abdomen, 105; Tetanus, 107; Injury to the Intestines, 109; Intestinal Obstruction, 110; Perforating Ulcer of the Stomach and Small Intestine, 111; Injuries to the Bladder, 111; to the Ureter, 112. The fate of Ligatures, 117. Post-operative Kraurosis, 120. The Cicatrix, 12093122

PART II

VAGINAL GYNÆCOLOGICAL OPERATIONS

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

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

CHAPTER XII

PREPARATION OF THE PATIENT FOR PERINEAL AND VAGINAL OPERATIONS:
OPERATIONS FOR INJURIES TO THE PERINEUM AND PELVIC FLOOR
Preparation of the Patient, 125. Operations for Repair of a Complete Laceration of the Perineum, 127. Operation for Laceration of the Pelvic Floor, 132125133

CHAPTER XIII

OPERATIONS UPON THE URETHRA AND BLADDER
Extirpation of a Urethral Caruncle, 134. Operations for Incontinence following Labour, 134; for Vesico-vaginal Fistula, 135; for Recto-vaginal Fistula, 139; for Cystocele, 140134141

CHAPTER XIV

OPERATIONS UPON THE VULVA AND VAGINA
Operations upon Bartholin’s Glands, 142. Operations for Atresia of the Hymen and the Vagina, 143. Dilatation of the Vulval Orifice, 143. Colpotomy, 144; Anterior, 145; Posterior, 147; Lateral, 148142148

CHAPTER XV

OPERATIONS UPON THE UTERUS
Passage of the Uterine Sound, 149. Reposition of a Chronic Uterine Inversion, 151. Curetting the Uterus, 152. Dilatation of the Cervix, 156Rapid Dilatation, 157; Gradual Dilatation, 159. Operations for Hypertrophy of the Cervix, 160. Trachelorrhaphy, 161. Vaginal Fixation, 164149164

CHAPTER XVI

OPERATIONS FOR NEW GROWTHS OF THE UTERUS
For Uterine Fibro-myomata, 165for Pedunculated Tumours, 165; for Sessile Tumours, 166; for Interstitial Tumours, 167. Vaginal Hysterectomy, 167for Carcinoma, 168; for Fibroids, 173165173

SECTION II

OPHTHALMIC OPERATIONS

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

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

CHAPTER I

GENERAL CONSIDERATIONS APPLICABLE TO OPERATIONS
UPON THE EYE
General Preliminaries to an Operation, 177. Local Preparation of the Patient, 80. Making and Healing of Wounds in the Globe, 182Purification of Hands, 182; of Instruments, 183; Direction of Incision, 183; Position of Incision, 184; Dressings, 186; Bandaging, 186177186

CHAPTER II

OPERATIONS UPON THE LENS
Surgical Anatomy, 187. Discission or Needling, 189for Cataract, 189; for High Myopia, 190. Capsulotomy, 192. Evacuation, 194. Evulsion of the Capsule, 195. Extraction of the Lens, 195. Modifications, 201; Delivery of the Lens by Irrigation, 203; Extraction of the Lens in its Capsule, 204; Subconjunctival Extraction, 204. Couching, 209187210

CHAPTER III

OPERATIONS UPON THE IRIS
Iridotomy, 211. Alternative Methods—Kuhnt’s Operation, 212; Ziegler’s, 213. Iridectomy—Optical Iridectomy, 214; Glaucoma Iridectomy, 217—for small Growths of the Iris, 225; for Prolapse of the Iris, 225. Transfixion of the Iris, 226. Division of Anterior Synechiæ, 227211227

CHAPTER IV

OPERATIONS UPON THE SCLEROTIC
Anterior Sclerotomy, 228. Cyclo-dialysis, 229. Sclerectomy, 231. Posterior Sclerotomy, 232. Paracentesis of the Anterior Chamber, 233. For Penetrating Wounds of the Globe, 234. Electro-magnet Operations—with Small Magnet, 237; with Giant Magnet, 238228239

CHAPTER V

OPERATIONS UPON THE CORNEA AND CONJUNCTIVA
Removal of a Foreign Body from the Cornea, 240. Cauterization of the Cornea, 240. Operations for Conical Cornea, 241. Removal of Tumours involving the Cornea, 243. Tattooing the Cornea, 243. Scraping Calcareous Films, 243. Operations upon the Conjunctiva—Removal of Foreign Bodies, 244; for Pterygium, 244; Expression, 245; Conjunctivoplasty, 245; Removal of Tarsal Cysts, 246240246

CHAPTER VI

OPERATIONS UPON THE EXTRA-OCULAR MUSCLES
Squint Operations, 247. Tenotomy, 248. Advancement, 251247254

CHAPTER VII

ENUCLEATION OF THE GLOBE AND ALLIED OPERATIONS
Enucleation, 255. Evisceration, 257. Mules’s Operation, 259. Frost’s Operation, 259. Operations upon the Socket after Removal of the Eye—Paraffin Injection, 260. Operations for Restoration of a Contracted Socket—Skin-grafting, 261; Inclusion of Flaps (Maxwell’s Operation), 261255262

CHAPTER VIII

OPERATIONS UPON THE EYELIDS
Surgical Anatomy, 263. Suture of Wounds of the Eyelids, 263. Operations for Ankyloblepharon, 264; for Symblepharon, 264. Upon the Palpebral Aperture, 265Canthoplasty, 265; Canthotomy, 265; Canthorrhaphy, 265; Tarsorrhaphy, 266. Ptosis Operations, 267; Shortening the Eyelid by Excision of a portion of the Tarsal Plate, 267. Attachment of the Lid to the Occipito-frontalis Muscle, 268. Advancement of the Levator Palpebræ Muscle, 272. Grafting a portion of the Superior Rectus into the Lid, 273263274

CHAPTER IX

OPERATIONS FOR ENTROPION, REPAIR OF THE EYELIDS,
TRICHIASIS, AND ECTROPION
Electrolysis, 275. Skin and Muscle Operation, 275. Rectification of a Faulty Curvature of the Tarsus—Burow’s Operation, 276; Streatfield’s Operation, 277. Transplantation of the Lash-bearing Area—Arlt’s Operation, 278. Ectropion Operations, 279—for Passive Ectropion, 280; Snellen’s Suture Method, 280; Fergus’s Operation, 281; Kuhnt’s Operation, 281; Argyll Robertson’s Operation, 282. For the Active or Cicatricial Form, 284; VY Operation, 284; Denonvillier’s Operation, 285; Fricke’s Operation, 285; Thiersch’s Skin-grafting, 287. Repair of large Losses of Substance from the Eyelids, 287; De Vincentiis’ Operation, 287; Dieffenbach’s Operation, 288275289

CHAPTER X

OPERATIONS UPON THE LACHRYMAL APPARATUS
For the Relief of Lachrymal Obstruction, 290Dilatation of the Canaliculus, 290; Slitting the Canaliculus, 291; Syringing the Lachrymal Duct, 292; Probing the Lachrymal Duct, 292; the Insertion of Styles, 293. For Obliteration of the Canals, 294; Obliteration of the Canaliculi, 294; Excision of the Lachrymal Sac, 294. Opening a Lachrymal Abscess, 297. Operations upon the Lachrymal Gland—Removal of the Palpebral Portion, 298; Removal of the Orbital Portion, 299. Operations upon the Orbit—Exploration of the Orbit (Krönlein’s Method), 299; Evisceration of the Orbit, 301; Opening an Orbital Abscess, 301290301

SECTION III

OPERATIONS UPON THE EAR

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

Aural Surgeon to the London Hospital.

CHAPTER I

EXAMINATION OF THE EAR: GENERAL CONSIDERATIONS
WITH REGARD TO OPERATIONS
Examination of the Ear, 305Sources of Illumination, 305; Technique of Examination, 306; Method of cleansing the Ear, 307. General Considerations with regard to Operations—Preliminary Surgical Toilet, 309; Anæsthesia, 310. Position of Patient and Surgeon, 313305313

CHAPTER II

OPERATIONS UPON THE EXTERNAL AUDITORY CANAL
Operations for Furunculosis, 314. Removal of Exostoses from the External Meatus, 316. Removal of Foreign Bodies—by Syringing, 322; by Instruments, 323; by Post-aural Incision, 326; by Operation upon the Mastoid, 327. Operations for Stenosis of the External Meatus, 328. Operations for Atresia, 330; for Aural Polypus, 331314334

CHAPTER III

OPERATIONS UPON THE TYMPANIC MEMBRANE AND
WITHIN THE TYMPANIC CAVITY
Surgical Anatomy of the Tympanum, 335. Paracentesis, 336. Artificial Perforation of the Tympanic Membrane, 340. Division of the Anterior Ligament, 341. Division of the Posterior Fold, 341. Intratympanic Operations, 342; Division of Adhesions, 342; Tenotomy of the Tensor Tympani, 346; Tenotomy of the Stapedius, 347. Removal of Granulations from the Tympanic Cavity, 348. Operations upon the Ossicles—Direct Mobilization, 349; Removal of the Ossicles, 351335363

CHAPTER IV

OPERATIONS UPON THE EUSTACHIAN TUBE
Catheterization, 364. Passing of the Eustachian Bougie, 369. Washing out the Tympanic Cavity through the Eustachian Tube, 372364372

CHAPTER V

OPERATIONS UPON THE MASTOID PROCESS: WILDE’S INCISION
AND SCHWARTZE’S OPERATION
Surgical Anatomy, 373. History of the Mastoid Operation, 375. Wilde’s Incision, 377. Schwartze’s Operation, 378. Treatment of Special Conditions—in an Infant, 389; Subperiosteal Abscess, 389; Bezold’s Mastoid Abscess, 389; Necrosis, 390; Osteomyelitis, 390373390

CHAPTER VI

THE COMPLETE MASTOID OPERATION
Methods of Operation, 392; Küster-Bergmann (Schwartze-Stacke) Operation, 393; Wolf’s Operation, 396; Stacke’s Operation, 397; Preservation of the Ossicles and Tympanic Membrane, 399. The Formation of Post-meatal Skin Flaps, 401. Closure of the Wound, 404. Skin-grafting after the Mastoid Operation, 405. After-treatment of the Case, 410. Difficulties and Dangers of the Operation, 412. Results, 415391416

CHAPTER VII

OPERATIONS UPON THE LABYRINTH
General Considerations, 417. Indications, 417. Surgical Anatomy, 420. Methods of Operating, 421; Curetting a Localized Lesion of Wall, 421; Opening the Vestibule, 422; Removal of the Cochlea, 424; Extirpation of the Labyrinth, 425417428

CHAPTER VIII

OPERATIONS FOR EXTRA-DURAL ABSCESS AND MENINGITIS
OF OTITIC ORIGIN
On Intracranial Complications in General, 429. Operations for Extra-dural Abscess, 430. Operations for Meningitis of Otitic Origin, 433429438

CHAPTER IX

OPERATIONS FOR LATERAL SINUS THROMBOSIS
OF OTITIC ORIGIN
General Considerations, 439. Exposure of the Lateral Sinus, 440. Opening of the Lateral Sinus, 442. Ligature of the Jugular Vein, 446. Exposure of the Jugular Bulb, 454439458

CHAPTER X

OPERATIONS FOR INTRACRANIAL ABSCESS
OF OTITIC ORIGIN
Indications, 459. Operation, 460. After-treatment, 469. Complications, 469. Prognosis and subsequent Progress, 470. Recurrence of Symptoms, 471459471

SECTION IV

OPERATIONS UPON THE LARYNX AND TRACHEA

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

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

CHAPTER I

ENDOLARYNGEAL OPERATIONS
Indications, 475. Operation by Indirect Laryngoscopy, 477. Operation by Direct Laryngoscopy, 479475486

CHAPTER II

EXTRA-LARYNGEAL OPERATIONS
Thyrotomy, 487. Hemi-laryngectomy, 495. Anatomy of the Laryngeal Lymphatics, 496. Total Laryngectomy, 498. Comparative Results of Extra-laryngeal Operations, 502. Infrathyreoid Laryngotomy, 510487516

CHAPTER III

OPERATIONS UPON THE TRACHEA
Tracheotomy, 517; in Diphtheria, 526; in Conditions other than Diphtheria, 544. Tracheo-fissure and Resection of the Trachea, 546517548

CHAPTER IV

INTUBATION OF THE LARYNX
Intubation v. Tracheotomy in Diphtheria, 549. Indications, 552. Operation, 553. Difficulties, 555. After-treatment, 556. Complications, 557549558

CHAPTER V

TRACHEOSCOPY AND BRONCHOSCOPY
Indications, 559. Tracheoscopy, 560. Upper Bronchoscopy, 562. Lower Bronchoscopy, 562. Complications, 563. Results, 566559566

SECTION V

OPERATIONS UPON THE NOSE AND ITS ACCESSORY CAVITIES

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

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

CHAPTER I

GENERAL CONSIDERATIONS IN REGARD TO OPERATIONS UPON
THE NOSE AND NASO-PHARYNX
Sources of Illumination, 569. Local Anæsthesia, 572. Local Ischæmia, 573. Bleeding and its Control, 574. The Protection of the Lower Air-passages from the Descent of Blood, 576. Shock, 577. Sepsis and other Complications, 577. Asepsis, 578. After-treatment, 578. Cleansing the Nose, 579. After-results, 580569580

CHAPTER II

OPERATIONS FOR INJURIES, DEFORMITIES, FOREIGN BODIES, AND
RHINOLITHS: OPERATIONS UPON THE TURBINALS:
OPERATIONS IN SYPHILIS AND LUPUS
Operations for Injuries to the Nose—Fractures of the Nasal Bones and Septum, 581. For Congenital Occlusion of the Nostrils, 582. Removal of Foreign Bodies, 584; of Rhinoliths, 586. Operations upon the Turbinals, 586; upon the Inferior Turbinal, 587; upon the Middle Turbinal, 592. For the Results of Syphilis—Sequestrotomy, 594; Post-syphilitic Adhesions of the Velum, 595. For Tuberculosis, 596581596

CHAPTER III

OPERATIONS UPON THE NASAL SEPTUM
For Deformities—Removal of Spurs, 597; Perforating the Septum, 598. For Simple Deviation, 598; Gleason-Watson Operation, 599; Asch’s Operation, 599; Moure’s Operation, 599. For Combined Bony and Cartilaginous Deformity—Submucous Resection, 601. Complementary Operations, 610. For Perforation of the Nasal Septum, 611. For Abscess, 612. For Hæmatoma, 612597612

CHAPTER IV

OPERATIONS FOR REMOVAL OF NASAL GROWTHS THROUGH THE
NOSTRILS: OPERATIONS FOR OBTAINING DIRECT ACCESS
TO THE NASAL CAVITIES AND NASO-PHARYNX
Removal by the Snare, 613. Removal by Forceps and Curettes, 615. Lateral Rhinotomy (Moure’s Operation), 618. Rouge’s Operation, 622. Combination of Moure’s and Rouge’s Operations, 625. Extension of Rouge’s Operation to allow of Access to the Maxillary Antrum, 625. Other Methods, 625613625

CHAPTER V

OPERATIONS UPON THE ACCESSORY NASAL SINUSES
Operations upon the Maxillary Sinus—Catheterizing the Maxillary Sinus, 626; Puncturing from the Nose, 626; from the Alveolar Margin, 628. Operation through the Canine Fossa only, 631; the Caldwell-Luc Radical Operation, 631; Drainage through the Nasal Wall only, 637. Operations upon the Frontal Sinus—Catheterizing and Washing out the Frontal Sinus, 638; Opening the Frontal Sinus in Acute Suppuration, 642; Killian’s Operation, 642; the Ogston-Luc Operation, 651; Kuhnt’s Operation, 653. Operations upon the Sphenoidal Sinus, 653; Sounding and Washing out, 653; Opening the Sphenoidal Sinus, 656. Operation in Multiple Sinus Suppuration, 659626660

CHAPTER VI

OPERATIONS INVOLVING THE NASO-PHARYNX: OPERATIONS
FOR RETROPHARYNGEAL ABSCESS: OPERATIONS
FOR NASO-PHARYNGEAL ADENOIDS
Methods of obtaining Access to the Naso-pharynx through the Nose, 661; through the Mouth, 662. Retropharyngeal Abscess, 664. Removal of Naso-pharyngeal Adenoids, 665661672

LIST OF ILLUSTRATIONS

FIG.PAGE
1.Secondary Cancer of the Ovary15
2.Secondary Cancer of the Ovary in Section15
3.An Infected Fallopian Tube23
4.A Tuberculous Fallopian Tube and Ovary: Entire and in Section24
5.Primary Cancer of the Fallopian Tube27
6.A Section of Primary Cancer of the Fallopian Tube27
7.A Gravid Fallopian Tube30
8.A Gravid Fallopian Tube, containing Twins32
9.A Diagram to show the Arterial Supply of the Uterus37
10.A Fibroid growing near the Right Uterine Cornu38
11.The Mattress Suture40
12.The Stump after Subtotal Hysterectomy40
13.A Bicornate Uterus42
14.A Bicornate Uterus shortly after Delivery43
15.Villous Disease of the Uterus45
16.An Adenomyomatous Uterus55
17.An Adenomyomatous and Tuberculous Uterus56
18.Uterus with the Decidua in situ58
19.Cancer of the Uterus64
20.The Fundus of a Uterus68
21.Portion of Ovary and Fallopian Tube71
22.A Uterus distorted by Fibroids76
23.A Gravid Uterus in Sagittal Section79
24.Diagram representing a Gunshot Injury of the Uterus91
25.The Pulmonary Artery and Adjacent Part of the Lung and Trachea103
26.A Pair of Pressure Forceps106
27.The Relation of Parts after Ricard’s Operation of Uretero-cysto-neostomy114
28.A Uterus in Sagittal Section119
29.Patient prepared for Operation126
30.Complete Laceration of the Perineum127
31.Long-handled Sharp-pointed Scissors curved on the flat128
32.Complete Laceration of the Perineum128
33.Complete Laceration of the Perineum129
34.Laceration of the Pelvic Floor132
35.Repair of a Lacerated Perineum, with Non-union of the Sphincter Ani, before a Plastic Operation133
36.Repair of a Laceration of the Perineum after a Plastic Operation133
37.Auvard’s Self-retaining Speculum136
38.Knives for freshening the Edges of a Vesico-vaginal Fistula136
39.Toothed Forceps for use in Vesico-vaginal Fistula136
40.Emmett’s Hook136
41.Sims’s Operation for the Repair of a Vesico-vaginal Fistula136
42.Simon’s Operation for the Repair of a Vesico-vaginal Fistula136
43.Repair of a Vesico-vaginal Fistula by Dédoublement137
44.Repair of a Vesico-vaginal Fistula. Sims’s Operation137
45.Stoltz’s Operation for Cystocele140
46.Sims’s Vaginal Rest144
47.Pozzi’s Retractors145
48.Anterior Colpotomy146
49.Martin’s Trochar for Pelvic Abscess147
50.The Passage of the Uterine Sound. Introduction of the point into the external os uteri149
51.The Passage of the Uterine Sound. Commencement of the tour de maître149
52.The Passage of the Uterine Sound. Completion of the tour de maître150
53.The Passage of the Uterine Sound. Entry of the sound into the uterine cavity150
54.Chronic Uterine Inversion151
55.Volsella for fixing the Cervix154
56.Hegar’s Dilators (three sizes) for dilatation of the Cervix Uteri154
57.Metal Bougies for dilatation of the Cervix154
58.Bozemann’s Double-channelled Tube154
59.Budin’s Celluloid Catheter154
60.Murray’s Flushing Curette; Blunt Curette154
61.Dilatation of the Cervix158
62.Marckwald’s Operation for Congenital Hypertrophy of the Cervix160
63.Hegar’s Operation for Supravaginal Elongation of Cervix160
64.Emmett’s Scissors (left) for Trachelorrhaphy162
65.Trachelorrhaphy162
66.Pedunculated Fibroid Polypi in various Stages of Extrusion165
67.Wire Écraseur166
68.Submucous Fibro-myomata, capable of Treatment by Morcellement166
69.Galabin’s Broad-ligament Needle (right)171
70.Jessett’s Broad-ligament Needle171
71.Vaginal Hysterectomy171
72.Vaginal Hysterectomy. Final stage172
73.Schauta’s Needle-holder172
74.Window of the Operating Theatre, King’s College Hospital179
75.Bull’s-eye Electric Hand-lamp180
76.Lang’s Eye Speculum182
77.Undine for washing out the Conjunctival Sac182
78.Cataract Extraction183
79.Sympathetic Ophthalmia184
80.Cystoid Scar after Glaucoma Iridectomy185
81.An Eye Bandage186
82.A Pressure Bandage186
83.A Lens Three Weeks after Needling187
84.Anatomy of the Anterior Segment of the Eye189
85.Eye Speculum191
86.Fixation Forceps191
87.Secondary Cataract192
88.Capsulotomy. The method of incising the capsule193
89.Capsulotomy. The method of dividing a dense band194
90.Iris Forceps195
91.Iris Scissors195
92.A Vectis195
93.Pagenstecher’s Spoon195
94.Lens Extraction196
95.The Knife entering the Anterior Chamber in Cataract Extraction197
96.Making the Counter-puncture in Cataract Extraction197
97.Incision and Iridectomy in Cataract Extraction198
98.Opening the Capsule with Forceps in Cataract Extraction199
99.Cataract Extraction200
100.McKeown’s Irrigation Apparatus for washing out the Anterior Chamber203
101.Subconjunctival Extraction204
102.Iridotomy211
103.Iridotomy211
104.Iridotomy by Ziegler’s Method213
105.Iridotomy by Ziegler’s Method213
106.Iridotomy by Ziegler’s Method213
107.Optical Iridectomy216
108.Optical Iridectomy216
109.Optical Iridectomy217
110.The Normal Angle of the Anterior Chamber217
111.The Angle of the Anterior Chamber from a Case of Recent Glaucoma218
112.The Angle of the Chamber in a Case of Chronic Glaucoma219
113.Iridectomy for Glaucoma219
114.Iridectomy for Glaucoma221
115.Iridectomy for Glaucoma221
116.Iridectomy for Glaucoma222
117.Glaucoma Iridectomy223
118.Prolapse of the Iris through a Punctured Wound of the Cornea226
119.Cyclo-dialysis Operation229
120.Cyclo-dialysis Operation231
121.Lagrange Operation for the Production of a Cystoid Scar in Chronic Glaucoma232
122.Lagrange Operation for Chronic Glaucoma232
123.Hollow Needle used for Paracentesis of the Anterior Chamber234
124.Author’s Chair for the Localization of Foreign Bodies in the Eye by the X-rays236
125.Small Electro-magnet for extracting Pieces of Steel from the Eye237
126.Large Electro-magnet239
127.Electro-cautery241
128.Tattooing Needles243
129.Graddy’s Forceps245
130.Tenotomy249
131.Tenotomy by the Open Method250
132.Prince’s Forceps for Advancement252
133.Advancement by the Three-stitch Method253
134.Enucleation257
135.Mules’s Operation. First step258
136.Mules’s Operation.258
137.Maxwell’s Operation for Contracted Socket. First step262
138.Maxwell’s Operation. Final step262
139.Canthorrhaphy266
140.Harman’s Operation for Ptosis270
141.Ptosis Operation. Panas’271
142.Ptosis Operation. Advancement of the Levator Palpebræ273
143.Ptosis Operation. Advancement of the Levator Palpebræ273
144.Treacher Collins’s Entropion Forceps275
145.Lid Clamp277
146.Streatfield’s Entropion Operation278
147.Arlt’s Operation for Trichiasis278
148.Snellen’s Sutures280
149.Fergus’s Operation for Slight Ectropion of the Lower Lid281
150.Modified Kuhnt’s Operation for Severe Ectropion. Second step282
151.Modified Kuhnt’s Operation. Fourth step282
152.Argyll Robertson’s Operation for Ectropion. Second step283
153.Argyll Robertson’s Operation for Ectropion. Final step283
154.VY Operation for Ectropion of the Lower Lid due to a Scar. First step284
155.VY Operation for Ectropion. Final step284
156.Denonvillier’s Operation for Ectropion of the Lower Lid. First step285
157.Denonvillier’s Operation for Ectropion285
158.Fricke’s Operation286
159.De Vincentiis’ Operation to replace the Loss of the Inner Portion of the Lower Lid288
160.De Vincentiis’ Operation completed288
161.Modified Dieffenbach’s Operation to replace the Loss of the whole Lower Lid. First step288
162.Modified Dieffenbach’s Operation. Third step288
163.Canaliculus Dilator290
164.Canaliculus Knife291
165.Lachrymal Syringe292
166.Muller’s Retractor for Excision of the Lachrymal Sac294
167.Axenfeld’s Retractor for Excision of the Lachrymal Sac294
168.Excision of the Lachrymal Sac295
169.Excision of the Lachrymal Sac295
170.Excision of the Palpebral Portion of the Lachrymal Gland298
171.Clar’s Lamp305
172.Gruber’s Aural Speculum306
173.Angular Spring Forceps306
174.Examination of the Ear307
175.Aural Forceps holding Cotton-wool307
176.Milligan’s Intratympanic Syringe308
177.Neumann’s Syringe for Subcutaneous Injection311
178.Burkhardt-Merian’s Aural Instrument314
179.Crocodile Forceps324
180.Imray’s Scoop for extracting a Foreign Body325
181.Aural Probe332
182.Wilde’s Aural Snare332
183.Wilde’s Snare being passed round an Aural Polypus332
184.Wilde’s Snare gripping the Neck of Polypus332
185.Polypus arising from the Attic Region332
186.Anatomical Preparation of the Middle Ear335
187.Paracentesis Knife held in position in the Hand337
188.Tympanic Membrane showing Incision in Acute Suppuration of the Middle Ear338
189.Line of Incision in Acute Suppuration of the Attic338
190.Lines of Incisions in Intratympanic Operations341
191.Cutting through Intratympanic Adhesions344
192.Free Edge of Tympanic Membrane cut through344
193.Sexton’s Instrument344
194.Method of using Siegle’s Speculum345
195.Division of Intratympanic Adhesion with Excision of Handle of Malleus346
196.Schwartze’s Tenotomy Knife347
197.Lucae’s Probe350
198.To show Sites of Perforation in Attic Suppuration and Caries of the Ossicles352
199.Removal of the Malleus by Wilde’s Snare. First position354
200.Removal of the Malleus by Wilde’s Snare. Second position354
201.Delstanche’s Ring-knife354
202.Removal of Malleus by Delstanche’s Ring-knife355
203.Ludwig’s Incus Hook356
204.Zeroni’s Incus Hook356
205.Removal of Incus by Zeroni’s Hook356
206.Pfau’s Attic Punch-forceps357
207.Removal of the Outer Attic-wall with Forceps357
208.Diagrammatic Section to show Correct and Wrong Positions of Incus Hook360
209.Eustachian Catheter365
210.Passing the Eustachian Catheter365
211.Passing the Eustachian Catheter365
212.Passing the Eustachian Catheter366
213.Passing the Eustachian Catheter366
214.Author’s Graduated Eustachian Bougie370
215.Left Temporal Bone, showing Anatomy of the Middle Ear and Mastoid Process373
216.Diagram showing Position of Sink Incisions in Post-aural Operations380
217.Schwartze’s Operation381
218.Schwartze’s Operation382
219.Schwartz’s Seeker383
220.Schwartze’s Operation completed384
221.The ‘Radical’ Mastoid Operation393
222.Stacke’s Protector394
223.The ‘Radical’ Mastoid Operation395
224.Pfau’s Curette for the Eustachian Tube396
225.The ‘Radical’ Mastoid Operation completed396
226.Wolf’s Operation397
227.Stacke’s Operation398
228.Post-meatal Skin Flaps401
229.Post-meatal Skin Flaps401
230.Closure of Wound after ‘Radical’ Mastoid Operation401
231.Körner’s Post-meatal Flap402
232.Panse’s Post-meatal Flap402
233.Stacke’s Post-meatal Flap402
234.Skin-grafting of Mastoid Wound Cavity after Operation406
235.Ballance’s ‘Stopper’ for pushing in the Graft406
236.Pipette for sucking Air and Fluid from beneath the Graft406
237.Skin-grafting of Mastoid Wound Cavity after Operation407
238.Skin-grafting of Mastoid Wound Cavity after Operation407
239.Posterior Portion of Skin Graft covering Outer Surface of Wound Cavity408
240.Diagram to show Exposure of the Semicircular Canals423
241.Operation upon the Labyrinth424
242.Extirpation of the Labyrinth425
243.Method of Removal of Bone by the Forceps434
244.Diagram to show the usual Points at which the Lateral Sinus is primarily infected442
245.The Lateral Sinus exposed and opened444
246.Incision for Exposure of the Internal Jugular Vein448
247.Exposure of the Internal Jugular Vein high up449
248.Ligature of the Internal Jugular Vein low down in the Neck450
249.Free Exposure of the Lateral Sinus, which has been incised, with Ligature of the Internal Jugular Vein451
250.Method of suturing the Open End of the Internal Jugular Vein in the Neck452
251.Topography of the Auditory Region of the Skull462
252.Exploration for a Temporo-sphenoidal Abscess463
253.Exploration for a Cerebellar Abscess467
254.Skiagram showing a Tumour of the Larynx476
255.Horsford’s Instrument for transfixing the Epiglottis478
256.Multiple Papillomata of the Larynx479
257.Tube-spatulæ used for Laryngoscopy481
258.Removal of Multiple Papillomata by Direct Laryngoscopy482
259.Intrinsic Tumour of the Larynx487
260.Extrinsic Tumour of the Larynx487
261.Thyrotomy490
262.Total Laryngectomy498
263.Total Laryngectomy. Gluck’s Method501
264.Infrathyreoid Laryngotomy510
265.Instruments for Laryngotomy512
266.Laryngotomy Canula fitted with Inner Tube513
267.Skiagram showing an Angular Tracheotomy Tube in the Trachea518
268.Anatomy of the Larynx and Trachea and the Position of Incisions for the Operations in this Region525
269.Tubes for Tracheotomy527
270.Trachea showing Ulceration caused by a Badly Fitting Tube537
271.Stenosis following Tracheotomy539
272.Tubes used in the Treatment of Stenosis of the Larynx539
273.Trachea showing Ulceration into the Innominate Artery after Tracheotomy542
274.Aneurism of the Aorta perforating the Trachea542
275.Sarcoma of the Trachea546
276.Instruments for Intubation of the Larynx553
277.Instruments for Bronchoscopy560
278.Instruments for Bronchoscopy562
279.Upper Bronchoscopy with the Patient in the Dorsal Position564
280.Lower Bronchoscopy with the Patient in the Dorsal Position565
281.Laryngoscope Lamp570
282.Clar’s Electric Light570
283.Frontal Search-light571
284.Meyer’s hollow Vulcanite Nasal Splint581
285.Krause’s Trochar and Canula583
286.Nasal Punch-forceps583
287.Post-nasal Forceps584
288.Nasal Dressing Forceps585
289.First Step in removing the Anterior End of the Inferior Turbinal, which is seen to have undergone Polypoid Degeneration587
290.Nasal Scissors588
291.Amputation of the Posterior End of the Inferior Turbinal590
292.Nasal Spokeshave592
293.First Step in the Removal of the Anterior End of the Middle Turbinal594
294.Second Step in the Removal of the Anterior End of the Middle Turbinal594
295.Cresswell Baber’s Nasal Saw597
296.The Gleason-Watson Operation for Deformity of the Septum599
297.Asch’s Cutting Scissors599
298.Lake’s Rubber Splint599
299.Bayonet Knife604
300.Incision for Submucous Resection of the Septum605
301.Making the Incision from the Convex Side in Submucous Resection of the Septum605
302.Dull-edged Detacher605
303.Denudation of the Septum in Submucous Resection606
304.Complete Denudation of the Deviated Septum606
305.Ballenger’s Swivel Septum Knife606
306.The Method of employing Ballenger’s Swivel Septum Knife607
307.Submucous Resection of the Septum607
308.Submucous Resection of the Septum608
309.Submucous Resection of the Septum608
310.Semi-diagrammatic Transverse Section of the Nose610
311.Operation for Perforation of the Septum612
312.Nasal Snare613
313.Luc’s Nasal Forceps616
314.Tongue Clip617
315.Incisions for Lateral Rhinotomy (Moure’s Operation)619
316.The Area of Bone removed in Lateral Rhinotomy619
317.Lateral Rhinotomy620
318.Rouge’s Operation. First stage622
319.Rouge’s Operation. Second stage623
320.Catheterizing the Maxillary Sinus626
321.Lichtwitz’s and Moritz Schmidt’s Antrum Needles627
322.Puncturing the Maxillary Sinus627
323.Antrum Drills629
324.Solid Rubber Obturators629
325.Antrum Nozzle629
326.Washing out the Maxillary Sinus from an Alveolar Opening630
327.The Incision in the Caldwell-Luc Operation upon the Maxillary Sinus632
328.The Caldwell-Luc Operation upon the Maxillary Sinus632
329.Opening the Maxillary Sinus from the Nose633
330.Carwardine’s Punch-forceps634
331.The Opening into the Maxillary Sinus from the Inferior Meatus of the Nose635
332.Denker’s Operation637
333.Catheterizing the Frontal Sinus639
334.Radiograph to show the Value of the Röntgen Rays639
335.Radiograph showing Canula in the Frontal Sinus639
336.Killian’s Operation upon the Frontal Sinus644
337.Killian’s Operation upon the Frontal Sinus644
338.Periosteal Elevators645
339.Killian’s Triangular Curved Chisel645
340.Citelli’s Bone-forceps645
341.Hajek’s Bone-forceps645
342.Killian’s Operation upon the Frontal Sinus646
343.Radiograph of the Sphenoidal Sinus653
344.Radiograph of the Sphenoidal Sinus653
345.Catheterizing the Sphenoidal Sinus654
346.Killian’s Long Nasal Speculum655
347.Radiograph showing a Probe in the Sphenoidal Sinus657
348.Sphenoidal Punch-forceps657
349.Adenoid Curette667
350.The Removal of Naso-pharyngeal Adenoids667
351.Removal of Naso-pharyngeal Adenoids668

SECTION I

OPERATIONS UPON THE FEMALE GENITAL ORGANS

PART I

ABDOMINAL GYNÆCOLOGICAL OPERATIONS

BY

JOHN BLAND-SUTTON, F.R.C.S. (Eng.)
Surgeon to the Middlesex Hospital and Senior Surgeon to the Chelsea Hospital for Women, London

CHAPTER I

CŒLIOTOMY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


CHAPTER II

OVARIOTOMY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Secondary Cancer of the Ovary Fig. 1. Secondary Cancer of the Ovary. An ovary converted into a solid mass of cancer secondary to a focus in the sigmoid flexure of the colon: it weighed 5 lb. Two-fifths size.
Secondary Cancer of the Ovary Fig. 2. Secondary Cancer of the Ovary in Section. This is a section of the ovary represented in the preceding figure. Half size.

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

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

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

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

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

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

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

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

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

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

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

Fibromata2Dermoids15
Sarcomata2Papillomata2
Carcinomata1Parovarian5
Simple cysts45Tubo-ovarian3
Adenomata25

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

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

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

Simple cysts and adenomata41with3deaths.
Dermoids38"5"
Sarcomata21"7"

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

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

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

Ovariotomy in Infants

ReporterAgeResultNature of
Tumour
Reference
1D’Arcy Power4 monthsR.DermoidTrans. Path. Soc., xlix. 186.
2MacGillivray11 monthsR.CystLancet, 1907, i. 1487.
3Roemer1¾ yearsR.DermoidDeutsche Med. Woch., 1883, ix. 762.
4Péan2 yearsR.DermoidClin. Chir., 1887–8, 8th series.
5Hooks2½ yearsD.DermoidAm. J. of Obst., 1886, xix. 1022.

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

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

Ovariotomy in Women of Eighty Years of Age

ReporterAgeResultReference
1Owens80R.Brit. Gyn. Soc. Journal, iv. 88.
2Richardson80R.Brit. Med. Journ., 1894, i. 523.
3Heywood Smith81R.Lancet, 1894, i. 1618.
4Spencer82R.Brit. Med. Journ., 1893, ii. 1271.
5Homans82R.Bost. Med. and Surg. Journ., 1888, 454.
6Edis81R.Brit. Med. Journ., 1892, i. 860.
7Bush84R.Ibid., 1894, ii. 67.
8Remfrey83R.Trans. Obstet. Soc., xxxvii. 152.
9Kraft84R.Hospitalstidende, Copenhagen.
10Owens 187R.Lancet, 1895, i. 542.
11Thornton94R.Trans. Obstet. Soc., xxxvii, 158.
12Bland-Sutton85R.Middlesex Hospital.
1 A second operation on patient No. 1 in the list.

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

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

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

References

Doran, A. On complete Intraperitoneal Ligature of the Pedicle in Ovariotomy. St. Bartholomew’s Hospital Reports, 1877, xiii. 195.

—— Pregnancy after the Removal of Both Ovaries for Cystic Tumour. Trans. Obstetrical Society, 1902, xliv. 231.

Bland-Sutton, J. On Secondary (metastatic) Carcinoma of the Ovaries. Brit. Med. Journal, 1906, i. 1216.

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

Le Bec. Ovariotomie double; un des kystes enlevé par la région lombaire, l’autre par le devant de l’abdomen; adhérences totales; guérison. Gaz. des Hôpitaux, 1887, 290.

Stocks. Prolapse of an Ovarian Cyst. Brit. Med. Journal, 1857, ii. 487.

Peters, H. Ovariotomie per anum. Wiener Klin. Wochensch., 1900, xiii. 110.


CHAPTER III

OÖPHORECTOMY

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

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

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

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

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

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

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

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

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

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

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

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

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

An Infected Fallopian Tube. Fig. 3. An Infected Fallopian Tube. The cœlomic ostium of the tube is unoccluded and is in the process of slowly engulfing the fimbriæ. Removed from a woman in the acute stage of salpingitis. Three-quarter size.

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

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

Tuberculous Fallopian Tube and Ovary Fig. 4. A Tuberculous Fallopian Tube and Ovary: Entire and in Section. Caseous matter has exuded through the cœlomic ostium of the tube and become encapsuled. Natural size.

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

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

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

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

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

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

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

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

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

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

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

Salpingitis49
Pyosalpinx31
Hydrosalpinx10
Tuberculous8
Ovarian abscess2

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

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

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

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

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

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

Primary Cancer of the Fallopian Tube
Fig. 5. Primary Cancer of the Fallopian Tube. An ovarian cyst associated with primary cancer of the corresponding tube. The cœlomic ostium is open and the cancerous material has leaked out on to the cyst wall. Half size.
    
A Section of Primary Cancer of the Fallopian Tube
Fig. 6. A Section of Primary Cancer of the Fallopian Tube. This is the cyst wall and cancerous tube represented in the preceding drawing: it shows the cancerous infiltration of the cyst wall. Half size.

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

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

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

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

References

Doran, A. A table of over fifty complete cases of Primary Cancer of the Fallopian Tube. Journal of Obst. and Gyn. of the British Empire, 1904, vi. 285.

Bland-Sutton, J. Tumours Innocent and Malignant, 4th Ed., 1906, 400.

—— On Cancer of the Ovary, Brit. Med. Journal, 1908, i. 5.


CHAPTER IV

OPERATIONS FOR EXTRA-UTERINE GESTATION

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

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

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

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

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

A Gravid Fallopian Tube. Fig. 7. A Gravid Fallopian Tube. There is a hole in the gestation-sac, and tufts of villi project through it. The patient was in the seventh week of her tenth pregnancy when she was seized with abdominal pain and died in ten hours from hæmorrhage. (Museum of St. Bartholomew’s Hospital.) Natural size.

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

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

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

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

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

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

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

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

A Gravid Fallopian Tube Fig. 8. A Gravid Fallopian Tube, containing Twins. (McCann’s case. Museum R. College of Surgeons.) Full size.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In a case of old-standing lithopædion it is unusual to find any trace of the placenta. J. W. Smith operated on a woman in whom a lithopædion had caused intestinal obstruction. The fœtus had probably been retained 15½ years, and the placenta was represented by a calcified encapsuled ball, with an average diameter of 6 cm.

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

A Table showing Cases of Concurrent Intra- and Extra-uterine Pregnancy (Compound Pregnancy) running to Term, with the Fate of the Mother and Children.

Recorder.Year.Fate of
Mother.
Intra-uterine
Child.
Extra-uterine
Child.
Cooke1863DiedDiedDied
Sale1871DiedLivedLived
Wilson1880DiedDiedLived
Galabin1881DiedDiedDied
Franklin1893DiedLivedDied
Matthewson1894LivedLivedKilled 1
Ludwig1896LivedLivedLived
Allardice1905Lived?Dead 2
Menge1907LivedLivedLived

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

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

References

Leopold. Ovarialschwangerschaft mit Lithopädionbildung von 35-jähriger Dauer. Arch. f. Gyn., 1882, Bd. xix. 210.

Menge. Eine reine Ovarialschwangerschaft mit bebendem Kinde. Vide Fränkische Gesellschaft für Geburtshülfe and Frauenheilkunde. Münch. med. Wochensch., 1907, liv. 2452.

Smith, J. W. Jour. of Obstet. and Gyn. of the British Empire, 1908, xiii. 180.

Stonham, C. Lithopædion, Trans. Path. Soc., 1887, xxxviii. 445.

Worrall. Ectopic Gestation complicating Normal Pregnancy. Abdominal section. Recovery. Med. Press and Circular, 1891, i. 296.


CHAPTER V

HYSTERECTOMY AND MYOMECTOMY

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

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

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

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

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

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

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

SUBTOTAL HYSTERECTOMY

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

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

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

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

A Fibroid growing near the Right Uterine Cornu Fig. 10. A Fibroid growing near the Right Uterine Cornu. It separates the ovarian ligament, Fallopian tube, and round ligament of the uterus from each other. Full size.

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

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

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

The Mattress Suture Fig. 11. The Mattress Suture. A diagram to show the method of applying it.
The Stump after Subtotal Hysterectomy Fig. 12. The Stump after Subtotal Hysterectomy. To show the method of applying the continuous suture.

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

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

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

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

TOTAL HYSTERECTOMY

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

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

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

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

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

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

Fig. 13. A Bicornate Uterus. This uterus is shown in coronal section; each cornu contains a fibroid. Removed from a spinster aged 32 on account of acute pain probably caused by the axial rotation of one cornu. Two-fifths size.

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

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

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

Fig. 14. A Bicornate Uterus shortly after Delivery. The pregnancy occurred in the left half. The vesico-rectal ligament is well shown.

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

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

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

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

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

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

St. Bartholomew’s7with3deaths
St. Thomas’s5"2"
St. George’s1"0"
Middlesex6"1"
University College3"0"
Samaritan17"4"
Soho (for women)1"0"
Chelsea Hospital for Women9"1"
49"11"

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

St. Bartholomew’s26with4deaths
St. Thomas’s40"2"
St. George’s8"0"
Middlesex50"0"
University College21"1"
Samaritan37"2"
Soho (for women)60"1"
Chelsea (for women)80"1"
New (for women)26"0"
348"11"
Villous Disease of the Uterus Fig. 15. Villous Disease of the Uterus. The uterus is shown in sagittal section. The cavity is dilated and occupied by a villous tumour growing from its posterior wall. Successfully removed from a multipara aged 83. Full size.

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

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

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

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

Table of Cases in which Hysterectomy was performed on Women of Seventy Years and upwards.

Reporter.Age.Nature of Operation.Result.Reference.
Bland-Sutton73Subtotal for Fibroid 28 lb.R.Trans. Obstet. Soc., 1900, xli. 300.
Stewart McKay70Subtotal for Fibroid 19 lb.R.Australian Med. Gaz., 1907, 14.
Bland-Sutton83Vaginal Hyst. for Villous disease. Fig. 15.R.Trans. Obstet. Soc., 1906, xlix. 46.
Malcolm74Total for Fibroids.R.Brit. Med. Journal, 1907, ii. 1571.

ABDOMINAL MYOMECTOMY

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

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

ABDOMINAL MYOMECTOMY AND ENUCLEATION FOR FIBROIDS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3. The remainder were spinsters or barren wives.

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

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

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

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

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

References to Reports of Hysterectomy performed for Fibroids in Malformed Uteri

Bland-Sutton, J. Fibroids in a Unicorn Uterus. Clin. Journ., Lond., 1901–2, xix. 1.

Bland-Sutton, J. Case of Fibroids in both halves of a Bicornate Uterus. Proc. R. Soc. of Medicine, 1908. Obstet. and Gyn. Sect., ii. 95.

Czerwenka. Uterus bicornis unicollis, &c. Centralbl. f. Gyn., Leipz., 1900, xxiv. 207.

Doran, A. The Removal of a Fibroid from a Uterus Unicornis in a Parous Subject. Brit. Med. Journ., 1899, i. 1389.

Gow, W. J. Cystic Intraligamentous Myoma with Double Uterus. Trans. Obstet. Soc., Lond. (1898), 1899, xl. 134.

Heinricius. Ein Fall von Myoma im rudimentaren Uterus bicornis unicollis. Monatschr. f. Geburts. u. Gyn., Berl., 1900, xii. 419.

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

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

Olshausen, R. In Veits’ Handbuch der Gynäkologie, Wiesbaden, 1907, Bd. ii, p. 607.

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


CHAPTER VI

ON THE RELATIVE VALUE OF TOTAL AND SUBTOTAL HYSTERECTOMY

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

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

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

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

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

1. The disease existed in the neck of the uterus at the time of the primary operation, but was overlooked.

2. Cancer attacked the cervical stump subsequent to subtotal hysterectomy.

3. The fibroid which necessitated the hysterectomy was really a sarcomatous tumour of the uterus.

4. The suspected growth on the cervix is not malignant, but a granuloma.

Each of these postulates requires separate consideration.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

An Adenomyomatous Uterus Fig. 16. An Adenomyomatous Uterus. The organ is shown in sagittal section in order to display the great thickening of the endometrium. From a spinster aged 43 years. Two-thirds size.

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

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

An Adenomyomatous and Tuberculous Uterus Fig. 17. An Adenomyomatous and Tuberculous Uterus. The uterus is opened by a vertical incision in its posterior wall. The anterior wall is occupied by a mass of tuberculous adenomatous tissue. The patient, a spinster aged 46, was in excellent health four years after the operation. Two-thirds size.

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

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

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

THE FATE AND VALUE OF BELATED OVARIES

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

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

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

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

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

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

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

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

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

Uterus with the Decidua in Situ Fig. 18. Uterus with the Decidua in Situ. The parts of the uterus occupied by the decidua represent the menstrual area of the uterus.

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

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

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

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

References to the History of Hysterectomy for Fibroids

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

Bardenheuer. Die Drainierung der Peritonealhöhle. Im Anhang: Thelen: Die Totalextirpation wegen Fibroid. Stuttgart, 1881, 271.

Goffe, I. Riddle. This surgeon furnishes an interesting account of the development of Total and Subtotal Hysterectomy for Fibroids, in The Transactions of the American Gynæcological Society, 1893, xviii. 372.

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

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

Literature Relating to Cancer of the Cervical Stump after Subtotal Hysterectomy

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

Bland-sutton, J. Essays on Hysterectomy, 1905, 2nd Ed., 60.

—— Journal of Obs. and Gyn. of Gt. Britain, 1904, v. 434.

Mann, M. Trans. Am. Gyn. Soc., 1893, p. 123.

Polk. Am. Journ. of Obstetrics, 1906, liv. 78.

Quénu. Rev. de Gyn. et de Chir. Abdom., 1905, Sept.–Oct., ix. 720.

Richelot. La Gynécologie, 1903, viii. 399.

Turner, G. Brit. Med. Journ., 1905, ii. 953.

References in Relation to the Occurrence of Cancer in the Uterus after Bilateral Ovariotomy

Blacker, G. F. Uterus with Fibroids and Carcinoma of the Cervix. Trans. Obstet. Soc., 1896, xxxvii. 213.

Bland-sutton, J. A Clinical Lecture on Adenomyoma of the Uterus. Brit. Med. Journal, 1909, 1.

Butler-Smythe. Carcinomatous Uterus removed eighteen and a half years subsequent to Double Ovariotomy. Trans. Obst. Soc., 1901, xliii. 214.

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

Martin, A. Die Krankheiten der Eierstöcke und Nebeneierstöcke, 1899, s. 907.

References concerning the Value of Belated Ovaries

Bland-Sutton, J. Abdominal Hysterectomy for Myoma of the Uterus, with brief notes of twenty-eight cases. Transactions of the Obstetrical Society, 1897, xxxix. 292.

—— The Value and Fate of Belated Ovaries. The Medical Press and Circular, 1907, ii. 108.

Bond. An Inquiry into some Points in Uterine and Ovarian Physiology and Pathology in Rabbits. British Medical Journal, 1906, ii. 121.

Doran, A. Subtotal Hysterectomy: after history of sixty cases. Transactions of the Obstetrical Society, 1905, xlvii. 363.

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


CHAPTER VII

HYSTERECTOMY FOR PRIMARY CARCINOMA OF THE UTERUS

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

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

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

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

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

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

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

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

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

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

The wound is treated in the following way:—

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

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

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

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

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

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

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

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

Cancer of the Uterus Fig. 19. Cancer of the Uterus. Coronal section through a uterus affected with primary cancer of the corporeal endometrium. The mass measured 10 centimetres transversely and 12 centimetres vertically. Removed by abdominal hysterectomy. Two-thirds size.

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

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

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

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

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

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


CHAPTER VIII

OPERATIONS FOR DISPLACEMENT OF THE UTERUS

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

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

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

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

VENTRO-SUSPENSION FOR RETROFLEXION OF THE UTERUS

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

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

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

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

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

VENTRO-FIXATION FOR PROLAPSE OF THE UTERUS

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

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

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

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

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

The Fundus of a Uterus Fig. 20. The Fundus of a Uterus. A long fibrous cord arises from the fundus as a result of hysteropexy performed nearly five years previously for inveterate retroflexion. Full size.

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

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

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

References

Kelly, H. A. Hysterorrhaphy. American Journal of Obstetrics, 1887, xx. 33.

Olshausen. Ceber ventrale Operationen bei Prolapsus und Retroversio Uteri. Centralblatt für Gynäkologie, 1886, x. 698.


CHAPTER IX

OPERATIONS UPON THE UTERUS DURING PREGNANCY,
PARTURIENCY, AND PUERPERY

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

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

CÆSAREAN SECTION

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

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

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

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

The instruments required are those given on p. 5.

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

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

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

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

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

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

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

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

Portion of Ovary and Fallopian Tube. Fig. 21. Portion of Ovary and Fallopian Tube. The parts were removed a year after a supposed complete oöphorectomy had been performed to induce an artificial menopause. This fragment of ovary maintained menstruation regularly. Full size.

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

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

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

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

References

Doran, A. Pregnancy after Removal of both Ovaries for Cystic Tumour. Journal of Obstetrics and Gynæcology of the British Empire, 1902, 11, i.

Gache, S. Opération césarienne sur une fille de 13 ans: Guérison. Annales de Gynécologie, 1904, p. 601.

Harris, R. P. Six self-inflicted Cæsarean Operations with recovery in five cases. Am. Journ. of the Medical Sciences, 1888, xcv. 150.

Sinclair, Sir William. Cæsarean Section successfully performed for the Fourth Time on the same Woman, with remarks on the production of Utero-parietal Adhesions. Journal of Obstetrics and Gynæcology of the British Empire, 1907, xii. 335.

Wallace, Arthur J. On Repeated Cæsarean Section. Ibid., 1902, ii. 555.

CÆSAREAN SECTION IMMEDIATELY AFTER THE DEATH OF THE MOTHER

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

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

A woman in the eighth month of pregnancy was found to be suffering from cancer of the neck of the uterus. The child was alive. I decided to perform hysterectomy. The uterus was exposed through a free incision in the abdominal wall and quickly detached from its cervix. The uterus with the fœtus inside was handed to an assistant, who quickly extracted the child. Although the time which elapsed from the complete etherization of the mother until the extraction of the child from the uterus was 2½ minutes, it required the display of some energy to induce the child to breathe. This is the first record as far as I know of a child being delivered alive from a uterus detached from its mother. The woman died on the fourth day after the operation, and the child on the fourteenth.

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

References

Hugier, M., and Monod, M. Cæsarean Operation immediately after the death of the Mother. Lancet, 1829–30, i. 899.

Möglich. Ueber Kaiserschnitt an der Toten. Münchener med. Wochensch., 1908, lv. 202.

Sippel. Sectio Cæsarea in mortua. Monats. f. Geb. u. Gyn., 1907, xxvi. 618.

OVARIOTOMY AND HYSTERECTOMY DURING PREGNANCY AND IN LABOUR

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

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

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

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

Cases in which Ovariotomy has been performed near the End of the Ninth Month of Pregnancy

Surgeon.Result to
Mother.
Result to
Child.
Reference.
PippingsköldR.StillbornAm. J. of Obstet., 1880, xiii. 308.
Bland-SuttonR.LivedBrit. Med. Jour., 1895, i. 461.
MorseR.LivedTrans. Obstet. Soc., xxxviii. 221.

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

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

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

References

Campbell, M. Case of Bilateral Ovarian Dermoid Tumour associated with Pregnancy. Lancet, 1907, ii. 1760.

Cullingworth, C. J. Three cases of Suppurating Dermoid Cyst, of or near the Ovary, treated by Abdominal Section. St. Thomas’s Hospital Reports, 1887–9, xvii. 139.

Hart, Berry. See Clarence Webster’s Researches in Female Pelvic Anatomy, Edin., 1892, p. 124.

Ivens, Miss F. Pregnancy complicated by Bilateral Ovarian Dermoid Cysts. Brit. Med. Journal, 1908, i. 625.

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

Thornton, K. A case of removal of both Ovaries during Pregnancy. Trans. Obstet. Soc., London, xxviii. 41.


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

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

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

Ovariotomy for Tumours obstructing Labour at Term

Operator.Nature of
Tumour.
Result to
Mother.
Fate of
Child.
Reference.
WilliamsCystR.No recordTrans. Obstet. Soc., xxvi. 203.
SpencerDermoidR.LivedIbid., xl. 14.
Boxall 1DermoidR.LivedIbid., xl. 25.
Bland-Sutton 1DermoidR.LivedLancet, 1901, i. 382.
Sinclair 1CystR.LivedLancet, 1901, i. 158.
Favell 1DermoidR.No recordBrit. Med. Journal, 1901, i. 894.

1 In these cases it was necessary to perform Cæsarean section in order to extract the tumour from the pelvis.

A Uterus distorted by Fibroids Fig. 22. A Uterus distorted by Fibroids. It contains a fœtus of four months’ development. Removed by the subtotal operation from a primigravida, aged 42. Half size.

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

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

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

References

Bland-Sutton. Surgical Diseases of the Ovaries, &c., London, 1896, 2nd Ed. pp. 180–91.

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

McKerron, R. G. Pregnancy, Labour, and Childbed with Ovarian Tumour, London, 1903.


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

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

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

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

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

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

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

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

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

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

A Gravid Uterus In Sagittal Section Fig. 23. A Gravid Uterus In Sagittal Section.

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

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

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

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

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

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

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

References

Bland-Sutton, J. The Inimicality of Pregnancy and Uterine Fibroids. Essays on Hysterectomy, 1905, 76.

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

Smith, J. L., and Shaw, W. F. On the Pathology of the Red Degeneration of Fibroids. Lancet, 1909, i. 242.


Cases of Hysterectomy performed on Patients in Labour in which the Obstruction was due to Fibroids

Operator.Result
to
Mother.
Fate
of
Child.
Nature of Operation.Reference.
SpencerR.L.Cæs. Sect., Subtotal Hyst.Trans. Obstet. Soc., xxxviii. 389.
Bland-SuttonR.D.Total Hyst. See Fig. 23.Trans. Obstet. Soc., xlvi. 238.
MorisonR.D.Cæs. Sect., Total Hyst.Northumberland and Durham Medical Journal, July, 1904.
AclandR.?Cæs. Sect. and Subtotal Hyst.Lancet, 1904, ii. 948.
SpencerR.L.Cæs. Sect., Total Hyst.Trans. Obstet. Soc., 1906, xlviii. 240.
SpencerR.D.Cæs. Sect., Total Hyst.Trans. Obstet. Soc., 1908.
PollockR.L.Cæs. Sect., Subtotal Hyst.Trans. Obstet. Soc., 1908.

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

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

A Table of Cases in which Abdominal Hysterectomy was performed for Pregnancy complicated with Fibroids

These cases are recorded in the Transactions of the Obstetrical Society, 1900–8, both years inclusive.

Recorder.Age of
Patient.
Period of
Pregnancy.
Result to
Mother.
Reference to Volume.
Horrocks?5th month?1900, xlii. 242.
Routh3333 weeksR.Ibid., 244.
Doran405th monthR.1901, xliii. 178.
Donald439th monthR.1901, xliii. 180.
Donald344th monthR.Ibid.
Donald344th monthR.Ibid.
Donald414th monthR.Ibid.
Routh?8½ monthsR.1902, xliv. 41.
Doran39 ?R.1904, xlv. 119.
Doran304th monthR.Ibid.
Doran30 ?R.Ibid.
Boyd428th monthD.Ibid., 106
Boyd403rd monthR.Ibid.
Fairbairn225th week post partumR.Ibid., 194.
Doran384th week post partumR.1904, xlvi. 274.
Taylor333rd monthR.1905, xlvii. 333.
Andrews?3rd day post partumR.Ibid., 4.
Lea397th week post partumR.Ibid., 1
Boyd424th month, totalR.1907, xlix. 49.
Bland-Sutton394½ monthsR.1907.
Dauber313rd monthR.1908.
McCann254½ monthsR.Ibid.
Spanton332½ monthsD.Ibid.

Table of Cases in which Abdominal Myomectomy was performed during Pregnancy

From the Transactions of the Obstetrical Society, 1900–8, both years inclusive.

Recorder.Age of
Patient.
Stage of Pregnancy.Result.Reference.
Donald313rd monthR.1901, xliii. 194.
Walls? ?R.Ibid., 195.
Routh?5th monthR.1904, xlvi. 279.
Spencer419th monthR.Ibid., 122.
Malcolm327th week post partumR.Ibid., 15.
Doran282nd monthR.1905, xlvii, 426.
Vaughan?4th monthR.Ibid., 427.
Vaughan?3½ monthsR.Ibid.
Swayne405th monthR.1908, l.
Swayne354½ monthsR.Ibid.
Williamson327th monthR.Ibid., 73.
Scharlieb374½ monthsR.Ibid.
Scharlieb393½ monthsR.Ibid.

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

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

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

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

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

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

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

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

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

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

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

References

Blacker, G. F. Clinical Lecture on Uterine Fibroids complicating Pregnancy. The Clinical Journal, 1908, xxxi. 309.

Küstner. Kaiserschnitt wegen eines Echinokokkus im Becken. Zentralbl. f. Gynäk., 1907, xxxi. 1390.

Skutsch, F. Ueber die Dermoidcysten des Beckenbindegewebes. Zeitsch. f. Geburts. and Gynäk., 1899, xl. 353.

Thornton, J. K. Removal of Hydatids of the Omentum and from the Pelvis. Medical Times and Gazette, 1878, ii. 565.

OPERATIONS FOR PUERPERAL SEPSIS (METASTATIC BACTERIÆMIA)

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

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

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

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

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

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

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

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

References

Bumm, E. Zur operativen Behandlung der puerperalen Pyämie. Berliner Klin. Wochensch., 1905, xlii. 829.

Cuff, A. A Contribution to the Operative Treatment of Puerperal Pyæmia. Journ. of Obstet. and Gyn. of the British Empire, 1906, ix. 517.

Ferguson, J. Haig. Abdominal Hysterectomy for Acute Puerperal Metritis and Acute Salpingitis. Obstet. Transactions, Edin., 1906, xxxi. 123.

Friedemann, G. Die Unterbindung der Beckenvenen bei der pyämischen Form des Kindbettfiebers. Münchener Med. Wochensch., 1906, liii. 1813.

Lendon, A. A. Puerperal Infection, Thrombosis: Ligature of the Right Ovarian Vein. Australian Medical Journal, 1907, xxvi. 120.

Michels, E. The Surgical Treatment of Puerperal Pyæmia. Lancet, 1903, i. 1025.

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

Trendelenburg, F. Ueber die chirurgische Behandlung der puerperalen Pyämie. Münchener Med. Wochensch., 1902, xlix. 513.


CHAPTER X

OPERATIONS FOR INJURIES OF THE UTERUS

Injuries of the uterus fall into six groups:—

1. Gynæcological injuries.

2. Obstetric injuries.

3. Injuries to the pregnant uterus.

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

5. Bullet-wounds of the pregnant uterus.

6. Stab-wounds of the pregnant uterus.

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

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

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

This advice is too sweeping. When the perforating instrument is clean, and there is little or no bleeding, the case may be left to itself; if untoward signs arise, cœliotomy should be performed. Sometimes a pelvic abscess occurs as a sequence to the accident, and will require evacuation through the vaginal fornix, or, perhaps, by means of an incision in the flank. Verco found a piece of a curette, 2¾ inches long, in an abscess cavity behind the uterus. The patient had been curetted two weeks previously.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Donaldson (1908) reports a remarkable case in which the uterus ruptured during forceps delivery; 12½ feet of small intestine, detached from the mesentery, were extruded with the fœtus. Cœliotomy was performed, the detached intestine cut away, and the proximal end of the bowel anastomosed into the cæcum. A long rent in the posterior wall of the uterus was closed with sutures. The patient survived the accident ten days, and died from sepsis; ‘the entire uterus seemed to be a sloughing mass.’ Donaldson states that, had he removed the uterus at the time he operated on the intestine, the patient would probably have survived.

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

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

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

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

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

1. Sew up the incision in the uterus.

2. Perform Cæsarean section.

3. Remove the uterus (subtotal hysterectomy).

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

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

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

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

Diagram representing a Gunshot Injury of the Uterus Fig. 24. Diagram representing a Gunshot Injury of the Uterus. The woman was aged 28, and in the seventh month of pregnancy. The bullet was extracted from under the skin on the left side, four inches behind the anterior superior spine of the ilium. The line A B represents the track of the bullet. (British Medical Journal, 1896, vol. i, p. 332.)

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

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

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

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

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

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

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

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

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

References

Albarran. Plaies multiples de l’intestin et de l’utérus gravide par balle de revolver. Bull. et Mém. de la Soc. de Chirurgie de Paris, 1895, xxi. 243.

Baudet, R. Plaies de l’intestin et de l’utérus gravide par balle de revolver. Bull. et Mém. de la Soc. de Chir. de Paris, 1907, xxxiii. 779.

Bland-Sutton, J. A Clinical Lecture on the Treatment of Injuries of the Uterus. The Clinical Journal, 1908, xxxi. 289. On two cases of Abdominal Section for Trauma of the Uterus. The Am. Journal of Obstetrics, 1907, lvi.

Braun-Fernwald, R. von. Über Uterusperforation. Zentralbl. f. Gyn., 1907, xxxi. 1161.

Congdon, C. Abdominal Section for Trauma of the Uterus. The Am. Journal of Obstetrics, 1906, liv. 618.

Donaldson, H. J. An unusual Obstetric Complication, causing the removal of 126 inches of Small Intestine. Surgery, Gynæcology, and Obstetrics, 1908, vi. 417.

Dudley, P. Discussion on Accidental Rupture of the Non-parturient Uterus. Trans. Am. Gyn. Soc., 1905, xxx. 21.

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

Harris, R. P. Cattle-horn Lacerations of the Abdomen and Uterus of Pregnant Women. The Am. Journal of Obstetrics, 1887, xx. 673.

Ivanoff, N. De l’étiologie, de la prophylaxie et du traitement des ruptures de l’utérus pendant l’accouchement. Annales de Gynécologie, 1904, 449.

Jakob, J. Gefahren der intra-uterinen instrumentalen Behandlungen. Zentralbl. für Gyn., 1906, xxx, No. 19, 561.

Jarman, G. W. Accidental Rupture of the Non-parturient Uterus, with report of cases. Trans. of the Am. Gyn. Society, 1905, xxx. 15.

Kehr, H. Über einen Fall von Schussverletzung des graviden Uterus. Centralbl. für Chir., 1893, xx. 636.

Kerr, Munro. On Rupture of the Uterus. Brit. Med. Journal, 1907, ii. 445.

Klien. Die operative and nichtoperative Behandlung der Uterusruptur. Arch. f. Gyn., 1901, lxii. 193.

Prichard, A. W. A case of Bullet-wound of the Pregnant Uterus. Brit. Med. Journal, 1896, i. 332.

Robinson, W. S. Death of Fœtus in utero from Gunshot-wound: Recovery of the Mother. Lancet, 1897, ii. 1045.

Steele, D. A. K. Stab-wound of Fœtus in utero. Surgery, Gynæcology, and Obstetrics, 1908, vi. 293.

Verco, W. A. The Australian Med. Gazette, 1908, 681.

Walla, A. von. Ruptura uteri completa, abdominale Totalextirpation. Heilung. Centralb. für Gynäk., 1900, xxiv. 497.


CHAPTER XI

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

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

THE AFTER-TREATMENT OF ABDOMINAL OPERATIONS

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

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

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

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

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

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

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

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

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

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

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

COMPLICATIONS OF ABDOMINAL GYNÆCOLOGICAL OPERATIONS

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

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

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

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

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

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

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

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

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

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

References

Büdinger. Über Lähmungen nach Chloroformnarkosen. Archiv f. klin. Chir., 1894, Bd. xlvii. 121.

Cotton, F. J., and Allen, F. W. Brachial Paralysis—Post-narcotic. Boston Med. and Surg. Journal, 1903, cxlviii. 499.

Halstead, A. E. Anæsthesia Paralysis. Surgery, Gynæcology, and Obstetrics, 1908, vi. 201.

Turney. Post-anæsthetic Paralysis. Clinical Journal, 1899, xiv. 185.


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

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

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

In dealing with this condition the surgeon carefully and gently cleans the extruded intestines and omentum with sterilized water, returns them into the abdomen, and resutures the wound.

References

Madelung, O. Ueber den postoperativen Vorfall von Baucheingeweiden. Verhandlung. d. Deutschen Gesellsch. f. Chir., Berlin, 1905, xxxiv, 2. Theil, p. 168.


Hæmorrhage. However carefully an operation may be conducted or whatever material may be employed for ligatures, there is a liability of bleeding after the patient has been returned to bed. Severe internal bleeding is usually due to the slipping of a ligature from an ovarian pedicle, or a uterine artery: it may come from a vaginal artery, especially in total hysterectomy, and occasionally from a vessel in an adhesion which has been missed in the course of the operation, for oozing which is scarcely appreciable when a patient is collapsed may become very free when reaction occurs.

Severe internal bleeding is manifested by very obvious signs: pallor, cold skin, rapid but feeble pulse, restlessness, and sighing respiration. When these symptoms are manifested the wound must be reopened, the blood and clot removed, and the bleeding point secured. It often happens, where the bleeding is due to the slipping of a ligature from the uterine or ovarian artery, that by the time the surgeon reopens the wound the patient is so bloodless that there is difficulty in determining the source of the bleeding. In very bad cases it is a wise plan to arrange for an assistant to perform the intravenous infusion whilst the surgeon deals with the bleeding vessel. (See Vol. I, p. 405.)

Intravenous injection is the best method of treating patients when the loss of blood has been great. It is unwise to transfuse more than three pints into the veins, or the lungs will become waterlogged and the patient will be later in great peril. When the loss is moderate in amount and the patient is not greatly enfeebled, a pint or more of saline solution may be poured into the abdomen before closing the incision, and this may be supplemented by the administration of six or more ounces of the solution by the anus at two-hourly intervals until the force of the circulation is restored.

In some instances the subcutaneous injection of normal saline solution may be employed. A suitable region is the loose tissue under and around the breasts. When this method is adopted the skin should be rendered antiseptic, otherwise troublesome abscesses and cellulitis will arise in the subcutaneous tissue at the situation where the saline solution has been injected.

Intrapelvic hæmorrhage. For many years I have maintained that two factors which have enabled hysterectomy to vanquish oöphorectomy in the treatment of uterine fibroids are rigid asepsis and perfect hæmostasis. In the early days of intrapelvic surgery there used to be much discussion on the subject of free blood in the pelvic cavity: some practical surgeons urged that it was harmful and would induce peritonitis, and others took the opposite view. From my own observations I came to the conclusion that effusions of blood in the abdomen were often quickly absorbed, but that this was not invariable; and that post-operative collections of blood were very liable to become septic, especially when drainage was employed. I also pointed out that the large effusions of blood in the abdomen due to tubal abortion, or to the rupture of a gravid tube, are often attended with fever, and in some instances the temperature rises to 103°. In such cases, when operative interference is undertaken, the deliquescent clot present in the pelvis often gives off a musty odour. Much light has been thrown on this condition by Dudgeon and Sargent, who have specially investigated the bacteriology of intraperitoneal effusions. These observers have isolated from intraperitoneal effusions of blood a white staphylococcus, which makes its appearance in the blood within a few hours of being effused, and they are of opinion that the febrile disturbances so frequently found after effusions of blood into the peritoneal cavity are due to the presence of this organism.

Apart from the pathological importance of these observations there is a point of practical value connected with them. The white staphylococcus will infect sutures and give rise to stitch-abscesses in the wound; in view of this fact it behoves the surgeon who has to deal with a stale effusion of blood in the pelvis and evacuates it by an incision through the abdominal wall, that in closing the incision he should employ through and through sutures, and not attempt to suture it layer by layer. I have noticed the same tendency to stitch-abscess in cases of diffuse pelvic inflammation due to infection by the gonococcus.

Pneumonia. This is a serious and not infrequent sequel of cœliotomy, especially when it concerns diseased conditions in the upper half of the abdomen: pneumonia occurs frequently as a sequel to ovariotomy, hysterectomy, and allied operations, and occasionally has a fatal ending. It may arise from inhalation, or may be due to the dorsal position (hypostatic pneumonia), or it may arise from infection.

Inhalation pneumonia is not uncommon, and although it is often attributed to the anæsthetic, especially ether, it is doubtless due to a combination of causes, such as a cold room, undue exposure of the body, septic teeth, the chilling effects of ether on the tissues of the lung, and occasionally to a dirty face-piece belonging to the ether or chloroform apparatus.

Hypostatic congestion of the lungs is liable to occur in the aged and in debilitated patients; it is a complication in such cases always to be guarded against.

Embolic pneumonia is the most serious form, and occurs as a sequel to operations for septic conditions, such as pyosalpinx, suppurating ovarian cysts, septic fibroids, and post-operative sepsis; it is also associated with thrombosis, especially when the pelvic veins contain septic clot.

In the preceding section attention was drawn to the appearance in intra-abdominal blood-effusions of a white staphylococcus: such collections of blood are prone to decompose and cause the temperature to rise.

On several occasions in which blood has been effused freely into the pelvic cavity, either as a consequence of tubal pregnancy, or as a sequel to an operation, such as an abdominal myomectomy, and the blood has been allowed to remain, or it has been inefficiently drained, the patients have died from septic pneumonia.

In cases of septic thrombosis the patients run a definite risk from pulmonary embolism. When the embolus is large the patient sometimes dies in a few minutes (see p. 101); but even in cases where the embolus is too small to promptly destroy the patient’s life, its lodgment in the lungs entails in some instances a very serious illness, and occasionally a fatal termination.

Parotitis. Septic parotitis, or, as it is sometimes called, symptomatic or secondary parotitis, to distinguish it from mumps, is an occasional sequel to abdominal operations of all kinds. Careful observations have shown that parotitis is more common after operations for septic conditions, and, although it occasionally occurs after operations which run an afebrile course, the conditions underlying it are mainly septic in character.

Septic parotitis is distinguished from mumps in the following points:—

It occurs as a complication of some other affection, is in itself non-contagious, and occasionally suppurates. There are two views held in regard to its etiology: some hold that it is due to direct infection of the duct (Stenson’s) of the parotid gland by micro-organisms from the mouth, whilst others maintain that the path of infection is mainly by the blood-stream.

Two able investigations have recently been published in regard to this condition, in which one writer (Bucknall) supports the view that it is an ascending affection from the mouth, and the other (Tebbs) brings forward evidence that the elements of infection reach it by the blood-stream.

Lequeu has seen many cases of post-operative parotitis, and at his suggestion Verliac and Morel investigated the condition in the laboratory. They came to the conclusion that this variety of parotitis originates in the ducts of the gland.

When parotitis complicates post-operative convalescence, it is almost entirely confined to septic cases: it may occur within two days of the operation or as late as the thirtieth day. It is more common between the sixth and tenth days, and its advent is accompanied by much disturbance. The parotid swells and becomes painful and tender; the skin over it is red and often brawny. These signs are accompanied by fever, malaise, and depression of spirits. In mild cases they subside in a few days, but in severe cases rigors occur, with high fever and suppuration.

The mild cases are best treated with warm fomentations, frequently changed. If suppuration occurs, the pus will need to be evacuated by a scalpel, but incisions in a suppurating parotid gland should be carried out with careful regard to the branches of the facial nerve (pes anserinus), and the large vessels intimately associated with it.

The surgeon need not be in a great hurry to use the scalpel in these cases, for it seems occasionally as if the skin would slough, and yet when it is incised no pus escapes. This septic parotitis is deceptive in the red and brawny appearance of the skin covering the swollen gland, and the misleading sense of fluctuation. In many instances the inflammatory products escape by way of the parotid duct.

Septic parotitis is an unpleasant and painful complication of an abdominal operation, but it is rarely dangerous and has only had a fatal termination in very exceptional cases.

Thrombosis. After operations on the pelvic organs, thrombosis occasionally occurs in the iliac, femoral, and saphena veins, accompanied by fever, pain, especially in the course of the long saphenous vein, and œdema of the limb. It is noticed most frequently about the twelfth day after operation.

In some patients the thrombosis is confined to the superficial veins of the calf and thigh, but when the femoral and internal iliac veins and the associated lymphatics are involved, the œdema is of a solid kind. Apart from the danger which ensues from the detachment of a fragment of clot and its arrest in the pulmonary artery, this complication is often very serious for the patient, for it entails a long confinement to bed, a tedious convalescence, and the œdema of the limb will sometimes persist for many weeks or months, in spite of topical applications, careful bandaging, or judicious massage.

Post-operative thrombosis was formerly fairly common after hysterectomy for fibroids and in the later stages of malignant disease of the uterus. Its frequency after operations for fibroids was attributed to the profound anæmia in patients who had severe and exhausting metrorrhagia. I am convinced that it is due to sepsis. In several instances I have caused the clot found in thrombosed veins to be examined bacteriologically, and pathogenic microscopic organisms have been isolated. I am also satisfied that in some cases of thrombosis of the veins of the thigh, especially those limited to the saphenous veins, the clotting spreads from the superficial veins of the hypogastrium which are infected from the abdominal incision.

Pulmonary embolism. In perusing the clinical histories of a series of cases of ovariotomy, hysterectomy, myomectomy, and, indeed, after almost any surgical operation, here and there a record may be read to this effect: ‘The patient appeared to be doing well after the operation, when she sat up, laughed and chatted with the nurse, then suddenly fell back and died in a few minutes.’

Anything more tragic than this it is difficult to conceive, and, as a rule, after such a sad occurrence, the relatives are so distressed that they rarely permit an examination of the body. Death in such circumstances is usually attributed to embolism of the pulmonary artery. In some instances this is an assumption, but there are many in which an embolus has been demonstrated, and a few in which the source has been detected.

Post-operative embolism of the pulmonary artery is an important matter for surgeons interested in the operative treatment of uterine fibroids, for it follows such operations more frequently than any other. In order to afford some notion of the relative liability of patients to this accident after subtotal and total hysterectomy for fibroids, I have gathered the following statistics, which are interesting as showing an extraordinary variation in the practice of different operators:—

Baldy ascertained that among 366 operations for fibroids in the Gynecean Hospital, Philadelphia, there were thirteen sudden deaths attributed to pulmonary embolism.

In the Middlesex Hospital between the years 1896 and 1906 (both years inclusive) there were 212 abdominal hysterectomies performed for fibroids. Three of the patients died from pulmonary embolism. Spencer, in eighty-five total hysterectomies, had two deaths from pulmonary embolism. R. Lyle, in eight cases of subtotal hysterectomy, had one sudden death.

Mallet collected the records of 1,800 cœliotomies: there were six deaths attributed to embolism, and of these, three followed operations for uterine fibroids. Chas. P. Noble, in forty-two vaginal myomectomies, lost two patients, one from septic endocarditis, the other from embolism; in the latter case the fibroid was gangrenous.

Olshausen, from the year 1896 to the end of 1905, performed 366 hysterectomies for fibroids; twenty-seven of these patients died. Five of the fatal cases were due to embolism.

Since 1894 I have performed more than a thousand operations of various kinds for fibroids, and have lost one patient from pulmonary embolism. This happened in 1900. The woman was forty-five years of age and profoundly anæmic from profuse and long-continued menorrhagia. Twelve days after subtotal hysterectomy she asked to be pillowed up in bed; this was done, when she suddenly slipped down the bed in agony and died in fifteen minutes. At the post-mortem examination the right pulmonary artery was found plugged with a thick clot. No thrombosed vessels were found in the pelvis.

The symptoms of pulmonary embolism may occur at any period from the hour of the operation up to the thirtieth day. In the majority of patients embolism happens about the twelfth day. The symptoms supervene with great suddenness and seem to be preceded by movement, such as sitting up, getting out of bed, and especially straining during defæcation. Withrow tells of a patient who was attacked whilst ‘putting on her clothes to leave the hospital’. She died in twelve hours. Reclus, at a meeting of the Société de Paris, 1897, mentioned that a patient quitting the hospital, apparently convalescent from hysterectomy, fell dead in the courtyard from pulmonary embolism. In one remarkable instance a patient complained of sciatic pain fifteen days after hysterectomy. In order to afford relief the surgeon flexed the patient’s thigh on her abdomen and then suddenly extended it. This dislodged a clot, and the woman was seized with the symptoms of pulmonary embolism and died in forty-seven minutes. At the post-mortem examination the pulmonary artery was found occluded with clot and the ovarian vein contained a thrombus (Byron Robinson).

It is important to note that these fatal cases of pulmonary embolism occur when they are least expected, and it is an unusual sequence in patients with obvious thrombosis of the femoral and saphenous veins.

The most constant symptoms are urgent dyspnœa accompanied by great distress; in some instances the patient becomes pallid and in others cyanotic. Death may follow in a few minutes; in less severe cases it is delayed several hours, the patient remains conscious, but suffers severe mental agony.

A pulmonary embolism is not necessarily fatal, for a woman after a pelvic operation may complain of sudden pain in the chest, urgent dyspnœa, exhibit great mental distress, and in a short time spit up sputum mixed with blood. In a few hours the urgent symptoms subside and in two or three days pass away, and the patient recovers. I have seen five examples of this mild form of pulmonary embolism after hysterectomy. One of the patients appeared to suffer from a succession of small pulmonary emboli.

The Pulmonary Artery and Adjacent Part of the Lung and Trachea Fig. 25. The Pulmonary Artery and Adjacent Part of the Lung and Trachea. The artery is completely occluded by a clot derived from a thrombus in the right auricle. (Museum of the Middlesex Hospital.) Three-quarter size.

Somerville Hastings refers to a woman thirty-six years of age, anæmic from profuse, long-continued menorrhagia due to a uterine fibroid, who, whilst waiting in the hospital for hysterectomy, was seized with pulmonary embolism and died three hours later. An embolus occupied the pulmonary artery, resembling a blood-clot found in the left common and internal iliac veins. Hastings also states that in a patient who died from pulmonary embolism, after an operation, a thrombus occupied the right cardiac ventricle, and he thought it possible that this intraventricular clot furnished the embolus (Fig. 25).

We must bear in mind that individuals apparently in good health die suddenly in the street, in the armchair, in a bath, or even during sleep: it is a fair assumption that some of the instances of sudden death occurring during convalescence from surgical operations may be due to failure of the heart absolutely unconnected with the operation. It is, however, undeniable that thrombosis of the pelvic veins after ovariotomy, or hysterectomy, is a source of fatal emboli. At present there is very little evidence available as to the cause of the thrombosis, but it can scarcely be doubted that sepsis, it may be only of a mild type, is responsible for some of the cases.

A careful consideration of the matter reveals beyond any doubt that pulmonary embolism occurs much more frequently after hysterectomy or fibroids than after any other operation, and it is especially liable to happen in women who are profoundly anæmic from profuse and prolonged menorrhagia. This indicates that long-continued and irregular losses of blood induce some change in the composition of this important fluid, which favours its coagulation.

It has been suggested that the practice of keeping patients strictly confined to bed for two or three weeks after hysterectomy and allied operations is responsible for the thrombosis which is the source of these fatal emboli. Some American surgeons act on this suggestion and insist on their patients getting out of bed a few days after such operations. This method does not commend itself to British surgeons. In my own practice I make it a rule, even in the most favourable conditions, to keep the patients confined to bed for two weeks. No patient is allowed up until her temperature has been normal for at least three days. The consequences of this practice appear to be justified, for in more than a thousand hysterectomies, only one of my patients lost her life in consequence of pulmonary embolism.

In cases of embolism of the pulmonary artery, death does not always occur immediately, but may be postponed for an hour or more after the lodgment of the embolus.

Trendelenburg is of opinion that it might be possible to remove this clot by direct surgical intervention. After careful consideration of the matter he carried out this operation on a woman aged sixty-three years; he raised an osteoplastic flap on the left side of the thorax, exposed the conus arteriosus, and intended to withdraw the clot, by means of a specially constructed pump, through a slit in its walls. The patient died from excessive bleeding before the clot could be extracted; the operation was hindered by an adherent pericardium.

Trendelenburg has carried out this operation on a man forty-five years of age. This patient was tabetic and sustained a spontaneous fracture of the femur. One month later he was seized with urgent dyspnœa and signs clearly indicating the lodgment of an embolus in the pulmonary artery. Trendelenburg exposed the heart, opened the pulmonary artery, and by means of polypus forceps succeeded in withdrawing 34 centimetres of clot. The incision in the artery was carefully closed with sutures. The man improved considerably as the result of the operation, but died thirty-seven hours later. At the post-mortem examination the left and right branches of the pulmonary artery contained an embolus. From the surgical point of view there are no reasons why such a bold example should not be repeated with success.

When patients who are profoundly anæmic from menorrhagia due to fibroids undergo hysterectomy, it is a useful measure to give them twenty grains of citrate of sodium twice daily in order to diminish the abnormal tendency of the blood to coagulate in the vessels. Certainly this drug should be administered if there is the least evidence of thrombosis.

Foreign bodies left in the abdomen. Every writer on ovariotomy and kindred operations insists on the importance of exercising the utmost personal vigilance in counting instruments and dabs before, and immediately after, an abdominal operation in order to avert the dangers which ensue when instruments, dabs, gauze, or drainage tubes are accidentally left in the abdominal cavity. Before the era of antiseptic surgery nearly all the patients in whom foreign bodies were left in the abdominal cavity died. In several instances the surgeon has discovered, on counting the sponges and instruments after the operation, one or more to be missing, and, failing to find them in the room, has reopened the wound and recovered the missing article. In many lucky cases, a sponge or compress has given rise to an abscess, and, the wound reopened, the sponge presented at the opening. Often a compress of cotton-wool or gauze has slowly ulcerated into the rectum and been discharged through the anus.

When things of this kind are left in the abdomen the risks are not so great now as in pre-antiseptic days, but they cause much discomfort and anxiety as well as suffering: moreover, such an accident entails reopening the wound and occasionally a serious operation for the removal of the missing article, and as a recent decision in a Court of Law fixes the responsibility on the operator, there is always the possibility of an action at law with all its vexations and the liability of being mulcted in damages.

The behaviour of foreign bodies left in the abdomen is curious and also interesting from the great length of time which metal instruments will sometimes remain without causing very urgent symptoms, and the tendency they exhibit to penetrate adjacent viscera.

Among the early cases Sir Spencer Wells reported one in which a pair of forceps was found in a patient’s bladder who died a month after ovariotomy. Olshausen mentions that a pair of forceps was passed by the rectum nine months after ovariotomy, and Terrillon tells of a pair of pressure forceps which remained eight months in the belly and came out close to the navel. One of the most remarkable instances is recorded by MacLaren, in which a pair of forceps was left in the abdomen in the course of a hysterectomy. Two years later, a swelling formed in the right iliac region; this was explored through an abdominal incision, and the hæmostatic forceps represented in Fig. 26 was found embedded in the omentum; the forceps had ulcerated into the cæcum and the blades were lodged in the vermiform appendix. The patient recovered.

A Pair of Pressure Forceps Fig. 26. A Pair of Pressure Forceps: this instrument had remained in the abdomen two years after hysterectomy. The forceps had ulcerated into the cæcum and the blades had lodged in the vermiform appendix. (After MacLaren.)

In order to illustrate the diminished risks run by patients when the instruments and dabs used in operations are thoroughly sterilized, reference may be made to a case recently reported by J. E. F. Stewart (Australia), in which he removed a pair of pressure forceps which had remained in the abdomen for ten years and a half. The patient, who had been more or less an invalid since the primary operation, had suffered from attacks of acute pain, constipation alternating with diarrhœa, and pains in the lower limbs. The instrument, which measured 5 inches long and 2½ across the handles, was lying point downwards in the pelvis, and the ring handles could be felt through the belly-wall before the operation: it had made its way into the small intestine.

The tendency for a foreign body, whether hard like forceps, or soft like gauze pads, to erode its way into the intestine is very remarkable. Thus Gifford operated on a patient with intestinal obstruction; an impacted mass was felt in the ileum, it was extracted through an incision in the gut and proved to be a pad of cotton-wool enveloped in gauze. She recovered. Three months previously this woman had undergone abdominal myomectomy.

Another source of risk to patients is the practice or habit of packing the pelvic recesses with strips of gauze temporarily, either with the hope of controlling oozing, or to serve as a drain. I have long abandoned this habit. The disadvantage of gauze stuffing which needs consideration in this section is the risk that some portion, or the whole of it, is sometimes left in the wound. Examples are known where long strips of ‘gauze stuffing’, sometimes amounting to a yard or more, have been passed through the anus a year after the operation. Many intractable sinuses have had a forgotten piece of gauze as the cause of their persistence.

A woman had cœliotomy performed for peritonitis, the consequence of criminal abortion; she had a long convalescence due to an intractable sinus. Eventually the patient was thought to have tuberculous disease of the appendages, and a mass, formed mainly by the Fallopian tube, was removed. The walls of the tube were intact, but when slit open the tube was found to contain a small gauze tampon (Kouwer).

The isolated records relating to foreign bodies left in the abdomen are very numerous. Thus Wilson in 1884 was able to collect twenty-eight cases from periodical literature and personal reports from friends. An interesting discussion took place on the reading of a paper on this subject before an American gynæcological society, by R. W. Waldo, and the number of cases related by the members is astonishing and refer to such things as sponges, dabs, forceps, a strip of iodoform gauze ‘a yard wide and two yards long’, a pair of spectacles, and ‘an operating-room towel’, which were left in the abdominal cavity.

The most comprehensive collection of records relating to foreign bodies left in wounds of all kinds has been made by F. von Neugebauer; they amount to 195.

References

Gifford, G. T. British Medical Journal, 1907, ii. 1042.

Kouwer, Prof. Zentralbl. für Gynäk., 1907, xxxi. 1447.

MacLaren, A. Annals of Surgery, 1896, xxiv. 365.

Neugebauer, F. v. Monatsschriften für Geburtsh. u. Gyn., 1900, Bd. xi, 821, 933. Zentralbl. für Gynäk., 1904, xxviii. 65.

Stewart, J. E. F. Australian Medical Gazette, 1906, xxv. 446.

Waldo, R. W. American Journal of Obstetrics, 1906, liv. 553.

Wilson, H. P. C. Trans. American Gynecological Society, 1884, ix. 94.


Tetanus. This dread complication of wounds occasionally occurs after ovariotomy, and during the ‘reign of the clamp’ it was especially frequent in Germany (Olshausen). Cases have been reported in England, and tetanus has been noticed to affect patients who have been ovariotomized in rooms recently plastered.

Since Kitasato demonstrated the bacillary origin of tetanus poison, and showed that the bacillus can be transported by dust, knowing its liability to attack suppurating wounds, we can understand that when the pedicle of an ovarian cyst was secured by a clamp and allowed to slowly slough away, more or less exposed to air and dust, it offered a nidus for the tetanus bacillus.

Tetanus, however, has not quite disappeared as a sequel to operations on the pelvic organs, for in 1902 a case was reported by Dorsett in which a patient died of this disease after hysteropexy, and the tetanus bacillus was detected in some wallaby tendon employed to suspend the uterus. Tetanus has also been traced to infected catgut employed in cholecystotomy (1905).

Ed. Martin reported the occurrence of tetanus after vaginal fixation of the uterus and colporrhaphia anterior. Cumol-catgut was employed.

Menzer has recorded a similar case which occurred in Dührssen’s Klinik (1901). The ligatures were of catgut.

Mallet refers to two post-operative deaths from tetanus. One patient had undergone an operation for bilateral pyosalpinx and the other had a fibroid of the uterus complicated with an ovarian cyst. There was an interval of eighteen months between the two fatal cases. Catgut was employed as the ligature material.

In practice it is important to remember that tetanus arises from infection: hence all instruments which have been in contact with this disease must be sterilized, and this should be effected by submitting them to prolonged boiling.

Tetanus occurs as a rare sequel to miscarriage and normal labour. Kraus and von Rosthorn have reported some carefully investigated cases of this kind.

References

Dorsett, W. B. Two fatal cases of Tetanus following Abdominal Section due to Infected Ligatures, &c. Am. Journ. of Obstet., 1902, xlvi. 620.

Mallet, G. H. Some Unusual Causes of Death following Abdominal Operations. Ibid., 1905, li. 515.

Martin, Ed. Postoperativer Tetanus (with references). Zent. f. Gyn., 1906, xxx. 395.

Meinert. Drei gynäkologische Fälle von Wundstarrkrampf. Arch. für Gyn., 1893, xliv. 381.

Menzer. Tetanus Infection after Vaginal Fixation of the Uterus. Zeitsch. f. Geb. u. Gyn., 1901, xliv. 517.

Olshausen, R. Tetanus nach Ovariotomie Billroth-Lücke’s. Handb. der Frauenkrankheiten, 1877–9, ii. 367.

Taylor, H. Tetanus after Hysterectomy. Am. Journ. of Obstet., 1908, lvii. 574.


Injury to intestines. Intestines great and small are very liable to injury in the performance of intrapelvic operations. Unless care is taken in opening the abdomen, the intestines are apt to be cut, especially when there has been chronic peritonitis, as in tuberculous and gonococcal infections, which cause the small intestine to adhere to the parietal peritoneum investing the anterior abdominal wall. Where cœliotomy is being performed a second or third time, through or near the original cicatrix, it is necessary to proceed with extreme caution for fear of cutting an adherent coil of gut.

Intestine is also liable to be torn in separating adhesions from the tumour, and great care is necessary when cysts are firmly adherent to the floor of the pelvis, for in separating them the rectum runs a great risk of being damaged.

In removing tumours to which the vermiform appendix adhered it is necessary to be careful and avoid mistaking it for an adhesion, for there is reason to believe that this structure has been divided and its nature overlooked; an accident of this sort leads usually to fatal peritonitis.

It has happened, in the course of removing very adherent ovaries and tubes from the floor of the pelvis, that in transfixing the pedicle a coil of ileum has also been transfixed with the needle and tied to the stump. This accident is not likely to happen now that the Trendelenburg position is almost universally employed.

In sewing the abdominal incision the intestines have been pricked with a needle, and in some instances the bowel has been accidentally included in the sutures and sewn to the abdominal wall. On one occasion while securing a very long incision with through and through sutures, while passing the needle through the abdominal wall, it broke, and the broken end came with great force against the anterior wall of the stomach and tore a hole in it. This I secured at once with suture and the accident had no bad consequences.

An unrecognized wound of the bowel in the course of a pelvic operation is almost certainly fatal. Accidental injuries, such as punctures and cuts, require immediate suture, and I have never known any harm follow. On the other hand, ragged tears in thickened and inflamed bowel require careful consideration in order to spare patients the inconvenience and distress of fæcal fistulæ.

In regard to small intestine a very small opening may occasionally be safely secured with fine silk, but in most cases it is wiser, if the bowel is thickened and inflamed around the hole, to resect well wide of the damaged portion and join the cut ends (circular enterorrhaphy).

Holes low down in the rectum are difficult to suture securely. These should be treated by drainage, using a wide rubber drain; the convalescence will be tedious, but the fistula will close.

It is useful to remember that if the rubber tube be too long it may enter the hole in the bowel and thus maintain the fistula. On one occasion I was asked to close a fæcal fistula which had followed an oöphorectomy. This fistula persisted five years. At the operation I found a hole in the sigmoid flexure with its margins adherent to the opening in the parietes, so that the tube passed directly into the bowel. The gut was detached and the opening closed with sutures, and it gave no further trouble.

If, in the course of an ovariotomy or hysterectomy, the surgeon discovers a cancerous stricture in the colon or cæcum he should resect the affected section, if it permits of this treatment; otherwise lateral anastomosis should be performed. (See Vol. II.)

Intestinal obstruction. It is difficult to estimate with any approach to accuracy the relative frequency of intestinal obstruction after operations on the uterus and its appendages; nevertheless the danger is real. The obstruction may be acute or chronic: it may occur within thirty hours of the operation or be delayed for months or years. The causes may be arranged under five headings:—

1. Adhesions to the abdominal wound.

2. Adhesions to the pedicle, stump, or a raw surface in the pelvis.

3. Strangulation around an adventitious band.

4. Obstruction due to an overlooked cancer in the colon.

5. Strangulation in a sac formed by a yielding cicatrix.

The form of intestinal obstruction with which we are most concerned here arises shortly after the operation and in the course of convalescence; it may be caused by adhesions to the abdominal incision, the pedicles, raw surfaces in the pelvis left after the removal of adherent cysts and tumours, and the cervical stump of a subtotal hysterectomy.

The subject is one of importance, for the complication is fairly common in the practice of some surgeons, and is one which it is very necessary to recognize, for, unless measures of relief are undertaken promptly, the patient surely dies.

From a careful study of the matter I have come to the conclusion that acute intestinal obstruction is more frequent after ovariotomy than after hysterectomy, and this is due to the fact that the stump or pedicle left after the removal of an ovarian tumour lies higher in the pelvis, and in closer relation to ileum and jejunum, than the cervical stump left after the removal of the uterus. This view also receives support from the fact that acute intestinal obstruction following hysterectomy is more frequent in the practice of those surgeons who perform subtotal hysterectomy improperly, and leave a large piece of the neck of the uterus sticking up like a median post in the floor of the pelvis. As far as I can judge from the scanty records relating to this complication after hysterectomy, it is the sigmoid flexure of the colon which is most commonly adherent to the cervical stump. The best way of avoiding this accident is to remove the supravaginal cervix so freely that, when the peritoneum is closed over the incision in the floor of the pelvis, there is nothing visible except a narrow thin line of suture at the base of the bladder.

The only rational method of treating acute intestinal obstruction following operations in the pelvis, is to promptly reopen the abdomen and set free the adherent coil of gut. Operations of this kind after hysterectomy are more often successful than when they are a sequel to ovariotomy, and this is, I think, due to the fact already mentioned, that when intestinal obstruction follows ovariotomy or oöphorectomy, the obstruction arises in the small intestine and is usually very acute and more dangerous; whereas after hysterectomy the obstruction affects, as a rule, the sigmoid flexure of the colon, and though it may be fairly acute, is not nearly so dangerous, and gives far better results to operative treatment.

Perforating ulcer of the stomach and small intestine. A rare cause of death after ovariotomy or hysterectomy is a perforating ulcer of the stomach or jejunum. Since 1887 I have seen three cases. In each instance the patient died from septic peritonitis. Rosthorn lost a patient from perforating ulcer of the stomach after hysterectomy. Olshausen states that he has seen at least four examples of this accident.2

Injuries to the bladder. This viscus has been injured in a variety of ways during operations on the pelvic organs. An overfull bladder has been mistaken for an ovarian cyst and been punctured with a trocar before the mistake was discovered. When tumours are impacted in the pelvis the bladder is often pushed up into the hypogastrium; this happens with bilateral ovarian tumours, incarcerated fibroids, and especially with large cervix fibroids. When the bladder is pushed up, care should be exercised in making the abdominal incision, or it will be cut. Punctures and incisions in the bladder should be immediately closed with sutures of fine silk.

The bladder is liable to be injured in the performance of subtotal and total hysterectomy, especially in the latter operation when separating it from the neck of the uterus. In the subtotal operation the risk arises chiefly in suturing the peritoneal flaps over the cervical stump, for the bladder is liable to be punctured with the needle as it lies close to the anterior flap.

Injuries to the ureter. Since the vulgarization of hysterectomy, injuries of the ureters have become common; nearly all are inflicted in cases where the neck of the uterus is removed, as in total abdominal hysterectomy, and in vaginal hysterectomy, because the vesical segments of these ducts come into close relationship with it.

British surgical and gynæcological periodical literature contains very little that concerns ureteral injuries, but it is only necessary to look into the pages of the Zentralblatt für Gynäkologie to find ample evidence that the integrity of the ureters is frequently sacrificed to modern pelvic surgery.

Blau published statistics from Chrobak’s Klinik in Vienna showing that in the interval January, 1900, to January, 1902, the ureters were injured fifteen times. In total hysterectomy seven times; in the course of ovariotomy on three occasions.

Sampson stated that from August, 1889, to January, 1904, the uterus was removed 156 times for cancer of its neck at the Johns Hopkins Hospital, Baltimore, and the ureters were injured nineteen times. The injuries were of various kinds, such as ‘ligating, clamping, cauterizing, cutting.’

In abdominal hysterectomy for fibroids the risk of injuring a ureter is not great. Thus Deaver writes that in the course of 250 abdominal hysterectomies he injured the ureter once, but the accident entailed the death of the patient.

I have performed hysterectomy on 1,000 occasions and injured the ureter once; my patient had a narrow escape for life and lost a kidney.

I have been present on five occasions when a ureter was injured. Four of the operations were for the removal of the uterus on account of fibroids, and one was an ovariotomy. Four of the patients died.

The injuries to which the ureters are liable in the course of hysterectomy are as follows:—

1. One or both ureters have been included in the ligatures applied to the uterine arteries.

2. One or both ureters have been cut or completely divided with scissors, or knife, in removal of the uterus.

3. A segment of a ureter 7 centimetres in length has been accidentally exsected.

4. One or both ureters have been compressed by clamps applied to restrain bleeding in the course of vaginal hysterectomy, and subsequently sloughed.

5. Ureters exposed in the course of ‘radical’ operations for cancer of the neck of the uterus often slough.

6. A ureter is sometimes transfixed by a needle and thread when sewing the layers of the broad ligament together in the course of a subtotal hysterectomy.

The most dangerous injury to the ureters occurs in the course of a subtotal hysterectomy, especially if it is not recognized at the time of the operation. In such circumstances the urine will slowly leak into the connective tissue of the broad ligament and form an extravasation extending into the loin.

In some cases the fluid will leak directly into the pelvis, and a sinus will form in the abdominal wound and allow the urine to escape; this may be the first intimation that a ureter has been injured, whereas when a ureter has sustained damage in the course of a total abdominal or a vaginal hysterectomy, the leakage of urine along the vagina will quickly apprise the surgeon of the accident.

There is another form of injury to the ureter which should be mentioned. Occasionally a fibroid, but more often a cyst or tumour arising from the base of the broad ligament, will involve the corresponding ureter and carry it upwards in such a way that, when the layers of the broad ligament are reflected, the ureter will be found crossing the crown of the tumour like a strap. In such a case the pressure has usually exerted a banal influence on the kidney, and it is often in the condition known as sacculation. In a case under my own care in which I attempted to remove a malignant tumour of the broad ligament, and in which the ureter ran over its upper pole in this way, thinking it was an adhesion, traction was made upon it, and the ureter came away with a portion of the renal pelvis. At the post-mortem examination the kidney was merely a thin-walled sac with purulent contents.

In all cases in the course of an abdominal hysterectomy it is useful for the surgeon to inform himself of the condition of the kidneys. Whilst performing a subtotal hysterectomy, one of the fibroids burrowed deeply between the layers of the left broad ligament; when all the bleeding was checked, I looked carefully to determine that the ureter was safe, and found it kinked by the ligature applied to the corresponding uterine artery; it was at once removed. On palpating the kidneys I found the right kidney small, and shrunken, and useless. Fortunately the woman recovered.

The method of treating an injured ureter varies greatly and will depend not only on the extent of the damage, but also on the time at which it is recognized. For example, if the surgeon recognizes the injury in the course of the operation, he will be able to deal with it at once. This we may term immediate treatment. The more difficult cases are those in which the injury is unrecognized at the time of the operation and only becomes obvious in the course of convalescence; the treatment in such circumstances may be called secondary.

The primary treatment of an injury to a ureter in the course of a pelvic operation will depend in a large measure on the ability, judgment, and experience of the surgeon, as well as on the extent of the injury. For example, if the ureter be partially divided, the opening may be closed with sutures of thin silk; when the duct is completely divided, the cut ends may be invaginated, the upper into the lower, and retained in position by suture. When five or more centimetres of the ureter have been accidentally exsected, none of these methods is applicable; in such circumstances several plans have been tried. Of these the simplest is ligature of the proximal end with the hope of inducing atrophy of the kidney; in several recorded instances this has proved successful. The surgeon who adopts this method should satisfy himself that the patient has another kidney, and that it is, as far as he can ascertain at the time, healthy. Some surgeons who have divided a ureter have promptly removed the corresponding kidney; others have secured the proximal end in the upper angle of the abdominal incision and removed the kidney subsequently.

The Relation of Parts after
Ricard’s Operation of Uretero-cysto-neostomy Fig. 27. The Relation of Parts after Ricard’s Operation of Uretero-cysto-neostomy (after Lutaud). A, the proximal end of the ureter with the mucous membrane reflected. B, the walls of the bladder, showing the mode of fixing the ureter to its walls. 1 and 2, sutures.

It has been suggested that when a portion of a ureter has been resected and the proximal end cannot be engrafted into the wall of the bladder, it should be turned into the cæcum or the sigmoid flexure, according to its position, and thus preserve to the patient the kidney and save her the distress of a urinary fistula. This method has not found favour with practical surgeons. The most promising procedure consists in engrafting the proximal end of the cut ureter into the bladder. This is known as uretero-cysto-neostomy, an operation which has been made the subject of a valuable thesis by Dr. Lutaud. This thesis appears to have been inspired as a result of two successful operations performed by Ricard. The principle of this method is as follows:

The abdomen is opened by the usual median subumbilical incision, and the peritoneum covering the damaged duct is incised and its proximal end exposed: the mucous membrane of the ureter is reflected like a cuff. An opening is made in the bladder wall in a situation convenient for making the junction, and two centimetres of the ureter are allowed to project freely into the vesical cavity, ‘à la façon d’un battant de cloche.’ The ureter is secured by sutures to the vesical mucous membrane, and to the muscular coat of the bladder. The sutures should be of thin catgut and must not perforate the bladder or the ureteral walls. The bladder itself near the junction should be attached by sutures to the adjacent peritoneum to prevent dragging (Fig. 27).

Lutaud significantly points out that we know little of the subsequent fate of ureters which have been engrafted into the bladder. The immediate results have been successful, but there is good reason to believe that when a ureter has been engrafted into the bladder, its walls become sclerosed by a chronic ureteritis, and its lumen is gradually stenosed. These changes take place slowly and cause little or no discomfort in connexion with the kidney or the bladder, so that they pass unnoticed.

If the opinion expressed by Lutaud, that the ureter becomes stenosed after uretero-cysto-neostomy, is found to be a constant, or even a frequent, sequel to the transplantation of a ureter into the bladder, it will cause surgeons to be careful, and not follow too literally the advice given by some writers to the effect that in performing the ‘radical operation’ for cancer of the cervix, if the ureters are implicated these ducts may be divided and their proximal ends engrafted into the bladder.

Lockyer, in removing a burrowing fibroid, wounded the bladder and divided the right ureter; he sutured the vesical incision and removed the right kidney. During the twenty-four hours following the operation there was anuria. The abdomen was reopened and then it was found that the left ureter had also been divided. The proximal end of this ureter was engrafted into the bladder through the wound which had been already sutured. Convalescence was disturbed by a urinary fistula. The woman recovered and reported herself in good health three years later.

It has happened that after nephrectomy for the cure of a ureteral fistula, the sequel of a ‘radical operation’, the remaining ureter became thoroughly blocked by recurrent growth and the patient died from anuria.

In the cases where the injury to a ureter has been overlooked in the course of the operation many difficulties arise before the true conditions are appreciated. In some instances they soon become obvious; for example, Purcell in 1898 performed an abdominal hysterectomy, next day the patient had complete anuria. The abdomen was reopened fifty-eight hours later; a distended ureter was easily recognized behind the ligatures applied to the right and left uterine artery respectively. The ligatures were removed, the swelling quickly subsided, and urine reached the bladder. The woman recovered.

When a ureter is injured in the performance of total hysterectomy, urine escapes by the vagina, and at first there may be some doubt whether the leak is due to an injury to the bladder or to the ureter. In such conditions the quantity of urine voided from the bladder is compared with that which escapes from the vagina; if the quantities are equal, or nearly equal, the leak is in a ureter. A more reliable method is to inject a solution of methylene blue into the bladder through the urethra. If the coloured fluid escapes from the vagina, the leak is in the bladder; if not, it is in the ureter. When a vaginal leakage occurs a few days after a vaginal hysterectomy, it is probably due to necrosis and sloughing of a ureter, or the duct may have been included in a ligature which has separated by sloughing.

Noble, in 1902, published an interesting series of injuries to the ureter. One of these is of great value, because it proves that a ureter may be accidentally ligatured and give rise to no symptoms.

A woman of thirty-three years of age was submitted to vaginal hysterectomy for cancer of the neck of the uterus, complicated with pregnancy. She died four days after the operation, and at the post-mortem examination the left ureter was found occluded with a ligature. The ureter and pelvis of the kidney were distended with urine.

The urine voided during the four days amounted on the first day to 480 c.c. (16 oz.); second day, 780 c.c. (26 oz.); third day, 1,440 c.c. (48 oz.); fourth day, 960 c.c. (32 oz.). These quantities would lull suspicion in regard to any patient, but the facts of the case are sufficient to raise suspicions of another kind, namely, that it is possible and probable that a ureter has been ligatured in the course of an operation, and the patient has recovered without any one having any suspicion that such an accident has happened.

As soon as the surgeon clearly establishes the existence of a ureteral fistula he is beset with the necessity of deciding which duct is the seat of damage. Some years ago, when it was the practice to remove the kidney for a persistent ureteral fistula, the decision involved the surgeon in a grave responsibility, for the removal of the wrong kidney could only be regarded as a catastrophe for the patient. Morris has recorded a case in which this actually happened. A woman had total hysterectomy performed for a cervix fibroid by a gynæcologist; in the course of the convalescence a ureteral fistula was recognized, and as this failed to close spontaneously, a surgical colleague performed nephrectomy, and next day found to his chagrin that he had removed the kidney belonging to the uninjured ureter. Serious accidents of this kind are less likely to happen now, because the surgeon can avail himself of the cystoscope and ureteral catheter; with these instruments it is possible, not only to decide with certainty which ureter is injured, but also to determine the position and extent of the damage. See also Vol. III.

It is important to remember that every ureteral fistula does not require an operation. It is always advisable, when it has been clearly established that a woman has a leaking ureter, to wait a little, certainly six weeks, for many fistulæ of this kind will gradually close. In describing such a case, Jonas draws attention to a cystoscopic sign of some value. He performed a total hysterectomy for fibroids, and on the tenth day the nurse reported the escape of urine by the vagina. The daily output of urine from the bladder, which had averaged 50 ounces, fell to 25 ounces. On cystoscopic examination, urine could be seen issuing from the right ureteral orifice; at first the left orifice could not be seen, but on careful watching a movement was detected similar to the contraction of a ureter discharging urine, but no fluid came from the opening. This is known as leergehen (empty contraction), and it indicates that there is a lateral opening, but not complete interruption in the continuity of the ureter. Such a case should have an opportunity of healing spontaneously. This happened in Jonas’s patient.

Weibel states that a ureteral fistula due to necrosis after a radical operation for cancer of the uterus usually occurs in the second week. The earliest day is the seventh, and the latest the eighteenth day after operation. The majority of these fistulæ heal in from three to twelve weeks. If a fistula persist for more than three months spontaneous healing is not to be expected. A ureteral fistula is a serious matter for the patient. Blacker has had three cases after total hysterectomy. In one the kidney was removed on account of septic changes. The second had an attack of suppression of urine lasting twenty-four hours; it passed off, the patient recovered and the fistula healed. The third died eight weeks after the hysterectomy with symptoms of pyæmia; a small abscess had formed near the site of the fistula.

The fate of ligatures. When a ligature is satisfactorily applied to a pedicle the tissue on the distal side of the ligature is isolated from the circulation. The fate of this tissue and of the ligature has been the subject of much speculation.

It is a matter of common observation that when animal tissues are cut off from the circulation, they atrophy; but if pathogenic micro-organisms gain access to such parts, suppuration ensues. In due course, through the activity of the living cells, the dead tissues are detached from the living, a process termed sloughing.

When a piece of healthy tissue is removed from the body and immersed in a sterile solution, and absolutely isolated from the atmosphere, decomposition is indefinitely postponed, but as soon as unsterilized air is allowed access to it, putrefactive changes ensue. The pedicle after ovariotomy is in an air-tight chamber, and if the tissues included by the ligature are healthy, and the silk employed for the purpose is absolutely aseptic, this pedicle, when returned into the abdomen, resembles the piece of tissue isolated from contact with the atmosphere. No septic changes occur, but aggressive leucocytes attack the silk and may, in course of time, effect its removal, even the knots. For this desirable result three conditions require to be fulfilled: (1) the ligatured tissue must be aseptic; (2) the ligature should be absolutely sterile; and (3) air or intestinal contents must be excluded.

These conditions may be prevented in many ways. The tissues included in the ligature are not always free from infective organisms, especially the Fallopian tube, which is usually included in the ligature, and this structure, especially in cases where oöphorectomy is performed for inflammatory diseases, often contains septic microbes; this endangers the ligature and leads to the formation of pus, with its complications, sloughing of the pedicle and abscess. The tissues may be healthy and aseptic, but the ligature may have been imperfectly sterilized, or become contaminated by assistants, or even by the hands of the surgeon during its application.

The operation may have been conducted aseptically and the tissues be healthy, but the ligature becomes infected by the admission of air as a result of drainage, or implication of the bowel or bladder.

I made a careful study of the fate of silk sutures employed in pelvic surgery extending over many years, and came to the conclusion that, even under favourable conditions, silk ligatures disappear very slowly. The silk used to secure an ovarian pedicle may, in very favourable circumstances, disappear in twelve months, but the knots require nearly double that time. The piece of silk which encircles the Fallopian tube is apt to behave in a curious way; in 1898 I removed an ovarian cyst the size of a fist, and tied its slender pedicle with thin silk. Although the recovery was uneventful, the patient complained during many weeks of cramp-like pains on the side from which the cyst was removed. These pains gradually subsided, and ten months later, during menstruation, the patient noticed on the napkin a tiny loop of silk, which she saved. This was the loop of silk which secured the Fallopian tube; it had ulcerated into the tube and been conducted into the uterus and escaped. I have since had a like condition, the loop making its appearance three weeks after an ovariotomy. It has been established by experiments on the long uterine cornu of rabbits, that an encircling ligature will ulcerate through, leaving the lumen of the cornu intact. Clinical observations regarding ligatures applied to Fallopian tubes in the performance of Cæsarean section for the purpose of preventing pregnancy prove that this is a useless measure (see p. 71), for these tubes in many instances have recovered their patency, and pregnancy has recurred. It is a fair inference that the ligature ulcerates into the lumen of the tube, which then heals behind it, without stricture of the canal. A similar condition of things sometimes arises after Cæsarean section, especially when the uterine incision is closed by two layers of sutures. Those sutures which involve the endometrium will ulcerate into the uterine cavity and cause irregular slight losses of blood until they escape.

A Uterus in Sagittal Section Fig. 28. A Uterus in Sagittal Section. Showing silk ligatures which had been introduced in the operation of Cæsarean section four years previously. (Museum, Royal College of Surgeons.) Full size.

It is important to emphasize the fact that silk sutures in uterine tissue will, in some instances, remain unabsorbed for many years. A patient who had been submitted to Cæsarean section in 1903 came under my care four years afterwards for the removal of the tumour which caused obstruction; the sutures used to close the uterine incision were visible, and a microscopic examination showed that each silk suture was enclosed in a fibrous tissue sheath (Fig. 28).

The fact that silk sutures will resist absorption for such a long period has an important practical bearing, because so long as pathogenic micro-organisms are denied access they remain inert, but if any septic condition arises in their neighbourhood, and these sutures become involved, they will give rise to abscesses and sinuses as surely as if they had been buried but a few days.

Patients often suffer great distress and annoyance on account of abscesses and sinuses due to septic ligatures, and a sinus will persist as long as the ligature remains. Abscesses and sinuses resulting from troublesome ligatures may escape in many directions; the most common spot is at the lower angle of the abdominal incision; the rectum is another channel of escape, and also the bladder. When a ligature makes its way into the bladder it will set up cystitis and serve as a nucleus for a vesical calculus. In an unusual case recorded by Edebohls, double oöphorectomy was performed for uterine fibroids; a year later the ligature on the left side escaped through the vagina; six months later he performed abdominal hysterectomy. The vermiform appendix was adherent to the stump on the right side; it was removed, and a silk ligature tied in a complicated knot was found in it, making its way towards the cæcum.

On one occasion a woman, who had been submitted to subtotal hysterectomy in the Antipodes, suffered from frequent micturition and fœtid urine; she came under my care. On dilating the urethra, it was found that the cervical stump had ulcerated through the posterior wall of the bladder and projected freely into the vesical cavity, bristling with thick silk ligatures encrusted with phosphatic deposit. The ligatures were removed, the urine soon became acid, and the vesical discomfort quickly subsided, in spite of the anomalous position of the cervical stump.

Until surgeons fully realized the importance of thoroughly sterilizing the silk employed for the pedicles in ovariotomy, it was quite common for the silk loops to ulcerate through the bladder wall and set up cystitis.

Many cases have been reported in which a loop of silk, effecting an entrance into the bladder in this fashion, has formed the nucleus of a phosphatic calculus.

Post-operative kraurosis. In a small proportion of patients (perhaps not more than one per cent.) who have undergone bilateral ovariotomy, oöphorectomy, or hysterectomy, the vulva undergoes the peculiar atrophic changes which are characteristic of the condition known as kraurosis vulvæ. This change, so far as my observations go, is chiefly seen in patients who have been submitted to these operations after the fortieth year of life. The cause of these changes is unknown. The condition is troublesome and inconvenient in married women, but spinsters rarely complain of it. Post-operative kraurosis is as rebellious to treatment, and its causation as inexplicable, as kraurosis occurring independently of operation.

The cicatrix. Although the employment of buried sutures has made abdominal incisions more secure in the process of healing, and renders them firmer after union, and thus reduces the chances of a yielding scar, and saves the patient the inconvenience of an abdominal hernia or the annoyance of wearing an abdominal belt, it renders the patient liable to another discomfort, namely, stitch-abscess. This complication arises from a variety of causes—for example, imperfect sterilization of the suture material, or of the patient’s skin preceding the operation. The sutures may be soiled by the hands of nurses and assistants, or the fingers of the surgeon. All these things may be safeguarded, but the operation may have been required for the removal of infected cysts, or pelvic peritonitis: in these cases it is wise not to bury sutures.

Troublesome buried sutures should be removed. In many instances this is easy of accomplishment, and in others it requires patience and often perseverance, even when the patient is under an anæsthetic. The simplest implement for removing a buried suture is a crochet-hook.

The disadvantage of stitch-abscesses, apart from the inconvenience they cause patients during their convalescence, is that they often cause the scar to yield at that spot, and necessitate the wearing of an abdominal belt. If the hernia is of small extent, and especially when it is situated near the lower angle of the scar, it is difficult to fit a belt which will restrain it without the use of perineal bands or straps. In such cases a truss, on the principle of those employed for inguinal hernia, is more satisfactory than a belt.

Occasionally a scar forms a raised hard red keloid band, and causes some anxiety to the patient. These keloid scars shrink and whiten in the course of a year or eighteen months.

Cancer of the cicatrix. Several cases have been recorded in which, after the removal of an ovarian adenoma, a new growth, described as ‘cancer of the cicatrix’, has formed in the scar. These growths are probably due to the soiling of the wound at the time of operation with epithelial fragments from the tumours.

After abdominal hysterectomy for cancer of the body of the uterus, or its cervix, the abdominal wound may become infected with this disease, and in cases where exploratory cœliotomy has been performed for diffuse cancerous disease of the peritoneum the cicatrix is liable to become permeated by malignant disease also.

References

Baldy, J. M. The Mortality in Operations for Fibroid Tumour of the Uterus. Trans. Am. Gynæcological Association, 1905, xxx. 450.

Bartlett, W., and Thompson, R. L. Occluding Pulmonary Embolism. Annals of Surgery, 1908, xlvii. 717.

Blacker, G. F. Lancet, 1909, i. 395.

Bland-Sutton, J. Hunterian Lecture on Thrombosis and Embolism after Operations on the Female Pelvic Organs. Lancet, 1909, i. 147.

Blau, A. Ueber die in der Klinik Chrobak bei gynäkologischen Operationen beobachteten Nebenverletzungen. Beiträge f. Geb. u. Gyn., 1903, Bd. vii. 53.

Bucknall, R. The Pathology and Prevention of Secondary Parotitis (with Literature). Med.-Chir. Trans., 1905, lxxxviii. 1.

Deaver, J. B. Hysterectomy for Fibroids of the Uterus. Am. Journ. of Obstetrics, 1905, lii. 858–74.

Hastings, S. A Preliminary Note on Embolism in Surgical Cases. Archives of the Middlesex Hospital, 1907, xi. 78.

Jonas, E. Temporary Uretero-vaginal Fistula after Panhysterectomy for Fibroid of the Uterus. Am. Journ. of Obstetrics, 1907, lvi. 731.

Lequeu. Sur les parotidites post-opératoires. Bull. et Mém. de la Soc. de Chir. de Paris, 1907, T. xxxiii. 1044.

Lutaud, P. Sur un procédé d’urétéro-cysto-néostomie dans le traiment des fistules urétéro-vaginales et urétéro-cervicales. Paris, 1907.

Lyle, Ranken. A Series of Fifty Consecutive Abdominal Sections. Journal of the British Gynæcological Society, 1906–7, xxii. 120.

Mallet, G. H. Am. Journ. of Obstetrics, 1905, li. 516.

Morris, H. Lectures on the Surgery of the Kidney. British Medical Journal, 1898, i. 1039.

Noble, C. P. Clinical Report upon Ureteral Surgery. American Medicine, 1902, iv. 501.

—— Myomectomy. New York Medical Journal, 1906, lxxxviii. 1008.

Olshausen, R. Veit’s Handbuch der Gynäkologie, 1907, 2nd Ed., Bd. i. 715.

Purcell, F. A. The Risks to the Ureters when performing Hysterectomy, &c. Journ. Brit. Gyn. Soc., 1898–9, xiv. 174.

Robinson, B. Sudden Death, especially from Embolism, following Surgical Intervention. Medical Record, 1905, lvii. 47.

Spencer, H. R. Discussion at Exeter on Uterine Fibroids, &c. British Medical Journal, 1907, ii. 452.

Tebbs, B. N. Symptomatic Parotitis. Med.-Chir. Trans., 1905, lxxxviii. 35.

Trendelenburg, F. Zur Herzchirurgie. Zentralbl. für Chir., 1907, No. 44, 1302.

—— Ueber die chirurgische Behandlung der puerperalen Pyämie. Münchener Med. Wochenschr., 1907, xxxiv. 1302.

Weibel, W. Das Verhalten der Ureteren nach der erweiterten abdominalen Operation des Uteruskarzinoms. Zeitsch. f. Geb. u. Gyn., 1908, lxii. 184.


SECTION I

OPERATIONS UPON THE FEMALE GENITAL ORGANS

PART II

VAGINAL GYNÆCOLOGICAL OPERATIONS

BY

JOHN PHILLIPS, M.A., M.D. (Cantab.), F.R.C.P.
Professor of Obstetric Medicine, King’s College, London Obstetric Physician and Gynæcologist to King’s College Hospital

CHAPTER XII

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

PREPARATION OF THE PATIENT

In operations upon the perineum and vagina, the same scrupulous precautions against sepsis should be taken as in abdominal section. Before proceeding to practical details, it will be useful to consider a few points regarding the distribution of bacteria in these parts. Not only the ordinary bacteria of the skin, but also those from the rectum, and, under certain conditions, from the urine and the vaginal secretion abound on the perineal and vulval surfaces. The healthy virgin vagina may be considered free from pathogenic organisms, harbouring only the harmless vaginal bacillus of Döderlein. After sexual congress the vagina contains pathogenic organisms, and in conditions such as carcinoma of the cervix and body of the uterus, and in all forms of vaginitis, many varieties of bacteria are present in great numbers.

The normal uterus is germ-free; in fact the external os uteri may be said to divide the bacteria-free from the bacteria-containing area of the genital canal. But in carcinoma and in the various forms of septic endometritis, the uterus not only contains many pathogenic bacteria, but acts also as a continual source of infection to the vagina and external genital organs. It follows, therefore, that this area may be exceedingly difficult to render sterile, and in certain conditions this is indeed impossible. None the less, every effort should be made to attain this object; for even if the organisms cannot be entirely removed, yet their numbers can be considerably reduced, and it must be remembered that the action of septic organisms is, to a great extent, directly proportionate to their numbers.

The same general principles apply to the preparation of patients for operations on the perineum and vagina as for operations on other parts of the body. Very particular attention, however, must be paid to the bowels; nothing is more prejudicial to the success of an operation, or more annoying to the operator, than to have the area of operation soiled by an escape of fæcal matter from an imperfectly emptied lower bowel. The aperient should be given at least 24 hours before the time of operation. A copious soap-and-water enema should follow after the usual interval, and, an hour or two beforehand, the lower bowel should be thoroughly washed out with a gentle stream of warm water.

Fig. 29. Patient prepared for Operation. In lithotomy position with crutch applied, Auvard’s speculum inserted, and volsella attached to the anterior lip of the cervix uteri. Kelly’s pad is omitted for sake of clearness. (From a photograph.)

The external genitals should be shaved, and washed with ethereal soap solution and hot water the day before the operation, then douched with a 1–2,000 solution of perchloride of mercury, and a compress, soaked in the same solution, laid over the vulva. After the enema has acted, and after the final wash-out, the washing and douching should be repeated and a fresh compress applied.

If there is any vaginal discharge, the vagina should be douched out three times a day for two or three days previous to the operation, with an antiseptic such as 1–4,000 perchloride of mercury, or 1% formalin. The healing of a perineal wound is considerably impaired if it be continually bathed in an unhealthy vaginal discharge.

When the patient is on the table and under the anæsthetic, the external parts should again receive a thorough final disinfection, and, in addition, the vagina should be thoroughly swabbed out with ethereal soap solution, by means of swabs on holders. A final douching with 1–2,000 perchloride of mercury completes the process.

In all cases of vaginal hysterectomy for carcinoma, particular attention must be paid to the preliminary disinfection of the vagina by means of douching for two or three days before the operation. The vagina is swarming with various kinds of bacteria, and by careful attention to these principles the risk of sepsis will be materially diminished.

After the above preparations have been carried out, the patient is anæsthetized and placed on the table in the lithotomy position, the legs being kept well apart and fixed by means of a crutch. The buttocks are brought well to the edge of the table, and a Kelly’s pad may be placed beneath them. The legs should be encased in sterilized towels or linen stockings, and towels placed on the hypogastrium (Fig. 29).

OPERATIONS FOR THE REPAIR OF COMPLETE LACERATION OF THE PERINEUM

Under the term colporrhaphy (suture of the vagina) is included any operation in which denudation and subsequent suturing of one or both walls of the vagina is carried out. Anterior colporrhaphy includes the various operations devised for cystocele; posterior colporrhaphy, the procedures carried out for incomplete rupture of the perineum (colpo-perineorrhaphy), prolapse of the pelvic floor, and to produce narrowing of the vagina.

Complete Laceration of the Perineum
  
Fig. 30. Complete Laceration of the Perineum. (From a photograph.)

a, a'. Ends of torn sphincter ani.
cli. Clitoris.
l.i. Labium internum.
m.v. Mons Veneris.
p.c. Preputium clitoridis.
sph. Sphincter ani.
ur. Urethral orifice.

The appearance of the parts in this condition is quite characteristic (Fig. 30); the laceration of the recto-vaginal septum appears as a triangular space with its apex upwards, its sides equal, and its base formed by the retracted sphincter ani (Fig. 32). The separated ends of the sphincter are seen as two slightly depressed circular spots at the base of each side of the isosceles triangle a, a'. The object of the operation is to adapt these two ends, repair the recto-vaginal rent, and re-form the perineal body. There is often much irregular scar tissue about the opening, which may cause additional difficulty at the operation.

Long-handled sharp-pointed Scissors curved on the flat Fig. 31. Long-handled sharp-pointed Scissors curved on the flat.

The instruments necessary are six Spencer Wells artery forceps, long dissecting forceps with hooked points, a pair of sharp-pointed angular and a pair of sharp-pointed curved scissors (see Fig. 31), flat curved needles and Schauta’s needle-holder (Fig. 73).

The preparatory treatment consists in regular gentle purgation daily for a week, dieting, rest in bed for three days, and antiseptic vaginal douches of lysol (1 drachm to the quart).

Operation. The patient is placed in the dorsal position on a Kelly’s pad, and after the usual purification, denudation is commenced. The skin over the circular depressions corresponding to the ends of the severed sphincter (Fig. 30, a, a') is seized with the dissecting forceps and slightly raised. This portion of skin on either side is removed by means of the scissors, thus baring the ends of the sphincter and opening up the cellular tissue.

The point of one blade of the scissors is now buried in the cellular tissue at this bared spot on the operator’s right side, and is carried along the free torn edge of the recto-vaginal septum between the deep and superficial tissues until the apex of the laceration is reached. A similar incision is made on the opposite side.

The triangles of the vaginal flap are now raised by means of catch-forceps and the scissors passed carefully into the cellular tissue, and the recto-vaginal septum is split transversely, producing a raw surface somewhat the shape of a butterfly in outline (Fig. 33). A median extension of the denudation is made in an upward direction for another inch in length to form a supporting column. This flap may, if the tissues are sufficiently redundant, be removed along the line running at its base. The raw surface should be swabbed over carefully, and any bleeding points secured by ligatures. Large venous sinuses are very often opened, and, should the bleeding recur after the adaptation of the flaps, the operation will inevitably fail.

Complete Laceration of the Perineum
  
Fig. 32. Complete Laceration of the Perineum. Semi-diagrammatic drawing of a ruptured recto-vaginal septum, indicating the method of passing the sutures for its repair.

r.m.m. Rectal mucous surface.
sph. Torn end of sphincter ani.
v.m.m. Vaginal mucous surface.

The arrows indicate the direction of the sutures.

Closure of the recto-vaginal rent is first carried out by interrupted sutures, as is seen in the semi-diagrammatic drawing (Fig. 32). The threaded needle in a holder is passed from the rectal side of the flap through the flap on to the raw surface, then over the rent on to the raw surface of the other side; it finally finds its exit again on the rectal side of the flap. Four or more sutures may be passed in this way, a final one bringing the cut ends of the sphincter ani together. Each suture should be tied and the ends cut short before the next one is inserted, and the knots will lie just beneath the mucous membrane of the rectum.

Complete Laceration of the Perineum Fig. 33. Complete Laceration of the Perineum. In A the ‘butterfly’ surface has been denuded and the recto-vaginal rent repaired (c).

a. Sutures passed through the sustaining column, but not tied.
b. The ‘buried’ spiral suture passed but not tied.

In B is shown the oval raw surface left to be brought together by sutures (d) after the buried suture (b') has been tied. (Diagrammatic.)

We have now a large butterfly raw surface to deal with. The extension corresponding to the head is first of all dealt with by four or more separate sutures (Fig. 33, a). The large raw surface is now reduced in size by the passage of a deeply buried suture (Fig. 33, b); those used in the preceding manœuvres are best of silk. The buried suture should be catgut, and is passed in a spiral direction, as is seen in the diagram; the area of the raw surface is very much reduced by it (Fig. 33, b').

The parts to be brought together will now present the appearance shown in Fig. 33, B, and they are approximated by means of silk sutures, which are entered on the skin surface on one side, passed beneath the raw surface, and made to emerge on the skin surface on the opposite side. Four to six of these may be inserted.

Great care must be taken to see that no bleeding points are left unsecured, and a current of hot 1 in 4,000 perchloride solution should be allowed to play over the surface, after which the sutures are tied. Each suture should be left about an inch and a half long in order to facilitate removal later on. A gauze drain should be passed into the vagina and an antiseptic gauze pad placed over the perineum.

After-treatment. The patient’s knees should be tied together, the urine drawn off by a catheter every six hours for the first 48 hours, and the wound kept as dry as possible. Throbbing and pain in the perineum with slight rise of temperature are generally indicative of suppuration taking place either between the flaps or along the sutures. A smart purge should be given on the morning of the third day and daily afterwards. If there are any scybala left in the rectum it is better to inject a little warm olive oil into it through a catheter before the bowels are expected to act.

The patient should be allowed to get up on the twenty-first day. There should be proper control of flatus and motions from the date of operation.

OPERATION FOR LACERATION OF THE PELVIC FLOOR

The objects of this operation are twofold: first, to secure the torn ends of the levator ani to the lateral vaginal sulcus and perineum; and, secondly, to draw up or lift the pelvic floor, which is more or less depressed.

Laceration of the Pelvic Floor
  
Fig. 34. Laceration of the Pelvic Floor. The double triangular surface has been denuded. (Semi-diagrammatic, from a photograph.)

The sutures, 1–5, on the operator’s right side are passed and tied; those on the left are passed but not tied.

a. Anus c. Cervix h. Site of hymen.
p1–p3. Sutures passed through the quadrilateral denuded surface.
r. recto-vaginal wall.
s. Speculum (Pozzi’s anterior retractor).
t, t. Tenacula.

The arrow denotes the direction in which the sutures are passed.

The patient is placed in the lithotomy position and a retractor is inserted in the anterior cul-de-sac in order to elevate the anterior vaginal wall: Fig. 34 shows the appearances then seen. The left forefinger or some gauze packing is placed in the rectum and a double triangular space is denuded by means of sharp-pointed scissors, the base line of the double triangle being formed by the hymen. Two tenacula are inserted as indicated in the drawing (Fig. 34, t, t). The mucous membrane is now removed from the M-shaped space, great care being taken to penetrate deeply into the lateral sulci. After all bleeding has been arrested in the usual manner, the sutures should be passed. On the left-hand side of the figure these are indicated as inserted, not tied, whereas on the right they are tied and cut. Subsequently the somewhat quadrilateral raw surface which is left is brought together by five deep sutures, and the operation is complete. A Y-shaped cicatrix will be the result.

Cases in which the perineum is apparently intact, but in which the sphincter is not united (Figs. 35, 36).

These are the cases in which a complete laceration of the perineum is apparently completely healed after operation, but the patient finds that she has incontinence both of flatus and fæces.

On inspection of Fig. 35 this will be well explained. The patient is lying on her back in the lithotomy position: a represents the sphincter which has been torn through; the two cut ends, b and c, are represented by two dark circular, somewhat depressed spots. The rectal orifice gapes; there is no sphincteric power present. The perineum anterior to the anus is firmly healed.

Operation. The most certain and effectual method in these cases is to split up the healed perineum antero-posteriorly and treat the case as one of complete laceration of the perineum (see p. 128). This has been carried out in the case represented in the illustration (Fig. 35), and Fig. 36 shows the result: the patient entirely recovered power over the sphincter ani and the sustaining power of the pelvic floor was much improved.

Repair of a Lacerated Perineum Fig. 35. Repair of a Lacerated Perineum, with Non-union of the Sphincter Ani, before a Plastic Operation. (From a photograph.)

a. Ununited sphincter ani.
b, c. Buried ends of torn sphincter.

    
Repair of a Laceration of the Perineum after a Plastic Operation Fig. 36. Repair of a Laceration of the Perineum after a Plastic Operation. (From a photograph.)

a. Repaired sphincter ani.
b. Anus.
s. Resutured perineum.


CHAPTER XIII

OPERATIONS UPON THE URETHRA AND BLADDER

EXTIRPATION OF A URETHRAL CARUNCLE

Indications. A urethral caruncle is a bright red, tender tumour, usually on the posterior portion of the urethral orifice.

The symptoms requiring interference are pain on micturition, dyspareunia, bleeding and discomfort on movement, and, occasionally, retention of urine which is probably due to apprehension of pain rather than to any mechanical obstruction.

Operation. To be effectual this must be thorough, and may take the form of deep cauterization with a Paquelin’s cautery, or excision. The latter operation consists in excising a wedge-shaped piece of the posterior wall of the urethra containing the caruncle. Free bleeding will usually take place, which must be controlled by means of hæmostatic forceps. The edges of the wound are brought together by fine silk or catgut sutures, which must be passed completely through the raw surfaces to prevent recurrent hæmorrhage.

The after-treatment consists in keeping the wound as clean and dry as possible.

OPERATIONS FOR INCONTINENCE FOLLOWING LABOUR

This is probably due to injury to the pelvic floor and the anterior fibres of the levator ani, producing a backward displacement of the urethra.

Operation. The operation recommended by Dudley consists of first denuding the vaginal mucous membrane over a horseshoe-shaped space between the clitoris and the urethral orifice and then drawing the urethra forward with sutures passed through the anterior portion of the orifice and inserted near the clitoris. It will then be seen that the urethra is carried forward nearly an inch. The raw edges are brought together in the usual manner by catgut or silk sutures.

The author’s experience of this operation has been unsatisfactory on the whole, and he has obtained better results by the wearing of a ring pessary.

OPERATIONS FOR VESICO-VAGINAL FISTULA

For simple vesico-vaginal fistula. This condition is fortunately very rare at the present time. Many operations have been devised for this condition, but the original one recommended by Sims, with subsequent modifications, appears to the author to be most efficient and applicable to the large majority of varieties of this condition.

Preparatory treatment. The chief object is to obtain a healthy condition of the fistulous edges, which are nearly always inflamed, thickened, and covered by urinary deposits, usually of a phosphatic character. These are best removed by means of a soft sponge or cotton-wool, and the raw edges treated with a weak solution of nitrate of silver (gr. ij to the ounce). Hot vaginal douches of lysol solution (ʒj to a quart) should be given night and morning, and the parts freely smeared with vaseline to protect them from the action of the irritating urine. Any cicatricial tissue which may be present around the fistula should be treated by submucous division.

Auvard’s Self-retaining Speculum
Fig. 37. Auvard’s Self-retaining Speculum.
Knives for freshening the Edges of a Vesico-vaginal Fistula Fig. 38. Knives for freshening the Edges of a Vesico-vaginal Fistula.
Toothed Forceps for use in Vesico-vaginal Fistula Fig. 39. Toothed Forceps for use in Vesico-vaginal Fistula.
Emmett’s Hook Fig. 40. Emmett’s Hook.

Operation. The instruments necessary are: a Sims’s or Auvard’s (Fig. 37) speculum; two flat spatulæ; three long-handled knives (Fig. 38), one with a long haft and a short straight narrow blade, and the others with angular blades (right and left); two long-handled, sharp-pointed, curved scissors (right and left); an Emmett’s hook for making counter-pressure (Fig. 40); toothed forceps (Fig. 39) and tenaculum; six Spencer Wells’s forceps; Schauta’s needle-holder (Fig. 73) with short curved needles.

The patient is placed in the lithotomy position. A strip of mucous membrane is then removed from the whole of the vaginal edge of the fistula by means of an angular knife. In the original operation Sims (Fig. 41) made the surface oblique, but Simon (Fig. 42) considered the raw surface should be at right angles to the mucous membrane. The blade of the knife should not wound the vesical mucous membrane.

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

a. Bladder mucous membrane.
b. Vaginal wall.
c. Suture passed but not tied.
d. Section of denuded surface.
e, e'. Liberating incisions.
f. The fistula.

    
Simon’s Operation for the Repair of a Vesico-vaginal Fistula Fig. 42. Simon’s Operation for the Repair of a Vesico-vaginal Fistula. Letters as in the preceding figure.

After the bleeding has ceased, the sutures, which may be of silk or catgut, are passed by means of the needle through the pared edge of the fistula on one side, passing across the fistula, and piercing the raw surface on the opposite side. The entry of the needle should be made about 1/4 – 1/3 of an inch from the raw edge (Fig. 44). Emmett’s hook, shaped like a button-hook, is useful to produce counter-pressure against the needle point. The sutures are tied, and milk is injected into the bladder to test the accuracy of the union.

As a rule, fistulæ are bounded by rather scanty and inelastic walls, owing to the presence of cicatricial tissue; it is therefore more advantageous not to remove any tissue in order to produce a raw surface, or as little as possible. To fulfil this condition, the method of dédoublement or flap-splitting, as practised by Walcher, may be carried out (Fig. 43, A, B, and C).

Repair of a Vesico-vaginal Fistula by Dédoublement Fig. 43. Repair of a Vesico-vaginal Fistula by Dédoublement.

A. The flap-splitting stage.
B. The flaps separated and the suture passed.
C. Suture tied, approximating the flaps.
a. Bladder mucous membrane.
b. Vaginal wall.
c. Suture.
e, e'. Liberating incisions.
k, k'. Flap-splitting incisions.

In A the flap-splitting is seen in section (k, k'); in B the flaps have been everted towards the bladder and vagina respectively and the suture passed. In C this suture has been tied; liberating incisions, e, e', have been made on the vaginal surface to prevent tension in the wound.

The patient is placed, as before, in the lithotomy position, and the cervix is pulled down, while the edges of the fistula are kept steady by a volsella on either side. The margin of the orifice is then split all round to a depth of from a quarter to half an inch. Vesical and vaginal mucous membrane flaps are thus produced, giving a large raw surface without any loss of substance. The sutures are passed as shown in Fig. 43, C.

Repair of a Vesico-vaginal Fistula
  
Fig. 44. Repair of a Vesico-vaginal Fistula. Sims’s Operation. The edge of the fistula has been denuded and the sutures have been passed.

a.v.w. Anterior vaginal wall.
cl. Clitoris.
s', s''. Retractors.
sp. Posterior speculum.
t. Tenaculum.
u. Orifice of urethra.
v.v.f. Vesico-vaginal fistula.

After-treatment. This is very simple: if the patient is able, she should pass water, either in the dorsal or genu-pectoral position, otherwise a catheter should be passed every six hours.

Modifications of this operation have been devised, more especially for the larger fistulæ: they will be briefly mentioned.

1. Repair by turning up vaginal flaps to form the base of the bladder is recommended by A. Martin of Berlin. He first frees the adherent edges of the fistula and then raises the flaps from the vaginal wall and brings them over the opening, suturing them carefully together. By this method the mucous membrane of the vagina forms the new lining to the bladder, and the exposed raw surface a new anterior vaginal wall. The edges of this latter denuded surface are united by sutures, as in the operation of colporrhaphy.

2. Closure of the fistula by detaching the bladder from the vagina and suturing it independently is described and practised by Mackenrodt.

The patient is placed in the lithotomy position, and the fistula is exposed: the cervix is drawn downwards and backwards by means of a wire loop or tenaculum, and the urethral prominence held with a pair of hooked forceps. An incision is then made in the median line extending across the fistula and through the vaginal walls down to the bladder, in this way exposing the entire base of the bladder. The edges of the fistula are then split so that the bladder and the vaginal walls are separated. The two vesical flaps are now carefully and separately sutured by catgut and the edges of the vaginal wound are brought together as much as possible: if necessary, the fundus of the uterus may be used to assist in closing the opening.

For vesico-utero-vaginal or juxta-cervical fistula. In this affection the cervix is involved, and it must therefore be carefully differentiated from the vesico-vaginal variety, in which the cervix is intact.

In operating upon such cases the chief difficulty will be found in denuding the surfaces necessary for the introduction of the sutures, owing to the density of the cicatricial tissues, which are always present. This is best overcome by drawing the cervix forcibly downwards and backwards and incising the anterior cul-de-sac; the bladder wall with its fistulous opening is then dissected off the anterior surface of the cervix and carefully sutured independently of the cervical laceration; the latter is treated by suture in the usual way (see p. 128). In the deeper forms of juxta-cervical fistula, the above technique is impossible, and suprapubic incision and suture of the bladder must be substituted.

RECTO-VAGINAL FISTULA

This condition may be defined as an opening between the rectum and vagina through which flatus, or fæces, or both, may pass from the former into the latter; it is chiefly the result of an imperfect union subsequent to an operation for complete perineum laceration. It may also be caused by the rupture of a pelvic abscess or by the spread of primary malignant disease of the rectal wall.

Operation. If the sphincter ani is incompletely united, it will be found much the most satisfactory proceeding to divide the healed portions of the perineum and make a complete perineal laceration; this may then be treated as described above (see p. 128).

If, however, the sphincter is intact and serviceable the fistula should be pared and the edges brought together by silk sutures. It is not infrequently necessary to perform a temporary colostomy (see Vol. II) in order to divert the fæcal contents of the bowel during the process of healing.

OPERATIONS FOR CYSTOCELE

In cystocele there is prolapse of the anterior vaginal wall and the corresponding area of the posterior bladder wall. Cystocele often complicates rectocele and prolapsus uteri, and operation upon it is often carried out in combination with colpo-perineorrhaphy.

Operation. The operation for the cure of this affection is very simple, and may be performed:—

(1) By denuding an oval space over the swelling and bringing the raw edges together.

(2) By Stoltz’s operation, which is really purse-string suture.

The instruments necessary are a bladder sound, two tenacula, sharp-pointed angular scissors, a needle-holder and fine silk.

(1) The parts are exposed with a Sims’s or Auvard’s speculum and a volsella, or silver wire is passed through the cervix, by means of which traction downwards and backwards may be exerted. The cystocele itself is fixed by tenacula, and, with the sound in the bladder, an oval incision is carried completely round the base of the cystocele. The whole area contained in this incision is denuded by knife or scissors, care being taken to avoid wounding the bladder mucous membrane.

Any bleeding having been controlled, a spiral buried suture, as in the operation for perineorrhaphy (see p. 128), is passed antero-posteriorly, thus reducing the size of the raw area and making a solid support in the median line. The raw edges are then brought together by sutures. The catheter should be passed every eight hours for three days, and then the patient should be allowed to micturate on her hands and knees.

Stoltz’s Operation for Cystocele
  
Fig. 45. Stoltz’s Operation for Cystocele. The oval surface has been denuded and the circumferential suture passed but not tied.

1,1',2,3. The four points first selected as boundaries for denudation.
s. Suture, the arrows denoting the direction in which it is passed.
sp. Retractor.
t. Tenaculum.
u. Urethral orifice.

(2) Stoltz’s operation. The instruments necessary are: a No. 8 male bladder sound; two tenacula; hooked forceps; sharp-pointed angular scissors, and a needle-holder (Schauta’s for preference).

The patient is placed in the lithotomy position and the parts are exposed by means of an Auvard’s speculum. A silver wire or tenaculum is passed through the posterior lip of the cervix, by means of which downward and backward traction may be exerted. Four points must be selected: two lateral (Fig. 45, 1, 1'), fixing the external boundaries of the surface to be denuded; one immediately behind the orifice of the urethra (2); and a fourth in front of the cervix (3). These four points should be capable of close approximation. They are carefully joined by curved incisions so that the area to be denuded is almost oval in shape. The bladder sound is now passed, and the mucous membrane of the vagina kept on the stretch by pressure on its point. The process of denudation should be carried out with a scalpel or pointed curved scissors. It will be found that bleeding rarely gives any trouble. The point of the needle threaded with silk is inserted on the operator’s right side of the urethral orifice and a little below it; it pierces the mucous membrane on the left side of the median line, and again appears upon the surface. By an in-and-out stitch all the way round the circle which has been pared, the point finally issues on the operator’s left side of the urethra and below it: by traction on these two ends the edges of the denuded surface are drawn together and the prolapsed bladder is sutured in its normal situation. A puckered cicatrix results. This method is valuable for prolapsus uteri when combined with the operation of posterior colporrhaphy.


CHAPTER XIV

OPERATIONS UPON THE VULVA AND VAGINA

OPERATIONS UPON BARTHOLIN’S GLANDS

The glands of Bartholin, or the vulvo-vaginal glands, are two racemose structures about the size of a pea, lodged between the layers of the triangular ligament, one on each side of the orifice of the vagina. Their ducts open a little in front of the fossa navicularis, on each side of the vaginal orifice, in the groove between the attached border of the hymen and the labium minus.

Removal of a cyst of Bartholin’s gland. These cysts really arise in the ducts rather than in the gland itself. The orifice of the main duct is very liable to become blocked from inflammation of the vulva, and leads to the formation of a single cyst varying in size from a cherry to an orange. Less common is the blocking of the secondary ducts, wherefrom a collection of small cysts results. The cyst forms a characteristic tense ovoid or pyriform swelling in the posterior third of the labium majus. The chief symptoms the patient complains of are discomfort in walking and pain on coitus.

Operation. The best procedure is complete excision of the cyst. A longitudinal incision is made over its cutaneous surface, and the cyst carefully dissected out, together with the gland itself: care must be taken not to perforate the vaginal mucous membrane stretched over the inner surface of the cyst. Brisk bleeding from vessels at the base of the cyst, usually follows from the cavity which contained the cyst and this must be carefully arrested, otherwise a large hæmatoma may result. The cavity is closed by five or six interrupted catgut sutures, passing deeply through its sides and floor, so as to ensure complete closure. A gauze drain may be inserted and retained for twenty-four hours.

The method of incising the cyst, swabbing its interior with undiluted carbolic acid, and packing it with gauze is not to be recommended, for cure is neither so rapid nor so certain as in excision.

Incision of an abscess of Bartholin’s gland. Abscesses arise by infection passing into the gland along the ducts, and are a very frequent accompaniment of gonorrhœa. The orifice of the duct can usually be seen red and prominent, and may exude pus if pressure be made over the abscess-sac. Sometimes the abscess bursts and spontaneous recovery may follow, but it is very liable to recur, for infection lurks among the smaller ducts and is carried to a fresh part of the gland, and the process may continue until the whole gland has been thus destroyed.

Operation. The abscess must be freely incised and all pockets and septa broken down. It is stuffed with iodoform gauze, which is changed daily, and the cavity is allowed to granulate up from the bottom. If the abscess recurs, or if it consists only of a small collection of pus surrounded by brawny œdema, the whole gland should be excised.

OPERATIONS FOR ATRESIA OF THE HYMEN AND THE VAGINA

Occlusion of the hymen is the commonest form observed. The vagina becomes slowly distended with blood, forming an elastic pelvic swelling (hæmato-colpos) upon which the uterus is, so to speak, perched. Later in the course of the disease, this organ itself (hæmato-metra) and the Fallopian tubes (hæmato-salpinx) may become affected similarly.

Indications. In atresia of the hymen symptoms only commence after puberty; there is then congenital amenorrhœa with periodic pelvic pain and gradual formation of a pelvic swelling. On inspection the hymen is distended and the blood-tumour above it gives a bluish tint to its surface.

Operation. After administration of an anæsthetic, careful palpation of the tubes should be made per rectum: if they are distended it is better to open the abdomen, ligature and remove them; if not, the hymen should be incised by means of a crucial opening and the characteristic tarry fluid allowed to escape: no hypogastric pressure should be used.

Irrigation and packing with gauze may be resorted to as after-treatment, but are considered unnecessary by a large number of operators.

Atresia of the vagina may be congenital or acquired. In the latter case the condition results from contraction of adhesions developed from damage done during labour; or it may follow acute septic vaginitis, the introduction of acids or irritating materials to produce abortion, or as a sequel to typhoid fever.

Treatment is by slow dilatation with Hegar’s bougies over an extended period of time; relapse is common.

DILATATION OF THE VULVAL ORIFICE

Indications. This is done for vaginismus due to a pathological spasm of the levator ani and resulting in more or less complete obstruction to coitus.

Sims’s Vaginal RestFig. 46. Sims’s Vaginal Rest.

Operation. Under an anæsthetic the vulval orifice should be thoroughly dilated by means of the thumbs, and for some days subse quently graduated Sims’s ‘vaginal rests’ (Fig. 46) should be inserted twice daily and worn for twenty minutes at a time. This treatment may be necessary for a fortnight or longer. In many cases of dyspareunia the cause will be found to be due to a thick, fleshy, and unruptured hymen or to tenderness about the remnants of that organ. Under these circumstances, exsection is the better plan to pursue. The hymen is seized with a pair of toothed forceps and removed with curved scissors along its entire base of attachment. Free bleeding often occurs from the raw surface, which must be controlled by ligatures. The two almost parallel cut edges must then be carefully brought together either by continuous or interrupted suture.

COLPOTOMY OR VAGINAL CŒLIOTOMY

By colpotomy is meant making an opening into the peritoneal cavity through the vagina; the operation is known as anterior or posterior colpotomy, according to whether the opening is made through the anterior or posterior fornix.

Colpotomy has certain advantages over abdominal section. There is less interference with the peritoneum and intestines, and therefore less shock; if pus is present, there is less risk of infecting the general peritoneal cavity, and better drainage; there is no abdominal scar, and therefore no risk of hernia; lastly, there are certain pathological products which can be more easily reached by this route. The operation is difficult in a nullipara, where the vagina is narrow, and easier in a multipara, where the vagina is more capacious, and it is still easier if the cervix can be drawn down as far as the vaginal orifice.

A serious disadvantage is that, during the course of the operation, it may be found impossible to deal adequately with the conditions for which the operation is being performed; in the case of a tumour, for instance, its size, position, or the presence of adhesions may render it necessary to complete the operation by the abdominal route. Further, in more than one instance, the abdomen has had to be opened after the completion of the operation on account of bleeding, the source of which could not be dealt with by the vagina.

Therefore, before deciding upon the removal of a tumour by colpotomy, all the above points must be taken into consideration.

Indications. When the above conditions are fulfilled, colpotomy is suitable for:—

(i) The evacuation of collections of pus or blood in Douglas’s pouch.

(ii) The removal of fibro-myomata, ovarian tumours of small size, and early tubal pregnancies.

(iii) The drainage of collections of pus or the removal of the appendages in cases of acute inflammation where immediate operation is necessary.

(iv) Conservative operations upon the Fallopian tubes or ovaries.

(v) A preliminary to the performance of vaginal hysteropexy.

(vi) Those cases in which the patient’s general condition is unfavourable to the performance of exploration by the abdominal route.

Anterior colpotomy is more suitable for removing small tumours growing from the anterior wall of the uterus, or for conservative operations on the ovaries. Posterior colpotomy is more suitable for removing inflamed appendages, and for evacuating collections of pus or blood from Douglas’s pouch.

Pozzi’s Retractors Fig. 47. Pozzi’s Retractors.

Posterior colpotomy has been used for many years for the opening of abscesses and hæmatoceles in Douglas’s pouch. The anterior operation is of more recent date, and its relative advantages and disadvantages and the indications for its use have not yet been definitely agreed upon by the majority of gynæcologists. Taking all things into consideration, the disadvantages of colpotomy seem to outweigh its advantages, and, except for the evacuation or drainage of collections of blood or pus behind the uterus, the operation may be said to have few indications.

Anterior Colpotomy Fig. 48. Anterior Colpotomy.

The patient is in the lithotomy position, the speculum is passed and the cervix pulled down by a tenaculum. The T-shaped incision has been made.

b. Outline of bladder.
c. Cervix.
cl. Clitoris.
l.m. Labium minus.
sp. Speculum.
u. Urethral orifice.
v,v',v''. Volsella.

Anterior colpotomy. A posterior Pozzi’s (Fig. 47) or Péan’s retractor is passed into the vagina, and the cervix is seized with a volsella and drawn downwards and backwards. A sound passed into the bladder defines its lower limit. A T-shaped incision is now made through the vaginal mucous membrane, the transverse portion just below the point to which the bladder has been found to extend (Fig. 48, b). This incision should pass completely through the vaginal mucous membrane, but no further, and should extend across the whole width of the anterior surface of the cervix. Some operators use a simple longitudinal or a transverse incision. The vaginal mucous membrane is now carefully pushed upwards with the pulp of the finger until the lower limit of the bladder is defined. Great help is gained at this stage by the use of the bladder sound. On pushing up the vaginal mucous membrane still further the peritoneum is reached, and is recognized by its white glistening appearance, and by the fact that its two opposed surfaces glide freely over one another under the finger. The next step is to open the peritoneum: it is picked up with catch-forceps, and a small transverse incision is made into it with a pair of scissors; the finger is passed through, and the incision is extended on either side, care being taken not to pass too far outwards for fear of injuring the ureters or uterine vessels.

After the peritoneum has been opened, the pelvic organs can be carefully examined with the fingers, and the purposes for which the operation has been undertaken can be proceeded with. The next step usually consists in drawing out the fundus of the uterus, by which much more room and much better access to the pelvic organs is gained. To accomplish this, the uterus is caught with a volsella in the middle line, as high up as possible, and drawn downwards and forwards. If necessary, a second volsella is applied above the first, and so on, until the uterus is delivered. A very complete examination of the appendages can now be made, for the tubes and ovaries can be drawn out of the wound and examined directly.

When the object of the operation has been attained, and all the blood has been carefully removed by swabs, the next and final step consists in closing the peritoneal and vaginal wounds. The uterus is replaced, and the peritoneal incision is closed by a single layer of catgut sutures; the vaginal incision is similarly dealt with. The vagina is cleared from blood-clot and gently irrigated with an antiseptic solution. A gauze plug is inserted lightly, and the patient is put back to bed. The catheter should be used every six or eight hours for the first twenty-four hours.

Posterior colpotomy. A posterior speculum is passed and the cervix drawn downwards and slightly forwards with a volsella. A transverse incision is then made through the vaginal mucous membrane at the junction of the posterior fornix with the cervix. This exposes the peritoneum more or less easily, and this structure is picked up with catch-forceps, and a transverse incision made into it with scissors; a finger is passed through this, and the incision is extended on either side. The pelvic organs can now be explored and the tubes and ovaries drawn down and examined. The peritoneal and vaginal incisions are then closed by separate layers of catgut sutures.

To open a collection of pus in Douglas’s pouch, the best method is to pass a pair of sinus-forceps, with the blades closed, into the most prominent part of the swelling. The blades are then opened and the forceps withdrawn. The finger passed into the abscess cavity gently breaks down any adhesions. The cavity is then irrigated with hot salt solution and a drainage tube inserted, which projects just outside the vulva: the lower end of the tube should be carefully packed around with cyanide gauze. The tube should be changed every day and the vagina douched with an antiseptic. Another method is to plunge a Martin’s trochar (Fig. 49) into any softened spot in the swelling and then withdraw the needle, leaving a blunt dilating forceps to extend the opening.

Martin’s Trochar for Pelvic Abscess Fig. 49. Martin’s Trochar for Pelvic Abscess.

In opening an abscess, the most stringent precautions against sepsis should be observed. The vagina must be most carefully prepared beforehand, by rubbing over with swabs and ethereal soap, and by a subsequent copious douche of 1 in 1,000 perchloride of mercury: otherwise continual reinfection of the abscess cavity occurs, and healing is much delayed.

Lateral colpotomy—Paravaginal section.

Indications. The object of the operation is to increase the amount of room in the vagina in certain cases of vaginal hysterectomy in elderly virgins, or in women who have a small vagina.

Operation. The same preliminaries are carried out as before. The incision is carried completely round the cervix at its junction with the vagina. The lateral margin of the vulva is then held tense, and an incision is made, beginning at the circumcervical incision running down the lateral vaginal wall, through the margin of the vulva and on to the skin externally, ending at a point midway between the perineum and the ischial tuberosity, i.e. about 1½ inches to the side, and in front of the perineum; the incision may be lateral only or bilateral. In sewing up, it is important to reunite the cut edges of the levator ani, or pelvic weakness will result.


CHAPTER XV

OPERATIONS UPON THE UTERUS

PASSAGE OF THE UTERINE SOUND

This is an operation which is much less frequently resorted to than formerly, owing partly to the risks of sepsis attending its performance and partly to the greater perfection of the bimanual examination. Passing the uterine sound should always be looked upon as a surgical operation. The facts learnt by the use of the sound are: (1) the length and direction of the uterine cavity; (2) the condition of the endometrium: bleeding as a rule follows withdrawal in fibro-myomata and endometrial disease; (3) whether a fibroid growth is projecting into the uterine cavity, and if so, how much.

Fig. 50. The Passage of the Uterine Sound. Introduction of the point into the external os uteri.
    
Passage of the Uterine Sound Fig. 51. The Passage of the Uterine Sound. Commencement of the tour de maître.

The sound may be passed in the dorsal position (Fig. 61), the cervix being held by a volsella and exposed by means of a posterior speculum, or in the left lateral position, the method usually adopted in the consulting room. In the latter the right index-finger is passed up to the anterior lip of the cervix, the sterilized sound is taken in the left hand with its concavity backwards and its bulbous end is slid gently along the palmar surface of the finger in the vagina until the os uteri externum is reached; through this it should be passed for about a quarter of an inch (Fig. 50). The instrument should now be steadied by the thumb and the two distal joints of the second finger of the right hand, and its subsequent movements controlled by the left (Fig. 51).

If the uterus is in a state of retroversion, the bulbous end will gradually enter the uterine cavity by pressing the handle of the sound forward and at the same time giving an upward and slightly backward impulse to its tip; the rough surface of the handle will be found to be looking towards the sacrum. Should the uterus be anteverted, the handle is held in the left hand as before and passed through an arc of a circle by raising the handle and turning it forward until it lies beneath the symphysis pubis, in the median line (tour de maître) (Fig. 52). The rough surface of the handle now looks anteriorly and the bulbous end is pressing against the internal os uteri; now bring back the handle directly to the perineum and it will glide into the uterine cavity (Fig. 53).

The Passage of the Uterine Sound Fig. 52. The Passage of the Uterine Sound. Completion of the tour de maître.
    
The Passage of the Uterine Sound Fig. 53. The Passage of the Uterine Sound. Entry of the sound into the uterine cavity.

Difficulties to be met with will be: (1) An acutely anteflexed uterus; if traction is made on the cervix with a volsella the canal is straightened and the difficulty overcome. (2) Spasmodic contraction of the internal os uteri; this soon passes off with a little steady pressure. (3) A fibroid may project into the lumen of the canal. (4) Congenital or acquired stenosis of the external os uteri.

When there is a septic discharge from the vagina, the sound should be passed in the dorsal position and through a speculum.

REPOSITION OF A CHRONIC UTERINE INVERSION

Indications. Chronic inversion of the uterus, with severe hæmorrhage and bearing-down pain. The uterine fundus presents in the vagina and simulates a fibroid polypus in process of extrusion.

Operation. This is most likely to be successful if continuous pressure be brought to bear against the inverted fundus while an attempt is made simultaneously to dilate the contracted cervix.

Chronic Uterine Inversion Fig. 54. Chronic Uterine Inversion. Aveling’s repositor in place with elastic cords A, B, and C, in action.

The patient is placed under an anæsthetic in the dorsal position and the whole hand is passed gradually into the vagina. The tips of the fingers and thumb should be pressed into the circular space at which the flexion of the walls of the body on the cervix has occurred. With the palm of the hand upward pressure is made, counter-pressure being exerted by the other hand over the lower hypogastrium. Reduction usually begins by a slight dimpling of the inverted fundus.

A more scientific method of exerting continuous pressure is by the application of Aveling’s sigmoid repositor and elastic cords (Fig. 54). This instrument consists of a vulcanite cup into which is secured a steel S-shaped rod terminating below in a loop. The cup is made of various sizes and should always be smaller than the inverted fundus over which it fits.

After it has been applied, the instrument is carefully packed round with gauze to keep it in place. Two elastic bands in front and two behind are fastened by one end to the steel loop and by the other end to an abdominal belt. By this means constant and direct pressure is obtained on the fundus uteri in the direction of the pelvic axis.

Pain is usual and must be relieved by morphine. The cup usually elevates the fundus and corrects the inversion in about twenty-four hours, but as much as three days has been occupied in the process.

CURETTING THE UTERUS—CURETTAGE

The term ‘curetting’ is applied to the operation of scraping away the lining membrane of the uterus, either for the relief of some pathological condition or for diagnostic purposes.

The endometrium is not removed in its entirety by curetting, for the uterine glands dip down to a slight extent between the muscle fibres of the uterine wall. The endometrium is removed as far down as the muscular coat, and, consequently, those parts of the glands lying amongst the muscular fibres are left intact.

Indications. These may be divided into the cases in which the operation is (1) Remedial and (2) Diagnostic in nature.

The diseased states of the endometrium are many and their exact pathology is still under discussion. It is, therefore, more practical to consider the remedial indications for curetting from the point of view of symptoms.

(i) Uterine hæmorrhage is the chief symptom which calls for curetting. The causes of the hæmorrhage may be certain forms of endometritis. Thus hæmorrhage is a prominent symptom of the so-called ‘hypertrophic glandular endometritis’, a diffuse overgrowth or adenomatous condition of the endometrium, probably the after-result of a previous inflammation. There is one form which gives rise to specially profuse hæmorrhage—the ‘polypoid’ or ‘villous’ form, which arises usually in women over forty years of age.

The hæmorrhage from fibro-myoma of the uterus may require removal of the endometrium in order to relieve the bleeding temporarily at any rate. When milder measures fail, curetting is of great service in arresting the profuse menorrhagia which so often accompanies subinvolution of the uterus.

Certain cases in which the actual cause of the hæmorrhage is not evident are relieved by curetting; amongst these are such conditions as arterio-sclerosis of the uterine vessels.

(ii) A leucorrhœal discharge is another symptom for which curetting is sometimes indicated.

It may be called for when the endometrium is congested and œdematous from such conditions as displacements of the uterus and chronic subinvolution.

It is better not to curette for a purulent uterine discharge; extension of the infection may be caused and give rise to pyosalpinx.

(iii) Sterility. Curetting should follow dilatation, in the hope that the new endometrium formed may afford a better nidus for the ovum.

(iv) Frequent abortion in the early months. Curetting often cures this by removing the diseased endometrium.

(v) Inoperable carcinoma of the cervix. Removal of the redundant portions of the growth by the curette, followed by cauterization or other measures, relieves the hæmorrhage and foul discharge. Great caution must be exercised, lest the peritoneum or bladder be opened into by the curette and the sufferings of the patient thereby increased. Cells of the disease may also be pushed into the pelvic lymphatics; considerable febrile disturbance may also follow the operation. In this condition a blunt curette (Fig. 60, B) may be gently used; the same instrument is safest in abortion up to the eighth week of pregnancy; after this date it is better to use the fingers only.

Fragments removed by the curette are subjected to microscopical examination for diagnostic purposes. The various conditions which may have to be diagnosed are:—

1. Carcinoma of the body of the uterus.

2. Retained products of conception.

3. Tuberculosis of the endometrium.

4. Chorio-epithelioma malignum.

Operation. The following instruments are required: a volsella (Fig. 55); a self-retaining weighted speculum (Fig. 37); uterine dilators (Figs. 56, 57); a uterine sound; a Bozemann’s tube (Fig. 58); Budin’s celluloid catheter (Fig. 59); and one or other flushing curettes.

Volsella for fixing the Cervix Fig. 55. Volsella for fixing the Cervix.
Metal Bougies for dilatation of the Cervix Fig. 57. Metal Bougies for dilatation of the Cervix.

a. As used by the author.
b. Ends of bougies considered unsuitable.

Hegar’s Dilators Fig. 56. Hegar’s Dilators (three sizes) for dilatation of the Cervix Uteri.
Bozemann’s Double-channelled Tube Fig. 58. Bozemann’s Double-channelled Tube.
Budin’s Celluloid Catheter Fig. 59. Budin’s Celluloid Catheter.

There are many varieties of curettes, and each has its own adherents. The most generally useful is Murray’s sharp flushing curette, which has a groove for the recurrent flow (Fig. 60, A). There are many varieties of blunt curettes. The model depicted in Fig. 60, B, enables the operator to clear out the uterine cornua and is of the best shape.

a, Murray’s Flushing Curette; b, Blunt Curette. Fig. 60. a, Murray’s Flushing Curette; b, Blunt Curette.

The patient is placed in the lithotomy position and the various antiseptic precautions already described are carried out. A speculum is passed and the cervix is steadied by a volsella applied to the anterior lip.

The cervix is first dilated up to a suitable degree for the passage of the curette; up to No. 12 Hegar is usually sufficient. The curette is now taken and passed into the uterus. In performing the operation a definite plan should always be followed so as to ensure that no part of the uterine cavity is missed. The curette is passed up to the top of the fundus uteri with its cutting edge directed to the posterior wall. It is then drawn downwards with steady pressure to just below the internal os. It is then again passed upwards and the manœuvre repeated with just sufficient change of direction to ensure the curette passing over fresh tissue. This is repeated until the whole of the posterior wall has been thoroughly dealt with from side to side. The anterior wall and sides of the uterus are then treated in turn in the same way. Finally the fundus is curetted by a lateral movement of the instrument, especial attention being paid to the Fallopian tube angles, which are very apt to escape the curette.

A rasping or grating sound indicates that the endometrium over a given part has been removed and that the muscular walls have been reached. In spite of the most careful attention it is very difficult to remove the endometrium completely. If a uterus be scraped, as it is thought, thoroughly, and be examined post mortem, strips of mucous membrane will often be found untouched, showing the difficulties of complete removal.

After the operation an intra-uterine douche of 1 in 2,000 perchloride of mercury or some other suitable antiseptic is given with a Bozemann’s tube or Budin’s catheter. If a flushing curette has been used, this of course has already been done. After the douche, some application may be made to the interior of the uterus: the best is iodized phenol (liquid carbolic acid, 2 parts; tincture of iodine, 1 part). To do this the interior of the uterus is first dried with a Playfair’s probe armed with cotton-wool; another similar probe is then taken, dipped into the solution, and passed into the uterus. The vagina is protected by inserting a plug of cotton-wool into the posterior fornix. The uterus is then lightly packed with ribbon gauze. If there is hæmorrhage, the packing should be firmer, and a vaginal tampon should be placed in below the cervix. The packing should be removed in twenty-four hours. The patient may get up at the end of a week and resume her ordinary duties in a fortnight.

DILATATION OF THE CERVIX

Indications. Dilatation may be performed:—

(i)As a means of diagnosis.
(ii)As a preliminary to the use of the curette or to removal of intra-uterine growths.
(iii)As a method of cure for spasmodic dysmenorrhœa.

Contra-indications to the rapid method of dilatation of the cervix are very few: a recent attack of peri- or parametritis would certainly be one, but when the effects of a salpingitis have quieted down there seems very little reason against its use. Where carcinoma of the body of the uterus is known to exist, and in old age, it should only be resorted to with the greatest caution, if at all.

Methods:—

(a) Rapid dilatation by means of graduated metal bougies.

(b) Gradual dilatation by means of tents.

(c) Combined gradual and rapid dilatation.

In a large majority of cases rapid dilatation is the operation selected. Its one disadvantage is that when a great degree of dilatation is necessary, or when the operation is performed too rapidly, the cervix is liable to be torn, an event which is especially liable to occur when the tissues of the cervix are rigid. These lacerations are longitudinal in direction and in the neighbourhood of the internal os uteri. They sometimes result in hæmorrhage, which can easily be controlled by plugging the cervical canal. Unless strict asepsis be maintained, these lacerations of course form a channel for infection of the pelvic cellular tissue.

It is obvious that dilatation will be easier to perform, and laceration less liable to occur, if the cervix is in a softened condition—a physiological state which is always present during pregnancy and labour. Efforts should therefore be directed, when possible, to ensure a soft state of the cervix before performing rapid dilatation.

Immediately after the cessation of a period, the cervix is soft and somewhat patent, and advantage may be taken of this fact. The introduction of a glycerine tampon two hours beforehand produces a certain amount of softening. But nothing ensures so much softening as the introduction of a tent into the cervix about twelve hours previous to the rapid dilatation.

It is therefore recommended in all cases, where possible, to perform dilatation by this latter means, viz. a combination of the gradual and rapid methods.

Rapid dilatation by means of graduated metal bougies. Hegar’s original dilators (Fig. 56) were solid vulcanite bougies, graduated from 1 to 26, the numbers corresponding to the diameter of the bougie in millimetres. Each was 5¼ inches in length, the handle measuring 1½ inches and the bougie the remainder. The bougie formed a slight curve and tapered off to a blunt point.

These bougies were rather short and too sharply pointed, and they could not be sterilized by boiling. To overcome these disadvantages, uterine dilators are now made about the same length as a male catheter, with a sharper curve than Hegar’s original one, and a blunter point; the larger sizes are of hollow metal for the sake of lightness. There are many varieties of dilator, each with minor differences as to length, curve, handle, and shape of the point.

The author uses metal bougies. These have somewhat the shape of the ordinary uterine sound, are thirty-five in number, and graduated in size. Like the sound, the upper portion is bent at an angle of about 160° with the solid handle, a circular shallow depression indicating the 2½ inch mark in the smaller numbers; in the larger this is not considered necessary.

Dilatation of the Cervix Fig. 61. Dilatation of the Cervix. The patient is in the lithotomy position. Auvard’s speculum has been inserted, a volsella attached to the anterior cervical lip and a bougie passed. (From a photograph.)

d. Right hand inserting bougie.
s. Speculum.
v. Volsella.

Operation. Instruments: an Auvard’s self-retaining weighted flushing speculum; a volsella; a Bozemann’s tube or Budin’s catheter; a uterine sound; and a set of dilators.

The patient is anæsthetized and placed in the lithotomy position with the legs supported by a crutch. Strict asepsis must be observed; the labia must be shorn of long hairs; this is followed by cleansing of the vagina and a vaginal douche, and finally the vulva is washed with antiseptic lotion. The speculum is passed and held by an assistant, but if self-retaining, as in Fig. 61, the assistant is not necessary: a sound is then inserted to ascertain the length and direction of the uterine cavity. If anteflexion be present, the anterior lip of the cervix should be seized with the volsella and fixed by slight traction. If retroversion or retroflexion be present, then the posterior lip should be fixed. Traction by the volsella tends to straighten out the uterine canal, and thus makes the passage of the bougies easier. The bougies are now passed in order, commencing with the size which will pass easily. The bougie is passed by means of the right hand into the cervical canal until the internal os uteri is reached; resistance will now be felt. Firm and continuous pressure in the proper direction must be made, and in a short time the resistance gives way, and the bougie will pass into the uterine cavity. An interstitial fibroid produces a tortuous channel and much difficulty will often be experienced in passing a bougie in such a case. It will be found on attempting to withdraw the instrument that it is grasped by the internal os uteri; in the course of one to five minutes this spasm will relax, and only then should the bougie be withdrawn. The next in size should be ready and introduced in the same manner, and the succeeding ones are inserted until the required dilatation is produced. Sterilized vaseline or glycerine of perchloride of mercury may be smeared over the point of the dilator to facilitate its passage. Each succeeding bougie should increase in size by not more than 1 mm.: occasionally a case is met with where this seems too large a difference, and it is really better to have them made with a ½ mm. difference. As a preliminary to the use of the curette, dilatation up to No. 12 Hegar is necessary. The index-finger can be introduced into the uterine cavity after the passage of No. 19 or 20 Hegar, while full dilatation up to No. 26 is required for any operation with scissors or the écraseur on intra-uterine growths.

It is evident that the degree of dilatation for exploratory purposes will be governed by the diameter of the operator’s finger, or rather of its second joint, and this varies very much in different people. By means of the finger a uterus can be explored in which the cavity is much longer than the operator’s finger, if the viscus be forced down on to the finger by the pressure of the other hand above the symphysis pubis. The operator must not be satisfied until he has felt the whole extent of the uterine wall, especially the two cornua, which are favourite seats of disease. After completion of the operation it is well to give an antiseptic intra-uterine douche by means of a Bozemann’s tube. The uterus and cervix should be lightly packed with sterile ribbon gauze, 1 inch wide; the free end is left projecting through the os uteri. The packing should be removed in twenty-four hours, and an antiseptic douche given.

Difficulties and dangers. The difficulty due to non-dilatability is overcome by means of the preliminary use of a tent. The complication produced by a fibroid, altering the direction of the uterine canal, has been mentioned. Extreme anteflexion or retroflexion gives trouble during the passage of the earlier numbers, but as dilatation is effected this disappears.

The dangers are:—

1. Laceration of the cervix.

2. Rupture of the uterus.

3. Sepsis and its sequelæ.

4. Hæmatoma between the layers of the broad ligament.

Laceration of the cervix has been referred to: it begins as a rule at the internal and extends towards the external os uteri; it may be deep or superficial, and is recognized as a sulcus into which the finger can be passed from above downwards: rarely, laceration into the peritoneum may take place.

Rupture of the uterus is liable to occur when the uterine wall has been weakened by the changes which accompany the completion of the menopause, or has been infiltrated by carcinoma, or, more rarely, by vesicular mole.

Sepsis may occur from absorption through a laceration if asepsis has not been maintained: it may lead to an attack of pelvic cellulitis or even septicæmia.

If the uterus is fixed or not freely mobile, and the condition is complicated by any tubal or ovarian disease, great care must be exercised in manipulation.

Gradual dilatation by tents. There are three varieties of tents—sponge, laminaria, and tupelo.

Sponge tents should never be used, for they are extremely difficult to render sterile.

The commonest and the safest to use, because they can be most easily sterilized, are laminaria tents, made from sea-tangle (Laminaria digitata). These are cylindrical rods, which expand evenly, from imbibition of moisture. Tupelo tents are larger than laminaria and expand more rapidly.

To use tents that are not absolutely sterile is to court disaster, and in former times they were responsible for many fatalities from sepsis. The best way to keep laminaria and tupelo tents is in a solution of 1 in 1,000 corrosive sublimate in absolute alcohol. They may be kept in this for an indefinite period, and so are always ready for use.

Contra-indications. All septic states of the uterus and cervix, for the retention of pent-up discharges is very likely to lead to local or general infection. Tents should never be used then in such conditions as carcinoma of the body of the uterus, sloughing polypus, acute endometritis and cervicitis.

Method of introduction of a tent. The patient is placed in the lateral or lithotomy position and a vaginal douche given. A Sims’s speculum is passed and the cervix seized and drawn down with a volsella so as to straighten the cervical canal. The direction and length of the uterine cavity is ascertained by passing the sound. The most suitable size of tent is now selected, and, being held in a special form of tent introducer or suitable pair of forceps, is passed into the cervical canal, well past the internal os uteri. The end should project slightly into the vagina. The vagina should then be douched again and lightly packed with sterilized gauze. The patient must remain in bed.

The tent should be left in position for twelve to fifteen hours, when it will have exerted its full action. The action of tents is twofold: it causes (1) dilatation, and (2) softening of the cervix, the softening being accompanied by an abundant secretion of mucus from the cervical glands.

Method of removal. Tents are removed by traction on the silk thread attached to the vaginal end. The part of the cervical canal which exerts the greatest resistance to the dilating action is the internal os uteri, and after the tent has been removed a well-marked constriction is always to be seen at this point. If there is much resistance to removal by reason of the tent being gripped at the internal os, it should be taken in a pair of forceps and gently pulled and levered out.

OPERATIONS FOR HYPERTROPHY OF THE CERVIX

This is a congenital condition and there is no thickening of the mucous membrane and underlying tissues; hence the diameter of the cervix is not increased. The operation best adapted for the treatment of this condition is the wedge-shaped incision, recommended by Marckwald (Fig. 62).

Operation. The cervix is split bilaterally into an anterior and posterior portion by means of scissors, and out of each portion is excised a wedge-shaped piece of tissue, leaving a deep groove. The sutures are passed as in Fig. 62, and the raw surfaces are brought together.

Marckwald’s Operation for
Congenital Hypertrophy of the Cervix Fig. 62. Marckwald’s Operation for Congenital Hypertrophy of the Cervix. The wedge-shaped portions have been excised and the sutures passed but not tied.

a,p. Anterior and posterior lip of cervix before exsection.
e.o.u. External os uteri.
i.o.u. Internal os uteri.
s,s'. Sutures.

    
Hegar’s Operation
for Supravaginal Elongation of Cervix Fig. 63. Hegar’s Operation for Supravaginal Elongation of Cervix. The cervix has been removed and four sutures passed but not tied.

c.m.m. Cervical mucous membrane.
s. One of the sutures.
sp. Speculum.
v.m.m. Vaginal mucous membrane.

Circular amputation, as carried out by Hegar, is more suitable for supravaginal elongation of the cervix, the result of prolapsus uteri.

The patient is anæsthetized and placed in the lithotomy position and the cervix is pulled down by a volsella and amputated transversely by a knife or scissors. A certain amount of retraction of the stump takes place, producing an inversion of the vaginal wall. The raw surface remaining must be covered by uniting the vaginal and cervical mucous membranes. Sutures are passed in the following manner: a short stout, straight needle, threaded with a loop of silk, is passed from the vaginal mucous membrane, across and beneath the raw surface of the stump, and emerges on the mucous membrane of the cervix (Fig. 63). From eight to ten of these sutures are passed at regular intervals and tied. The sutures are removed on the tenth day and the patient should be kept in bed for fourteen days.

TRACHELORRHAPHY.

Indications. This operation is performed for the repair of certain forms of laceration of the cervix. It was formerly practised in every case in which a laceration occurred: it is now only permissible in cases in which there is extroversion of the mucous membrane with certain symptoms, such as hæmorrhage or free leucorrhœal discharge accompanied by backache on exertion and general ill health. It was formerly considered that there was a direct relation between cervical laceration and cancer, but further inquiry has failed to corroborate this view.

The instruments required are: a Sims’s or Auvard’s speculum; long-handled, angular-bladed knives (right and left); Emmett’s scissors (right and left) (Fig. 64); toothed dissecting forceps; short stout needles with sharp triangular points, straight or very slightly curved.

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

Operation. As it is usually found that subinvolution is present and kept up by the laceration, it is best to perform a preliminary curettage (see p. 154) before proceeding to the operation proper.

Trachelorrhaphy Fig. 65. Trachelorrhaphy. The patient is in the lithotomy position. The left half of the cervix has been denuded and two sutures, a, a' and b, b', passed. The right half is intact, but the method of passing the needle n is indicated.

ant. Anterior lip of cervix.
post. Posterior lip of cervix.
t,t. Tenacula.
o.u.i. Os uteri internum.
sp. Speculum.
w. Wire.

The patient is placed in the lithotomy position and an Auvard’s speculum is inserted. A piece of stout silver wire or a tenaculum is passed deeply through the anterior and posterior lips of the cervix; steady traction can be made through these and the uterus kept fixed while denudation and suturing are carried out. Should marked extroversion be present, with hypertrophy of the cervical glands, the curette should be freely applied to the diseased surface.

The uterine sound is passed to mark the situation of the internal os uteri, and an antero-posterior linear piece of lining membrane, about a quarter of an inch in breadth, must be allowed to remain untouched. This is necessary to prevent total occlusion of the cervical canal when the denuded flaps are sutured (Fig. 65).

Denudation. The right half of the anterior and posterior lips of the cervix (upper and lower from the operator’s point of view) are first pared by means of the angular knives and scissors, great care being taken to see that the deep angle of the reflexion is not overlooked. The other side is then treated in a similar manner. The tissues will be found extremely hard and resistant, especially if there be much cicatrization about the angle of the laceration.

The passage of the sutures (Fig. 65). The short stout, triangular-pointed needle is first doubly threaded with silk or stout chromicized catgut so that a loop of three to four inches in length is produced. The needle and the silk suture are passed as in Fig. 65, two on either side.

The triangular-pointed needle must be held in Schauta’s specially strong holder (Fig. 73), and should be made to pierce the cervix near the raw surface on one lip, and pushed through the tissues immediately below this to emerge on the strip of unpared cervix already mentioned. It is then carried across the sulcus and is made to emerge through the opposite lip of the cervix. A stout wire is now hooked into the loop and pulled through the needle track. When the two wire sutures are inserted on either side, the flaps are brought together and the wires twisted together.

Results. Primary union is the rule, and the wire sutures may be removed at the end of the tenth or twelfth day. The cervix has the appearance observed in the nullipara, and may lead to complications in any ensuing labour from difficulty of dilatation.

Dührssen modifies Emmett’s operation by a flap-splitting procedure which, however, does not appear to possess sufficient advantages to warrant its general introduction.

VAGINAL FIXATION (Hysteropexy)

This operation consists in the fixation of the retroverted fundus uteri in an anteverted position, by suturing it to the anterior vaginal cul-de-sac.

Indications. These are somewhat uncertain, and the field of utility of the operation is rapidly becoming more limited. Advocates of this procedure recommend it for backward displacement of the uterus with or without adhesions. It is considered specially applicable to cases in which slight retroversion is complicated by moderate prolapsus. The results which have so far obtained do not appear to be so good as those resulting from the use of a well-fitting pessary.

Operation. The technique recommended by Dührssen appears to be the most satisfactory, and is as follows: The patient is anæsthetized and placed in the dorsal position with the knees supported by a Clover’s crutch. After purification of the parts (see p. 126) the cervix is pulled down as far as possible by means of a volsella: a curettage is then carried out as a preliminary measure (see p. 154). If cervical hypertrophy is present, amputation by Marckwald’s method (see p. 160) should be performed, as an elongated cervix acts as a preventive to satisfactory anteversion of the uterus. A transverse or T-shaped incision is now made as in vaginal hysterectomy (see p. 169), and the cellular tissue pushed up by the index-finger until the peritoneum is reached. The peritoneum is now seized with a volsella and cut through, and the edges sutured to the lips of the vaginal wound. The uterine fundus is then anteverted by means of a sound: by pressing the handle of the instrument towards the perineum the fundus is brought into the wound. By means of a rectangular curved needle a stout silk suture is passed through the anterior wall of the fundus as high up as possible: the vaginal flaps are not included, as the suture is to be used for traction only. The uterus is now forcibly pulled down and two other sutures are introduced in the same manner higher up. Three sutures of catgut are passed through the uterine wall, including the vaginal and peritoneal flaps. The silk traction sutures are now withdrawn and the permanent ones tied. The vaginal wound is carefully sutured by means of fine silk.

Difficulties and dangers. The risks of the operation are peritonitis and wounding of one or both ureters or the bladder wall. Absolute rest for fourteen days is necessary and no local after-treatment is called for.


CHAPTER XVI

OPERATIONS FOR NEW GROWTHS OF THE UTERUS

Uterine growths include primary malignant disease and fibro-myomata; the former should be treated by exploration and subsequent vaginal hysterectomy (see p. 168), while the latter should be dealt with according to their relations and attachments to the uterine wall.

OPERATIONS FOR UTERINE FIBRO-MYOMATA

Fibro-myomata may present themselves to the operator in one of the following forms:—

1. As a fibroid polypus still intra-uterine or presenting through a naturally dilated and thinned-out cervix (submucous pedunculated).

2. As sessile growths presenting by their lower segments at the os uteri, which may be closed, or may be in varying degrees of dilatation (submucous sessile).

3. As tumours incorporated in the uterine wall (interstitial).

Pedunculated Fibroid Polypi Fig. 66. Pedunculated Fibroid Polypi in various Stages of Extrusion. (From drawings made at time of operation.)

Operations for pedunculated tumours. If a fibroid polypus be still intra-uterine (Fig. 66) the proper treatment is to dilate the cervix (see p. 156), and, if the pedicle be sufficiently thin, to seize the growth with a pair of stout polypus forceps and twist it off by a slow rotary movement of the handles. Should the pedicle be thicker than the finger, the use of the wire écraseur is advisable. This is a scientific snare, with a loop of pianoforte wire and a handle or wheel by which it can gradually be tightened, causing the wire to slowly cut through the stalk of the growth (Fig. 67).

Wire Écraseur Fig. 67. Wire Écraseur.

The cervix is steadied with a volsella and the loop of the écraseur is shaped and bent to the size and position of the fibroid. The instrument is then passed into the uterine cavity and the noose pushed over the tumour up along the pedicle. The wire loop is then tightened up by means of the handle or wheel, and the wire cuts its way through and separates the growth from the uterine wall. It is somewhat dangerous to put any traction on the tumour before its separation, as is recommended by some writers, as the uterine wall itself may become somewhat inverted and the wire loop may cut through into the peritoneal cavity.

If the fibroid polypus has passed through the external os uteri, treatment is more simple. Slight traction may be made upon it by means of forceps, and the pedicle severed with scissors; no hæmorrhage takes place, owing to the retraction of the stump.

Operations for sessile tumours. In submucous sessile fibroids (Fig. 68) in which the lower segment of the uterus is somewhat thinned out and dilated, operative interference may be as follows: Preliminary dilatation of the cervix by bougies may be necessary. The capsule of the tumour is then incised with a sickle-shaped knife and the growth is enucleated by means of the finger or a blunt spoon. In some cases mere incision of the capsule is sufficient, and the uterus expels the growth later on.

Submucous Fibro-myomata, capable of Treatment by Morcellement Fig. 68. Submucous Fibro-myomata, capable of Treatment by Morcellement. (From drawings made at time of operation.)

Another method of treating these cases is by the operation of morcellement, which consists in removing the tumour piecemeal by means of specially made forceps.

The instrument used by the author consists of a strong pair of forceps somewhat like those used in lithotomy, with the two distal ends notched with sharp teeth like a volsella. A portion of the tumour is seized between these two blades, and partly cut and partly twisted off. With patience and care the whole tumour may be thus removed. In one case the author was enabled to remove two large growths, each filling a pint measure. This operation is specially suitable in women in whom an abdominal operation is to be avoided.

Operations for interstitial tumours. Interstitial fibroid tumours, if not above the size of a small fœtal head, should be treated by vaginal hysterectomy (vide infra); if large, by hysterectomy by the abdominal route (see p. 36).

Vaginal hysterectomy. By vaginal hysterectomy is meant removal of the whole uterus by the vagina, with or without the appendages. The advantages that the vaginal operation possesses over abdominal hysterectomy are, there is less disturbance of peritoneum and intestines, less shock, and no abdominal scar or risk of subsequent hernia. The operation is limited to uteri not exceeding in size the head of a full-time fœtus.

Indications. (i) Malignant disease of the uterus (fundus or cervix) in an early stage: chorio-epithelioma malignum.

(ii) Certain cases of fibro-myoma of the uterus.

(iii) Certain cases of inflammatory disease of the uterine appendages complicated by recurrent attacks of local perimetritis.

(iv) Other conditions, such as intractable uterine hæmorrhage, usually due to uterine myo-fibrosis, and, as a last resort, severe dysmenorrhœa.

It has also been advised for irreducible chronic inversion of the uterus, and for severe procidentia uteri. No case of the former has occurred in the author’s experience in which the operation was found necessary. In the latter condition the operation is not to be recommended, the almost certain result of the procedure being prolapse of the vaginal walls and the intestines (enterocele).

Vaginal hysterectomy for carcinoma. The only cases suitable for operation are early ones, in which the disease is still confined to the uterus itself, which should be freely mobile in all directions. No signs of infection of the surrounding cellular tissue and vaginal walls should be present. It cannot be too strongly insisted that all cases should be thoroughly examined under anæsthesia to settle this point before operation is decided upon. Rectal examination is most important to estimate the condition of the sacro-uterine ligaments, the cervix being pulled down so as to place them on the stretch.

Occasionally, cases of carcinoma of the cervix are seen, in which the cellular tissue immediately surrounding the cervix is apparently free from disease, but if search be made further outwards, a hard, fixed mass is found plastered, as it were, on to the side of the pelvis, indicating advanced disease of the lymphatic glands, or cellular tissue at the outer part of the broad ligaments. Such cases are hopeless for operation.

If the disease is in the sloughing stage, and there is foul discharge, Paquelin’s cautery should be applied to the diseased surface, followed by vaginal douches of formalin (ʒj to the pint), or some other efficient antiseptic, given three times a day for three days prior to operation. The operation consists of three main stages:—

(a)Separation of the cervix from the vagina, pushing up of the bladder and ureters, and opening the anterior and posterior peritoneal pouches.
(b)Removal of the uterus by ligaturing and dividing the broad ligaments.
(c)Treatment of the peritoneal and vaginal flaps thus left.

First of all, the growth, if of the cervix, should receive careful preliminary attention, for it constitutes a continuous source of infection, not only by means of septic organisms, but also of cancer cells, which may become implanted in the wound and cause early recurrence. The cervix is drawn down with a volsella and all visible growth is burnt away with the Paquelin cautery, until apparently healthy tissue only is left. The cervix is then completely closed by the application of a volsella or three or four stout silk sutures, passing through both anterior and posterior lips. The ends of the sutures may be left long if preferred and serve as tractors.

After these preliminary measures against infection have been completed, the removal of the uterus is proceeded with. A posterior speculum, Auvard’s or Pozzi’s, is passed, and the cervix is drawn downwards and somewhat backwards by traction on the volsellum or the long ends of the silk sutures. A sound is passed into the bladder to define its lower limit. A transverse or T-shaped incision (Fig. 48) is now made through the vagina at the level of the cervico-vaginal junction in front. This constitutes the anterior incision, and the transverse portion should extend completely across the anterior aspect of the cervix, passing through the whole thickness of the vagina, but no further.

The knife is now laid aside, and the operator proceeds to push up the vagina and bladder from the anterior aspect of the cervix with the index-finger or a winged director, until the anterior peritoneal pouch is reached. This is at once recognized by its glistening white appearance and by the manner in which its opposing surfaces glide over one another.

This part of the operation must be conducted very cautiously for fear of injury to the bladder: the pulp of the finger only must be used in the separation. The frequent use of the bladder sound is very useful at this stage, as it is quite easy to wound this viscus laterally. Bleeding from the divided twigs of the vaginal vessels often obscures the field of operation and renders the separation of the bladder troublesome: it well repays the operator to stop all bleeding after making the vaginal incision.

The peritoneum is next picked up and opened with scissors. The anterior fold of peritoneum may sometimes be more easily reached after the bases of the broad ligaments have been ligatured and divided, thus allowing the uterus to be drawn down more readily, and making the peritoneum more accessible. An anterior retractor is then passed to keep the bladder out of the way.

A second incision similar to the first is now made across the posterior aspect of the cervix at the level of the cervico-vaginal junction, more or less cellular tissue is traversed, and the posterior peritoneal pouch is opened. By joining the ends of these two incisions the cervix is completely separated from the vagina.

Galabin’s Broad-ligament Needle Fig. 69. Galabin’s Broad-ligament Needle (right).
Jessett’s Broad-ligament Needle Fig. 70. Jessett’s Broad-ligament Needle.

The uterus is now suspended in the pelvis by the attachments of the broad ligaments only; the next step consists in ligaturing and dividing these. The cervix is drawn over towards the patient’s right side by an assistant, so as to expose the base of the left broad ligament. Additional space is gained by drawing aside the left wall of the vagina by means of a retractor. By passing the left index-finger behind the broad ligament the tube and ovary can be easily felt, and if necessary the bent finger can pull them down for inspection; the finger is then placed beside the cervix below and behind the base of the broad ligament. A Galabin’s or Jessett’s (Fig. 70) needle, carrying a stout silk suture, is passed through the ligament from before backwards, on to the tip of the finger (Fig. 71).

Vaginal Hysterectomy
  
Fig. 71. Vaginal Hysterectomy. The patient is in the lithotomy position, the vaginal incisions have been made and the peritoneal cavity opened. The left broad ligament is exposed, and a Galabin’s needle threaded with silk is being passed from before backwards on to the index-finger of the operator’s left hand inserted into the peritoneal cavity. (Semi-diagrammatic, from a photograph.)

a, a', a''. Retractors.
c. Cervix.
p. Supravaginal cervix denuded of its coverings.
ut. Uterine artery.
b.lig. Broad ligament.
n. Galabin’s needle.
v. Volsella.

The ligature should be passed about one-third of an inch up the broad ligament. It is then tied tightly and the ends left long and drawn aside. The segment of broad ligament included in the ligature is divided as near the uterus as is justifiable; in carcinoma of the cervix at least half an inch from the disease should be allowed. Care must be taken at this stage to avoid injury to the ureters; these lie about one inch distant from the cervix; consequently all ligatures must be passed as near the cervix as possible compatible with being clear of the disease.

A second ligature is now passed through the broad ligament above the first and then a third, and more if necessary. The second generally includes the uterine artery, which can always be recognized by its strong pulsation under the finger; the third ligature will control the Fallopian and ovarian arteries. After the arteries on the left side have been secured and divided, attention is directed to the right broad ligament. The cervix is drawn over to the left side, the fundus delivered, and the upper portion of the right broad ligament is dealt with in a similar manner, but from above downwards. If the ovaries and tubes are diseased, they can now be removed by piercing the pedicle and tying the stump in the usual way.

The uterus having been extirpated, the next step consists in dealing with the wound. First, all bleeding is stopped, and the wound is swabbed clean and dry. The ligatures on either side are tied in two bunches and the ends cut off just within the vagina (Fig. 72). The anterior and posterior flaps of peritoneum are united with a few catgut sutures passed by means of Schauta’s needle-holder (Fig. 73); the walls of the vaginal vault are treated in a similar fashion, leaving a circular orifice in the median line into which gauze can be inserted for the purpose of drainage.

Vaginal Hysterectomy
  
Fig. 72. Vaginal Hysterectomy. Final stage. The uterus has been removed, and the peritoneal flaps are in process of suture.

a, a', a'', a'''. Retractors.
f, f'. Spencer Wells forceps attached to the anterior
and posterior vaginal flaps.
p. Circular orifice left open in the peritoneal flaps
for insertion of gauze drain.
sp. Stump of left broad ligament with bundle of
ligatures (l).
cl. Clitoris.
l.m. Labium majus.
u. Urethra.

Schauta’s Needle-holder Fig. 73. Schauta’s Needle-holder.

Some operators prefer to control the vessels in the broad ligaments by means of hæmostatic forceps instead of ligatures. Each broad ligament is clamped in three or more portions and the tissue between them and the uterus cut through. They must be allowed to remain in position for at least forty-eight hours, as recurrent hæmorrhage is possible if they are removed earlier. The only advantages of the forceps appear to be the rapidity with which the operation can be carried out, and the good drainage. The disadvantages are, that it is a somewhat unsurgical proceeding; there is often much pain from the nipping of the broad ligaments, and inconvenience from the presence of the handles between the labia; the intestines may be damaged; sloughing and risk of sepsis must be reckoned with.

After-treatment. The catheter should be used at first four times daily; the author recommends that the gauze should be removed at the end of twenty-four hours, but some operators retain it longer. The ligatures should be pulled upon a little daily after the seventh day, and they gradually cut their way through the tissues in their grasp. No vaginal douching should be administered until after the expiration of a week.

Vaginal hysterectomy for fibroids. This is not often called for. The operation is necessarily limited to fibroid uteri not exceeding in size a fœtal head. Uterine fibroids of such a size can usually be treated in other ways, either temporarily by curetting, or, if submucous, permanently by enucleation through the vagina. The operation is most suitable for uteri containing many small fibroids causing severe hæmorrhage which cannot be controlled by more palliative measures.

The vagina must be large enough to admit of delivery of the uterus through its lumen. Therefore, in virgins and nulliparæ, the abdominal operation is always to be preferred. In any case, if the vagina be too narrow, additional room may be gained by lateral vaginal section (see p. 148) or episiotomy.

The operation does not differ in technique from the removal of the uterus for carcinoma, already described. In some cases it may be preferable to bisect the uterus in the sagittal plane before removing it, after the cervico-vaginal attachments have been separated and the peritoneal pouches opened.


SECTION II

OPHTHALMIC OPERATIONS

BY

M. S. MAYOU, F.R.C.S. (Eng.)
Assistant Surgeon, Central London Ophthalmic Hospital; Surgeon, The Children’s Hospital, Paddington Green

CHAPTER I

GENERAL CONSIDERATIONS APPLICABLE TO
OPERATIONS UPON THE EYE

Operations upon the eye differ so widely from general surgical operations that it is necessary to say something of the preparations for them before passing on to their actual performance. Although not formidable in themselves, they require great accuracy and presence of mind; slight mistakes, such as too small an incision, may cost the patient his sight, which sometimes may be almost more important than life itself.

Most intra-ocular operations are performed without general anæsthesia; it is therefore important that the patient should be given confidence by talking to him during the operation, so that he may follow the instructions of the surgeon during its performance; loss of self-control on the part of the patient, movement of the head, screwing up of the eyes, &c., may lead to disastrous results, however well performed the operation itself may be.

GENERAL PRELIMINARIES TO AN OPERATION

The urine should always be examined, especially in cases of cataract, as not infrequently this disease is associated with diabetes, and it is often advisable to treat the general condition before operation.

The bowels should be opened by an aperient the night before the operation, as it is desirable to keep them confined for the first two days afterwards, so as to avoid straining. During the first week after a major operation, when the patient is confined to bed, they should be evacuated in the supine position.

The best time for operating, if possible, is the morning, as the patient has had a night’s rest and is less likely to lose self-control. Usually there is some pain after the cocaine has gone off, and the patient is better able to stand it during the daytime.

Anæsthetics. General anæsthesia should be induced in all patients with congested eyes, in small children, patients who are deaf, and those who show a want of self-control. Chloroform should be used for all intra-ocular operations, and should be given to the full surgical degree. It should be given on a towel or an inverted mask specially made for the purpose, a Junker’s inhaler being used during the time the actual operation is being performed. As the surgeon usually stands at the head of the patient, the anæsthetist should stand on the side away from the eye being operated on. The local use of cocaine in addition to general anæsthesia is indicated when operating on patients to whom it is advisable to give as little anæsthetic as possible.

Local anæsthesia is obtained by the use of a 4% solution of cocaine instilled four or five times before the operation at intervals of three minutes; a drop of the solution should also be instilled into the eye which is not being operated on, to prevent an accidental reflex stimulation of the conjunctiva and screwing up of the eyes. Adrenalin (1–1,000) may be used in conjunction with the cocaine; it is especially useful in squint operations, as it lessens the hæmorrhage. Eucaine and stovaine have been used, but are not nearly so satisfactory. Under ordinary circumstances the only pain felt during an intra-ocular operation is during removal of the iris; this is obviated to a great extent by instilling the cocaine at least 15 minutes before the operation is performed, so as to allow time for its diffusion into the anterior chamber. The patient should be warned when to expect the pain, so that he may not move; his self-control may be tested beforehand by pricking the nose with a pin.

Window of the Operating Theatre, King’s College Hospital Fig. 74. Window of the Operating Theatre, King’s College Hospital. The windows are fitted with outside blinds so that either can be used separately, or the surgeon may stand in the angle and operate with his back to the light. A recess beneath the window allows the patient’s face to be brought close to the light on dark days.

The theatre. The theatre should possess, as far as possible, all the modern improvements found in an up-to-date general surgical operating-room. The light should proceed from a single large window, which, if possible, should face the north. The window should consist of a single pane of glass or of two panes forming the angle of the theatre; it should begin about 5 feet from the floor and should extend to the ceiling (Fig. 74). The advantage of an angular window is that it allows the operator to stand with his back to the light in the angle, and so enables onlookers to see. No top light should be allowed, as it produces a corneal reflection which may prevent the operator from seeing the position of his knife in the anterior chamber. Beneath the window there should be a recess for the end of the operating table, so that the patient’s face can be brought close to the window if necessary (Fig. 74). This recess is formed by building the main wall of the theatre further out than the window, which has to be supported by a transverse girder.

Bull’s-eye Electric Hand-lamp Fig. 75. Bull’s-eye Electric Hand-lamp. For use when artificial illumination is required.

The window should be fitted with outside blinds so that the theatre can be easily darkened for the operations, such as capsulotomy, which require the use of artificial light. The best artificial light is a small enclosed electric hand-lamp fitted with a bull’s-eye, by means of which the operation field can be brilliantly illuminated while the surrounding area is left in comparative darkness (Fig. 75). Failing this, a single powerful lamp with a ground-glass globe, placed in front of the patient, will serve, the rays of light being brought to a focus on the eye by means of a large convex lens of about + 10 D.

For squint operations it is desirable to have a light fixed to the ceiling, directly over the head of the operating table, for testing the position of the eyes either by the reflection of the light from the surface of the cornea or by the Maddox rod test.

The operating table should be provided with a means of adjusting its height and the position of the head-piece, so that the patient’s head can be brought to about the level of the operator’s elbows when the latter is standing upright with his arms at his side.

After operation the patient should be warned to lie still and not to strain in any way; he should be carried to bed and should lie on his back if possible. If a patient cannot sleep on his back it is better that he should lie on the sound side than be without rest. A length of bandage should be fastened round the wrist of the hand on the same side as the eye which has been operated upon, and should be attached to the bed so as to prevent the hand being put up to the eye during sleep. After major operations, such as those for cataract and glaucoma, the patient is confined to bed for ten days, during the first four of which the head should not be raised from the pillow, the bowels being evacuated while the patient is in the supine position; but old patients with a tendency to bronchitis or hypostatic pneumonia must be propped up in bed and allowed to get up earlier: in these patients it is better to perform the operation in the summer if possible. In old people and patients with a tendency to melancholia the mental condition must be carefully watched, as frequently they cannot stand the confinement to bed and darkness.

LOCAL PREPARATION OF THE PATIENT

When operating upon the eye, a surgeon has to face the great difficulty that he is operating in an area which is not always aseptic, since it is practically impossible to render the conjunctival sac sterile. At the same time, the conjunctiva has been shown to be sterile in health in 25% of cases, pyogenic organisms (principally the staphylococcus albus) being found only in 15%; but, although these are usually not of a very virulent character, they are by far the most frequent cause of sepsis; ten cases of suppuration after operation which the author has examined were all due to this organism. After the methods of purification given below, this percentage is considerably reduced, so that, if due precautions are taken, the risk of sepsis is comparatively small. On the other hand, if conjunctivitis or lachrymal obstruction be present, the risks are enormously increased, especially in the latter condition owing to the frequent presence of the pneumococcus in the discharge, unless special precautions are taken. It is, therefore, of the utmost importance that every case should be examined for lachrymal obstruction before operation. Care should be taken also to see that there is no purulent discharge from the nose or any septic sores about the face.

Sepsis after intra-ocular operations manifests itself in one of two forms: either by suppuration, which usually ends in a rapid and complete destruction of the eye (panophthalmitis), or more rarely in less virulent cases by recurrent attacks of hypopyon associated with acute irido-cyclitis; or by a plastic irido-cyclitis, which may lead to slow disorganization of the eye, with always the possibility of destruction of the other eye by sympathetic cyclitis (sympathetic ophthalmia). Although these conditions are comparatively rare, owing to the improvement in modern aseptic and antiseptic methods, every surgeon of experience will meet with these disastrous complications; indeed it has been suggested that immunization with staphylococcus vaccine should be carried out before major intra-ocular operations, since infection is generally due to this organism.

The methods of purifying the eye before operation. On the second night previous to the operation the eye should be bandaged and examined the following morning for conjunctival discharge. If any be present, an examination for organisms should be made, and the operation postponed until the conjunctival condition has improved. In the event of the case being extremely urgent, the conjunctiva should be swabbed over with nitrate of silver (10 gr. to the oz.) immediately before the operation; some surgeons prefer 1–2,000 perchloride of mercury. If lachrymal obstruction be present, the sac should be thoroughly washed out with boric lotion and protargol (10%) injected. The canaliculi may be temporarily occluded subsequently (see p. 294). If the lashes be very long they should be cut short. Epilation is performed by some Continental surgeons, but is not practised in this country. Various forms of specula are made to keep the lashes out of the field of operation; of these, a modification of Lang’s is perhaps the best (Fig. 76).

Lang’s Eye Speculum Fig. 76. Lang’s Eye Speculum. Designed to hold the lashes away from the field of operation.

On the morning of the operation the lids should be thoroughly cleansed with soap and water, followed by 1–2,000 solution of perchloride of mercury, special attention being paid to the lid margins and lashes. The conjunctival sac should be washed out with boric lotion and a pad of cyanide gauze applied over the closed lid.

GENERAL CONSIDERATIONS AS TO MAKING AND HEALING OF WOUNDS IN THE GLOBE

It has already been pointed out that the great danger in intra-ocular operations is sepsis. It is the aim and object of every ophthalmic surgeon to make such wounds into the globe as will become rapidly shut off from the conjunctival sac. Delay in the healing tends to the formation of a fistulous opening into the globe. This aperture in the continuity of the globe may lead either directly on to the surface or beneath the conjunctiva, subsequent inflammation in which may spread to the interior of the eye.

Undine for washing out the Conjunctival Sac Fig. 77. Undine for washing out the Conjunctival Sac.

Cocaine and other solutions used at the time and subsequently to operation should be sterilized. To ensure this the solutions should either be boiled immediately before use, or put up in drop bottles made in one piece with a long tapering neck, which is sealed off, and can be broken immediately before use. These bottles can be kept in an aseptic solution so as not to soil the hands of the surgeon.

The hands of the surgeon are purified. After the dressings have been removed, the patient’s head and the area surrounding the operation are covered with sterilized towels. In operations such as advancement, where sutures are used, it is desirable that the face should be covered with sterile muslin, with a hole cut in it for the eye, so as to prevent the sutures being contaminated from the skin of the face. The eyelids are again washed in 1–2,000 perchloride of mercury lotion, and the conjunctival sac is washed out with a strong stream of boric lotion or normal saline by means of a sterilized irrigator or an undine (Fig. 77) which has been kept in a bowl of lotion.

Instruments. Non-cutting instruments are boiled for 15 minutes in distilled water and placed in a tray of 1–80 carbolic lotion. Some surgeons prefer to place the instruments in the tray without lotion on sterile wet lint, as this excludes infection from the surgeon’s hands due to the lotion running off them on to the instrument. Failing distilled water, a small quantity of soda may be added to the water used for boiling, but this has the disadvantage that a deposit is liable to form on the instruments. This may be obviated to a certain extent by not placing them in the solution until it is boiling. Cutting instruments should be sterilized by dipping them in liquefied carbolic acid (crystals dissolved by heating with 10% of water) for half a minute immediately prior to use and then into absolute alcohol to remove the acid; they are then placed in the tray. The greatest care should be taken to see that cutting instruments and needles do not touch the side of the dish. The edges and points should always be carefully tested immediately before sterilization on a drum covered with fine kid specially made for the purpose. The points should pass through the drum by the weight of the instrument held flat on the open palm; the cutting edge should also be tested. Scissors are best tested by cutting wet cigarette paper, special care being taken to see that the edges are good near the points. Immediately after operation the instruments should be boiled, and dried whilst hot in order to prevent rust.

Cataract Extraction Fig. 78. Cataract Extraction. The drawing shows the line of incision. Note the conjunctival flap.

The direction of an incision into the globe should be as oblique as is consistent with the object of the operation, so as to allow larger healing surfaces to come into apposition. With this object in view it is desirable that a conjunctival flap should be formed to all wounds wherever possible (Fig. 78). Further, owing to the extreme vascularity of the conjunctiva, as has been shown elsewhere,3 wounds in it become firmly united after 48 hours. As a rule sutures are best avoided and are seldom required.

Position of the incisions. Corneal incisions are to be avoided, if possible, for the following reasons: firstly, the cornea being free from blood-vessels heals comparatively slowly; secondly, the wound is liable to become fistulous owing to the rapidity with which the epithelium grows down the side of the wound. On the other hand, incisions situated from 3 to 6 millimetres behind the limbus are liable to injure the ciliary body, and, in addition to irido-cyclitis being set up by the trauma, the iris or ciliary body will prolapse into the wound and prevent the union of its edges, with the result that sepsis may spread into the globe along the prolapsed portion of the uveal tract and set up an irido-cyclitis which may not only ruin the eye affected but may also cause a sympathetic irido-cyclitis in the other eye (Fig. 79).

Sympathetic Ophthalmia Fig. 79. Sympathetic Ophthalmia. The exciting eye of a case following cataract extraction. The section shows the incarceration of the iris in the wound.

The site of election of an incision into the anterior part of the globe is therefore about 1 millimetre behind the limbus; that is to say, as near the cornea as is consistent with obtaining a good conjunctival flap to cover the wound in the globe (Fig. 78). When possible it is advisable to make all incisions in an upward direction for the following reasons: They are more easily performed; any deformities, such as an iridectomy, are hidden by the upper lid; more perfect rest is obtained, as the wound is not exposed in the palpebral aperture, the eye being turned upwards when the lids are closed.

Cystoid Scar after Glaucoma Iridectomy Fig. 80. Cystoid Scar after Glaucoma Iridectomy.

The immediate danger of the passage of a knife into the anterior chamber of the eye is the wounding of the lens. To avoid this the point of the knife should be always kept superficial to the iris if a clear lens be present in the eye. After operation the chief danger is prolapse of the iris into the wound. This is best avoided at the time of operation by carefully replacing the iris with the spatula at the end of the operation, but unfortunately prolapse not infrequently occurs during the first few days owing to the reaccumulation of the aqueous in the anterior chamber and its sudden escape through the imperfectly healed wound as the result of straining or of some movement on the part of the patient; the iris may be carried into the wound with the escaping aqueous, and a fistulous opening or a scar may form subsequently (Fig. 80).

The less manipulation used consistent with the object of the operation the less likelihood is there of cyclitis following it. All instruments should be held lightly in the fingers, which should be as far as possible responsible for the fine manipulation required. The part of the hand not actually holding the instrument should be steadied on the face before the instrument is brought in contact with the eye.

When more than one operation has to be performed on the same eye it is desirable that all ciliary injection after the first operation should have disappeared before the second is undertaken.

Dressings. A pad of sterilized wool, with a few layers of cyanide gauze moistened with 1–6,000 perchloride of mercury lotion next the closed eyelid, held in position by a bandage, is all that is necessary.

Bandaging. The bandage is started on the forehead over the affected eye and is carried in a direction away from the eye to be covered. A complete turn is made to encircle the head and is fixed with a pin. The bandage is then brought up beneath the ear and over the eye and fixed with pins on the forehead (Fig. 81). When absolute rest is desired, it is necessary to bandage both eyes. After intra-ocular operations this is desirable for the first three days. When pressure is desired, a figure-of-eight bandage should be used (Fig. 82). A useful bandage (Moorfield’s bandage) for occlusion of both eyes is made from stockinette, which fits closely over the eyes and nose and is fastened with tapes.

An Eye Bandage Fig. 81. An Eye Bandage. The first turn, A, encircles the head and is fixed with a pin. This portion of the bandage can be put on before the operation and obviates movement of the head. The turn B is then brought up below the ear and fixed with pins.
    
A Pressure Bandage Fig. 82. A Pressure Bandage. The first turn of a 1½-inch bandage encircles the head. It is then carried beneath the ear and over the head in a figure-of-eight. The final turn goes round the head and is fixed by a pin at the point of crossing of the previous turns.

The dressings should not be disturbed for at least 24 hours. The lids are then cleansed with 1–6,000 perchloride of mercury lotion, and the lower one is pulled down so as to allow the escape of tears and to see if any discharge be present. The upper lid should not be touched. If no discharge be present the eye is re-dressed. If discharge be present the conjunctival sac should be washed out carefully with boric lotion. Most wounds with conjunctival flaps are shut off in 48 hours, after which time it is advisable to wash out the conjunctival sac twice a day with boric lotion. Great care should be taken to see that no undue pressure is made on the globe. The patient should be warned not to screw up the eyes or strain whilst the dressing is being performed.


CHAPTER II

OPERATIONS UPON THE LENS

Surgical anatomy. The lens consists of fibres which are developed from cells originating in an inclusion of the fœtal epiblast. A normal lens is surrounded by a capsule, the anterior half of which is lined with a single layer of epithelial cells on its inner surface. In fœtal life the cells which line the posterior half of the capsule go to form the lens fibres, so that after birth the lens capsule is lined by cells only on its anterior surface. The lens capsule, which is deposited from the epithelial cells lining it, consists of a highly elastic membrane; small wounds in its continuity, therefore, gape widely. Throughout life the cells lining the capsule continue to become new lens fibres, but at the same time the bulk of the lens does not increase markedly. This is due to the fact that the lens fibres become more closely packed together and lose some of their watery constituents (sclerosis). The older central part of the lens is the first to undergo this process, with the result that a definite hard nucleus is found in the lenses of people about the age of thirty to thirty-five and upwards.

A Lens Three Weeks after needling Fig. 83. A Lens Three Weeks after needling. The section shows the swelling and breaking up of the lens in the anterior chamber. The iris has become adherent to the needle puncture.

Chemically the lens fibres are composed of crystallin, which is closely allied to a serum globulin and is therefore soluble in salt solution. When the lens capsule has been opened, by operation or accident, the saline aqueous is admitted to the lens, which becomes opaque, swells up, and is gradually absorbed (Fig. 83). In those under the age of thirty, therefore, a simple incision into the capsule is all that is required to cause it to be absorbed. But, as has already been pointed out, the lens develops a hard nucleus after that age and will not then be absorbed satisfactorily by simply opening its capsule; to remove it, as is done in senile cataract, the hard nucleus must be extracted from the eye.

The lens is held in position by the suspensory ligament, which consists of interlacing fibres attached on the one hand to the ciliary process and on the other to the capsule at the lenticular margins (Fig. 84). Prolapse of the vitreous after cataract extraction is prevented by the integrity of this ligament and the posterior capsule of the lens, together with the hyaloid membrane of the vitreous. The tension on the fibres of the suspensory ligament, in addition to keeping the lens in its place, also exercises traction on the lens capsule. In dislocated lenses there is a gap in the suspensory ligament either as the result of injury or of congenital malformation; when such cases require operation there is some difficulty in producing a sufficient gap in the capsule to promote their absorption, owing to the mobility of the lens and the want of traction on the incision in the capsule.

Anatomy of the Anterior Segment of the Eye Fig. 84. Anatomy of the Anterior Segment of the Eye.
Cil. P. Ciliary process.S. Ch. Canal of Schlemm.
L. P. Lig. pectinatum, between the fibres of which are the spaces of Fontana.
Sup. C. Ly. S. Suprachoroidal lymph-space which extends backwards between the choroid
and sclerotic.
M. Longitudinal portion} of the ciliary muscle.
C. M. Circular portion
O. Circulus arteriosus.S. Lig. Suspensory ligament of the lens.
E. Epithelium covering the ciliary process.
Pars Cil. Pars ciliariis retinæ. Pars plana of the ciliary body.
R. The retina.} The junction of these with the pars plana is known as the ora serrata.
C. The choroid.
J. Iris.S.M. Sphincter muscle.Cry. Crypt.
M. M. Pigment epithelium.S. Cornea. Substantia propria.
B. M. Bowman’s membrane.D. M. Descemet’s membrane.
A. Cap. Anterior capsule of the lens.C. P. Canal of Petit.

DISCISSION OR NEEDLING

Discission of the lens has for its object the tearing open of the anterior capsule, so that the lens substance may be broken up and absorbed.

Indications. This operation will be required:

(i) For cataract in patients under the age of about thirty. The forms of cataract for which these operations are usually performed are: (i) complete congenital cataract, in which the whole lens is opaque and consists of little more than a shrunken capsule which may have to be extracted if discission is unsuccessful; (ii) lamellar cataract, of sufficient density to interfere seriously with vision; (iii) posterior polar cataract in rare instances; (iv) traumatic cataract, to complete the absorption of the lens by breaking up its fibres.

Before operating on any form of cataract the following facts must be ascertained as far as possible:—

(a) Vision. It must be remembered that in children a defective eye retaining the power of accommodation is often more useful than an eye which sees better but has to wear different glasses for different distances. Vision must be reduced to less than 6/18 in both eyes after correction with glasses before the operation should be undertaken. In rare cases, in children, and in traumatic cataract where the cataract is very dense and confined to one eye, it may be removed partly to improve the personal appearance and partly to enable the patient to see large objects.

An eye without a lens (aphakia) will not work with an eye with a lens even if the former be corrected with glasses.

If the patient be unable to see letters, he should have a ready and quick perception of light, no cataract, however dense, being sufficient to prevent this.

(b) A patient should have a good projection of light; that is to say, he should be able to locate the light when thrown into the eye with a mirror whatever direction it comes from. Children generally turn the head towards the light, provided that they can see it and that the eye is not defective from other causes.

(c) Note whether the pupils are equal and active. In children most useful information can often be obtained as to the condition of the fundus by means of the pupil, which often will not react when the patient is unable to appreciate light.

(d) The condition of the fundus of the other eye, if observable, should be taken into account, as many diseases of the fundus, such as choroiditis and myopia, are bilateral, and would influence the prognosis considerably.

(e) The lachrymal sac and conjunctiva should be free from all signs of inflammation (see p. 181).

(ii) For the removal of a lens for high myopia. In selected cases operation gives very satisfactory results with great improvement of vision; indeed full normal distance vision has been obtained without glasses. The operation, however, is only justifiable under certain circumstances, the chief of which are:—

(a)The amount of myopia should exceed 18 D.
(b)Distance vision should be defective—less than 6/18 with glasses.
(c)Ophthalmoscopically the macular region should be sound.
(d)Binocular vision should be absent.
(e)The patients should be children or young adults.
(f)If there is some serious reason why the patient is unable to wear glasses.

In emmetropia, if the lens be removed, a glass of + 11 D. has to be placed before the eye for distance vision and + 14 D. for near vision. It is impossible to predict the exact amount of correction of myopia which will be produced by the removal of the lens, owing to the surgeon’s inability to estimate the refractive power of the lens associated with the distortion of the posterior pole of the globe. Usually a patient with about 22 D. of myopia is rendered emmetropic by the operation.

There are two main objections which have been raised to the operation: first, that there is a slight risk of septic infection, sympathetic ophthalmia even having been known to occur; secondly, that retinal detachment seems rather more common after operation than in ordinary myopia of the same degree. As a rule it is only advisable to perform the operation on one eye, the patient using the other for reading purposes, but under certain circumstances, as when the operation has been successful for a considerable period of time, it would be justifiable to perform it on the other eye. The operation should never be performed on patients having only one eye.

Instruments. Speculum (Fig. 85), fixation forceps (Fig. 86), discission needle.

Eye Speculum Fig. 85. Eye Speculum.
Fixation Forceps Fig. 86. Fixation Forceps.

Operation. First step. The operation is best performed by artificial light. The pupil having been dilated with atropine and the eye anæsthetized with cocaine (a general anæsthetic being necessary, however, for young children), the speculum is inserted by first drawing up the upper lid, making the patient look down, and inserting the top blade, and then drawing down the lower lid, making the patient look up, and inserting the lower blade. The speculum is opened to its full width without undue strain on the canthus and is kept in position by tightening the screw. The eye is steadied by fixation forceps held in the left hand, which grasp the conjunctiva as close to the cornea as possible directly opposite to the spot at which the puncture is to be made; the puncture is made directly behind the limbus and the needle is passed into the anterior chamber.

Second step. Using the shaft of the needle lying in the cornea as a fulcrum on which to rotate the needle, an incision is made in the anterior capsule of the lens, and the lens fibres are broken up by a stirring movement. The needle is then rapidly withdrawn in the same plane in which it was inserted so as to avoid making a crucial incision in the cornea with the spear-like end and thereby losing the aqueous. The best way to make sure of this is to mark one side of the handle so that it may be inserted and withdrawn in the same position. A pad and bandage are then applied.

After-treatment. The pupil should be kept dilated subsequently by the use of atropine twice a day until the lens has become absorbed. The bandage may be removed about the fourth day and dark glasses worn.

The effect of the operation on the lens varies considerably. It may swell up so rapidly that the tension of the eye becomes increased, in which case an evacuation may have to be performed; in other cases, especially in the cases of a patient with high myopia, several needlings may be required before absorption is complete.

CAPSULOTOMY

Capsulotomy is the division of the opaque capsular membrane left after a cataract has been removed.

Secondary Cataract Fig. 87. Secondary Cataract. Opaque capsule after cataract extraction.

Indications. After a cataract has been removed, either by discission or extraction, an opaque membrane is usually left. This is due to the proliferation of the cells in the anterior capsule of the lens while attempting to lay down new lens fibres. Although the posterior capsule is clear and free from cells, those from the anterior capsule may spread to it and so render it opaque. A fibrinous exudate may also organize and help to thicken the membrane (Fig. 87). For these reasons and also because the soft matter may not have absorbed entirely, it is not advisable to operate too soon after a cataract has been removed. There should be at least six weeks’ interval after an extraction has been performed. A few surgeons operate earlier than this, the idea being that the membrane is then softer and more easily divided.

Although the operation of discission for after-cataract (capsulotomy) is simple it is not to be undertaken lightly. The patient’s vision should be less than 6/18. In former days the operation was looked upon as attended with as much risk as the extraction, owing to the frequency with which it was followed by inflammation. The reasons for this seem to have been want of proper antiseptic precautions, the passage of the needle through the non-vascular corneal tissue instead of through the conjunctiva, and also the use of a badly made needle, often resulting in prolapse of the vitreous into the wound. A proper discission needle should have sufficient width in its spear-like point to cut a hole large enough to admit the shaft freely; hence needles which have been sharpened several times should be discarded. It need hardly be said that there should be no signs of cyclitis (keratitis punctata) present when the operation is undertaken.

Instruments. These are the same as for discission, with the addition of a needle with a long cutting edge.

Capsulotomy Fig. 88. Capsulotomy. The method of incising the capsule. The fulcrum of movement of the needle is where the shaft lies in the sclerotic.

Operation. Capsulotomy is best performed by artificial light under cocaine. The cutting needle is inserted into the anterior chamber as in the previous operation. The point is then thrust through the membrane below (but it should not penetrate deeply, otherwise the vitreous will be torn) and an incision is made in an upward direction. This incision usually gapes sufficiently to give a clear pupil (Fig. 88). Those surgeons who operate early try to cut out a triangular portion of the membrane. When a dense band is present which gives before the needle and cannot be divided, a second or ordinary discission needle should be passed into the anterior chamber from the limbus opposite to the cutting needle. The discission needle is made to pass behind the band whilst the cutting needle lies in front of it. By a rotary movement of the discission needle around the cutting needle the band is carried against the edge of the latter and so divided. The needles are then withdrawn (Fig. 89).

Capsulotomy Fig. 89. Capsulotomy. The method of dividing a dense band. This is done with two needles.

Results. These are good as a rule, but the operation may have to be performed again owing to an insufficient or non-central opening being obtained in the membrane, or to a fresh membrane forming; this is liable to take place if any irido-cyclitis follow the operation.

After-treatment. This should be carried out as described for needling.

EVACUATION

Indications. (i) In cases of increased tension associated with soft lens substance in the anterior chamber.

(ii) To accelerate the absorption of soft lens matter from the anterior chamber. As a rule it is only undertaken for the former condition.

Instruments. Speculum, fixation forceps, bent broad needle, curette.

Operation. Under cocaine.

First step. An incision is made behind the limbus, usually in an upper segment of the cornea, by means of a bent broad needle. The point of the instrument is passed into the anterior chamber immediately behind the limbus with the handle at right angles to the cornea; directly the anterior chamber has been entered the handle is depressed so that the point of the instrument shall turn forwards and avoid injuring the iris. The blade is passed on into the anterior chamber until the point reaches about the centre of the pupil. It is then either withdrawn directly, or, if a larger incision be desired, lateral pressure is made so that in withdrawing the blade the wound is enlarged.

Second step. Evacuation. With the rush of aqueous which follows the incision some soft matter is usually evacuated; then a curette may be introduced, if necessary, and the lens fragments removed by gentle manipulation. Occasionally the iris may prolapse into the wound; if this happens it should be replaced, but if it occur more than once the prolapsed portion should be removed. Suction apparatus has been used for removing the soft lens matter, but it is not to be recommended in most cases, owing to the difficulty of sterilization and the trauma which it may cause. After-treatment as for needling should be carried out.

EVULSION OF THE CAPSULE

Indications. (i) In congenital cataract when the lens consists of little more than a dense capsular mass.

(ii) In dense capsular membranes following removal of a lens by discission in which a cutting needle cannot make a hole.

Instruments. Speculum, fixation forceps, keratome, capsule forceps, discission needle.

Operation. A general anæsthetic is usually desirable.

First step. The pupil is previously dilated with atropine. In the case of congenital cataract a discission needle is first passed into the mass to estimate its consistency. If it consist of little more than capsule an incision is made at the limbus with the keratome as described for evacuation.

Second step. The blades of the capsule forceps are then inserted closed, opened, and the opaque capsule grasped and withdrawn from the eye. The speculum is then removed and a pad and bandage applied. The pupil should be kept dilated with atropine subsequently, as a certain amount of irido-cyclitis following the operation is not infrequent. Occasionally the iris may become entangled in the wound, and it should then be removed.

EXTRACTION OF THE LENS

Indications. (i) For all forms of cataract in patients over thirty years of age.

(ii) For cases of high myopia over the same age.

(iii) For lenses containing foreign bodies.

(iv) For displacement of the lens causing irritation.

Probably no operation in surgery has so many modifications, many of which possess advantages and disadvantages which counterbalance each other so nearly that the individual surgeon must decide for himself which is the most satisfactory to carry out. The opinion of many surgeons, including the author, is that the ideal operation is one which can obtain sight for the patient at one sitting. The operation described below is carried out with this object in view, the various modifications and the indications for their use being subsequently discussed.

Instruments. Speculum, two pairs of fixation forceps, a Graefe’s knife, iris forceps (Fig. 90), iris scissors (Fig. 91), capsule forceps, cystotome, curette or spoon, iris spatula, vectis (Fig. 92), or lens spoon (Fig. 93).

Iris Forceps Fig. 90. Iris Forceps. Care should be taken to see that the teeth dovetail properly.
Iris Scissors Fig. 91. Iris Scissors. Their cutting power should be tested on wet cigarette paper before use.
A Vectis Fig. 92. A Vectis. It should be made of stiff steel.
Pagenstecher’s Spoon Fig. 93. Pagenstecher’s Spoon. It is an advantage to bend the shaft near the spoon to a right angle.

Operation. The operation is performed under cocaine and is divided into five steps:—

1. Incision.

2. Iridectomy.

3. Opening the lens capsule.

4. Delivery of the lens.

5. Toilet of the wound.

Lens Extraction Fig. 94. Lens Extraction. Showing the position of the hands when making a section upwards with a Graefe’s knife.

First step. The incision. The surgeon, standing behind the patient’s head and holding the knife with the edge directed upwards, in the right hand for the right eye and in the left hand for the left, fixes the eye with a pair of forceps held in the other hand, by grasping the conjunctiva below and to the inner side as close to the limbus as possible (Fig. 94). Most continental surgeons stand in front of the patient and cut upwards. The point of the knife is then passed on the flat into the anterior chamber from the outer side, 1.5 millimetres behind the corneo-sclerotic junction.

The Knife entering the Anterior Chamber in Cataract Extraction Fig. 95. The Knife entering the Anterior Chamber in Cataract Extraction. The point of the knife is directed downwards and inwards.
   
Making the Counter-puncture in Cataract Extraction Fig. 96. Making the Counter-puncture in Cataract Extraction. The counter-puncture is shown completed.

It is first directed downwards and inwards until the chamber is penetrated (Fig. 95). The knife-point is then directed horizontally and passed across the anterior chamber in a line parallel with an imaginary tangential line across the top of the cornea. The counter-puncture is then made, the knife emerging 1 millimetre behind the corneo-sclerotic junction (Fig. 96). In making the counter-puncture the beginner is apt to go too far back in the sclerotic owing to the angle of the chamber being placed behind the limbus; he should therefore aim for a point about 1 millimetre inwards from the limbus. The knife is next made to cut upwards by a sawing movement so that a flap is formed of corneal tissue about 3 millimetres in breadth (a breadth and a half of a new Graefe’s knife), the upper margin being at the corneo-sclerotic junction. When the corneal flap has been made, the knife should lie beneath the conjunctiva, from which a flap about 3 or 4 millimetres in length should be formed. The knife-edge is then turned forward and made to cut its way out. In making the section, care must be taken not to prick the patient’s nose or eyelid with the point of the knife, as it may cause him to move his head with disastrous results. This is more likely to happen with patients who have sunken eyes.

Incision and Iridectomy in Cataract Extraction Fig. 97. Incision and Iridectomy in Cataract Extraction.

Second step. Iridectomy. The patient is made to look downwards. A pair of iris forceps are inserted, closed, into the anterior chamber, opened, and the iris grasped near its root, and withdrawn. The piece of iris is then removed with the iris scissors, dividing it parallel with the incision as close to the eye as possible (Fig. 97). If the conjunctival flap hinders the insertion of the iris forceps into the anterior chamber, it may be turned forward over the cornea with the point of the closed forceps.

Opening the Capsule with Forceps Fig. 98. Opening the Capsule with Forceps in Cataract Extraction. The forceps are inserted closed, brought in contact with the lens, opened, and the capsule grasped between the blades and withdrawn by a gentle side-to-side movement.

Third step. The capsule of the lens is opened. This is done in order to allow the lens nucleus and soft matter to escape. Since the anterior capsule becomes opaque after the removal of the lens, owing to the multiplication of the cells in their attempt to lay down new lens fibres, it is desirable to remove a portion of the anterior capsule from the pupillary area. This may be performed (a) by means of capsule forceps which are inserted closed, and when in position over the lens are opened as widely as possible without entangling the iris, then pressed down on to the anterior capsule of the lens and closed; in this manner the portion of the capsule thus included is removed by a slight lateral movement (Fig. 98); (b) by means of a cystotome, the lens capsule being opened by a triangular or T-shaped incision over the pupillary area; (c) by the point of the knife as it passes across the anterior chamber; (d) by a discission needle before the section is made. When the capsule of the lens has been opened properly the lens nucleus is usually seen to come forward. The advantage of the capsule forceps over the other methods is that they remove a larger portion of the capsule and leave no tags which may become incarcerated in the wound. On the other hand they are somewhat more difficult to use; more pressure on the lens is required, and therefore dislocation of the lens in its capsule may result. It is, therefore, not advisable to use them in cases in which a fluid vitreous is suspected. If the teeth of the forceps are not well made they will not grasp the capsule; it is therefore always advisable to have the cystotome in readiness. The cystotome also should be used when the anterior chamber becomes filled with blood so that the margin of the iris cannot be seen and there is a risk of the iris being grasped by the forceps.

The method of opening the capsule with the point of the knife or needle is useful in cases of extraction without iridectomy; the pupil should be dilated before the operation.

Fourth step. Delivery of the lens is performed by a gentle pressure, combined with massage, on the extreme lower margin of the cornea with a curette or spoon, until the upper margin of the lens presents in the wound, when the pressure is gradually made upwards over the cornea until the lens is delivered. Delivery of the lens may be prevented by—

(a) Imperfect opening of the capsule, which is usually the result of using a blunt cystotome; if capsule forceps are used this difficulty hardly ever arises.

(b) Too small an incision. The margin of the nucleus may present and not be able to pass the wound. The wound must then be enlarged with the iris scissors and the lens delivered in the ordinary way. Only by experience can the amount of pressure required for the delivery of the lens be gauged.

(c) A sticky consistency of the cortex is not infrequently found in cases of immature cataract. When the lens presents and cannot be delivered readily it may be helped out by means of the cystotome plunged into its substance, pressure being used on the cornea at the same time.

Cataract Extraction Fig. 99. Cataract Extraction. Replacing the iris, and any tags of capsule which may be in the wound, with an iris spatula.

If from these or any other causes the suspensory ligament rupture and the vitreous present in the wound, the lens should be removed with the vectis. The vectis, which should be made of stiff steel, is passed vertically into the incision and behind the lens nucleus by depressing the handle; with a steady gentle pressure forwards it is then withdrawn together with the nucleus. The forward pressure should be such as to prevent the instrument slipping on the nucleus, for if it does so the accident is nearly always followed by a rush of vitreous. A Pagenstecher’s spoon may be used instead of the vectis, and is to be preferred in cases where a small nucleus is suspected, since the latter may slip through the loop of the vectis and fail to be delivered.

Fifth step. Toilet of the wound. After the nucleus has been extracted, all the soft matter should be removed as far as possible by gentle expression with the spoon. The angles of the coloboma in the iris should be replaced by stroking it inwards on its anterior surface with the iris spatula, paying particular attention to the angles of the wound (Fig. 99). The spatula should also be passed throughout the extent of the wound so as to free it from any capsule which may have prolapsed into it. The conjunctival flap is then placed in position by stroking it upwards with the iris spatula.

After-treatment. Atropine is instilled either at the time of operation or at the first dressing, and continued until all signs of redness of the eye have disappeared. The patient should remain in bed for at least ten days, both eyes being bandaged during the first four days. The eye that has been operated on should be covered for at least two weeks; subsequently a shade or dark glasses should be worn.

Modifications. The operation may be modified in various ways.

The incision. The position of the incision has undergone many modifications. The one described above is now in general use.

The size of the incision should be increased when (a) a large nucleus is expected, as in old people; (b) an immature cataract is to be extracted; or (c) a fluid vitreous is suspected, so that the lens may be delivered with as little pressure as possible.

The iridectomy may be omitted. Extraction without iridectomy is undoubtedly the ideal operation; it leaves the pupil unbroken and the eye looking normal to external appearance. Further, the pupil reacts more strongly to light than if an iridectomy has been performed. The presence of the iris further prevents the prolapse of any capsule into the wound. At the same time it is attended with considerable risk of prolapse, which, as has been pointed out, is a very great danger to the eye. With proper care this probably only occurs in about 5% of the patients operated upon, but is so serious that the opinion of most surgeons is in favour of the combined method (iridectomy and extraction); but at the same time it is the practice of many surgeons to omit the iridectomy under the following circumstances: first, if the patient be young and the deformity will interfere with his getting employment; secondly, if extraction of the lens in its capsule be performed the unbroken circle of the iris will help to prevent the prolapse of the vitreous which is otherwise so liable to take place.

Eserine (gr. ii ad i) should be used to prevent prolapse of the iris after the extraction has been performed, and should be continued once a day until a good anterior chamber is present, which is usually in about twelve to twenty-four hours, when atropine should be substituted. If the iris betray any liability to prolapse after the operation, as shown by the drawing upwards of the pupil, an iridectomy should be performed before the patient leaves the table. In any case the eye should be examined on the evening of the operation, and, if prolapse has occurred, that portion of the iris should be removed. If a prolapse of the iris occurs and is not discovered until the wound has healed, the conjunctiva should be dissected off the surface in the form of a flap and the iris tissue drawn out of the wound and removed, the angles caught in the scar being freed if possible. The opening in the globe is subsequently closed by replacing the conjunctival flap in position, or, if it has not been possible to preserve the conjunctiva over the cicatrix, by raising a flap from the ocular conjunctiva in the neighbourhood and stitching it down over the opening in the globe. Not infrequently this operation is followed by an attack of acute iritis, which usually subsides under treatment.

Preliminary iridectomy. The iridectomy may be performed at a previous operation. It has the advantages that the surgeon learns how the patient will behave under operation, and how the eye will react to such an operation. There is an absence of bleeding at the second operation, which makes it easier, and there is less liability for the iris to become adherent to the capsule. The disadvantages, which seem to outweigh the advantages, are that there is a double chance of sepsis, and that the patient has to submit to two operations when one is sufficient. It is only performed by the author in cases in which there is a tendency to increased tension in the eye due to swelling of the lens in the early stages of the cataract. When a preliminary iridectomy is performed a keratome may be substituted for the Graefe’s knife in making the incision for the iridectomy, a much smaller one being necessary.

McKeown’s Irrigation Apparatus Fig. 100. McKeown’s Irrigation Apparatus for washing out the Anterior Chamber. The second and third terminals are the most useful.

Delivery of the lens by irrigation. McKeown removes the soft lens matter by a process of irrigation into the anterior chamber, a practice not yet much adopted, but of considerable service in removing the soft matter after the extraction of the nucleus, especially in immature cataract. It is also probable that the thorough removal of the soft lens matter by this method reduces the number of cases of cyclitis following the operation, since the soft matter forms a suitable medium for the growth of organism. The apparatus used is shown in Fig. 100, nozzle No. 2 being the most useful; it is inserted into one angle of the wound and a stream of sterilized normal saline solution at 39°C. (in the flask) is allowed to flow into the anterior chamber; this stream is obtained by raising the flask until sufficient pressure is obtained. An undine may be substituted for the flask. Care should be taken that there is a free return of fluid from the anterior chamber; irrigation should be continued until as much as possible of the soft matter has been removed.

Extraction of the lens in its capsule. This operation is frequently performed in India, where patients will often not return for needling of secondary cataract (capsulotomy). Although the method undoubtedly yields good results, the percentage of eyes damaged by loss of the vitreous must be higher than when the posterior capsule of the lens is left intact. The operation may be performed with or without an iridectomy, the lens being removed by pressure on the cornea with a large strabismus hook. If the vitreous should present, the lens should be removed with the vectis.

Extraction of the lens in its capsule is also performed when the lens is dislocated and causing irritation. If the lens be in the anterior chamber immediate extraction is called for, as glaucoma is a usual complication. Eserine is first instilled in order to contract the pupil and prevent the lens passing back into the posterior chamber; an incision is then made as for a cataract extraction and the lens removed by means of the vectis. Complete dislocation of the lens into the vitreous rarely requires operation, as the patient is able to see. Partial dislocation (luxation) occasionally calls for extraction, the vectis usually being employed for delivering the lens, but before undertaking the operation an attempt should be made to get the lens into the anterior chamber by dilating the pupil and making the patient lie face downwards; if this is successful eserine should be instilled to contract the pupil behind the lens and so retain it in the anterior chamber, from whence it can more easily be extracted. Some surgeons prefer to fix the lens with a needle passed through the sclerotic behind the ciliary body before making the incision.

Subconjunctival extraction. In order to diminish the risks of sepsis, more especially in cases in which the conjunctiva is affected with trachoma, some continental surgeons deliver the lens into a pocket beneath the conjunctiva, whence it is subsequently removed. The operation has the additional advantage of a better blood-supply to the corneal flap, which is also held in better position after the operation.

Subconjunctival Extraction Fig. 101. Subconjunctival Extraction. The section in the sclerotic being completed with a Graefe’s knife, the figure shows the method of undermining the conjunctiva to form a pocket into which the lens is delivered and from which it is subsequently removed.

Operation. A section upwards is made with a Graefe’s knife as in the ordinary method of extraction previously described, the lens capsule being opened with the point of the knife as it is passed across the anterior chamber. When the section through the sclerotic has been completed and the knife lies entirely beneath the conjunctiva it is withdrawn.

The wound in the conjunctiva on the outer side is then enlarged upwards with scissors, and an iris spatula is passed beneath the conjunctiva from the small wound on the inner side and the point made to appear in the wound on the outer side; by this means the conjunctiva is raised on the spatula, and by means of sharp-pointed scissors a pocket is made in an upward direction by undermining the conjunctiva (Fig. 101). Delivery of the lens is then performed into this pocket, from which it is subsequently removed, the conjunctival wound on the outer side being closed with a stitch. The advantage of this form of subconjunctival extraction over other forms which have been devised is that if difficulty is met with in delivering the lens, &c., the operation can be readily converted into an ordinary extraction by completing the division of the conjunctival flap.

Complications. These may be immediate or remote.

Immediate. 1. If the knife-point become entangled in the iris as it is passed across the anterior chamber it should be slightly withdrawn, if this can be done without loss of aqueous, the iris being thereby disengaged.4

2. Loss of the aqueous before the section is complete may result in the entanglement of the iris as before described, or the iris, owing to the presence of the aqueous in the posterior chamber, may bulge forward in front of the knife-blade. The latter complication is more likely to occur if the section be made too rapidly. The iris may sometimes be disengaged by depressing the handle of the knife towards the patient’s chin and raising the blade towards the cornea so as to allow the aqueous in the posterior chamber to escape. If this cannot be accomplished, the section should be completed and the iris, which may be divided by the knife, removed subsequently when doing the iridectomy.

3. Avulsion of the iris due to movement of the patient’s head. This is more liable to take place if the eye has not been properly cocainized some time before the operation. The grasping of the iris by the forceps is always felt by the patient to a certain extent, and he should be warned not to move. Avulsion is usually not complete and only results in a larger iridectomy than was intended.

4. Dislocation of the lens. (a) When opening the capsule, either from too great pressure of the capsule forceps, or from the patient moving his head. The lens must then be delivered by the vectis. (b) If, in delivering the nucleus, the upper edge is not made to present by pressure on the lower part of the cornea, the nucleus, especially if it be small, is liable to be dislocated upwards beyond the incision. It must then be removed with the vectis. In cases where a small nucleus is suspected, pressure should be made on the sclerotic above the incision with a curette, as well as on the lower part of the cornea, so as to make the nucleus present in the wound.

The lens may be dislocated backwards into the vitreous; if this should happen and the lens cannot be delivered, the flap must be replaced in position and the eye bandaged. Unfortunately this complication is usually followed by irido-cyclitis and loss of the eye.

5. Loss of the vitreous. There are two chief phenomena which may indicate that loss of vitreous is about to take place after the extraction of the lens.

(a) The wound gapes unnaturally after the expulsion of the lens, and the clear vitreous may be seen presenting in the wound in the still unruptured hyaloid membrane.

(b) There may be an apparent deepening of the anterior chamber owing to the fluid vitreous making its way forward through the ruptured hyaloid into that cavity.

If the vitreous presents in the wound before the lens has been removed, the latter should be delivered as rapidly as possible by the vectis, as has previously been described.

If the vitreous be lost or one of the phenomena previously mentioned occurs after the delivery of the lens, the speculum should be removed from the eye and the conjunctival flap replaced in position as quickly as possible. The eyelid is then carefully raised from the surface of the eyeball by means of the lashes held in the finger and thumb and carried downwards over the globe until it is in the closed position, and a bandage is then applied.

As little manipulation as possible should be carried out when once the vitreous has shown itself about to present, and unless the iris be obviously in the wound no attempt should be made to replace it.

Loss of vitreous may be the result of subchoroidal hæmorrhage, which may only make itself manifest after the patient has been put back to bed.

Loss of vitreous is frequently accompanied by hæmorrhage into the vitreous, as is seen subsequently by the floating opacities therein. As a rule these clear, and useful vision is obtained.

Detachment of the retina may follow loss of vitreous even months after operation. This complication seems more liable to occur if the vitreous which is lost in the first instance be normal and not of the fluid type.

6. Intra-ocular hæmorrhage (see Glaucoma Iridectomy, p. 224).

Remote. 1. Panophthalmitis is a result of infection of the wound. It usually makes its appearance about the third day and must be treated by evisceration. Occasionally the purulent material is limited to the line of the incision or even to the anterior chamber; in the latter instance the wound should be opened up and the anterior chamber washed out with peroxide of hydrogen solution (10 vols. %). Microscopic examination of the pus should be made and a vaccine prepared and administered; in two cases so treated by the author a good recovery resulted.

2. Escape of the aqueous beneath the conjunctiva usually occurs about the third day, owing to the conjunctival wound having healed without the opening into the globe being properly shut off. This is accompanied by considerable pain, with chemosis and some œdema of the upper lid. It is usually distinguishable from acute iritis by the pupil being evenly dilated and discoloration of the iris being absent. The condition usually subsides in three or four days, when the wound in the globe has become shut off.

3. Acute iritis not infrequently occurs after extraction. It usually comes on about the third day and may be accompanied by hypopyon. It may settle down under atropine, leeching, and dry heat, but may also pass on into the more chronic form; adhesion of the iris to the capsule, however, frequently results. More rarely the disease may not make its appearance till two or three weeks after the operation (latent sepsis), the patient suffering from recurring attacks of hypopyon. In these cases in which the hypopyon persists, washing out the anterior chamber with peroxide of hydrogen (10 vols. %) and the administration of a vaccine is of service.

4. Chronic irido-cyclitis is usually primary, but may occasionally follow an acute attack of iritis. Of all the disastrous complications, this is by far the worst. It may not only destroy the sight of the eye on which the operation has been performed, but may set up sympathetic ophthalmia in the other eye. The eye does not settle down well after the operation, there being usually some prolapse of the iris or capsule into the wound. It remains injected or flushes up on exposure to light. After a time (usually about the end of the third week) keratitis punctata makes its appearance, and the tension of the eye may become decreased or occasionally increased. The disease may resolve or go on to shrinking of the globe. Energetic treatment with atropine and hot fomentations locally, with the internal administration of iron, is indicated. The administration of staphylococcus vaccine causes only temporary improvement in most instances. In six cases so treated by the author the improvement was only temporary, in spite of the fact that there was a definite local reaction to the vaccine and in two cases the staphylococcus albus was isolated from the fluid in the anterior chamber. If at the end of two months the eye be red and well-marked keratitis punctata be present, and if the pupil be beginning to be drawn up and the eye shows no tendency to improve, enucleation should be seriously considered; this is especially advisable if the projection of light has become defective, showing that the retina is probably detached. If any signs of sympathetic irritation, such as mistiness of vision, ciliary flush, or photophobia, appear in the eye which has not been operated on, the exciting eye should be enucleated. On the other hand, if well-marked inflammation has developed in the sympathizing eye, which may also be cataractous, and the other eye has a fair amount of vision, it becomes extremely questionable whether it is advisable to enucleate the exciting eye. Every case must be judged on its own merits according to the extent and severity of the disease. In a few cases in which the incarceration of the capsule in the wound leads to a very chronic cyclitis, its division with a cutting needle will sometimes lead to subsidence of the inflammation. It is most important that every eye that has been operated on should be examined for the presence of keratitis punctata, especially before allowing the patient to use the eye or before another operation is performed on it.

5. Glaucoma following extraction occurs as a result of (a) soft lens matter blocking the angle of the anterior chamber. As a rule the tension will usually subside under eserine, but evacuation of the anterior chamber (see p. 233) may have to be performed; on the whole the results are satisfactory. (b) The incarceration of the capsule in the wound, pulling forward the iris and blocking the angle of the anterior chamber. Division of the lens capsule is usually sufficient to make the tension subside. Failing this, sclerotomy should be performed; the prognosis is not nearly so good when the increased tension is due to this cause.

6. Striate keratitis usually makes its appearance on the second or third day after operation. The cornea near the line of incision presents a grey striped appearance with the striæ arranged at right angles to the wound. Pathologically the condition is due to an infiltration of the deeper layers of the cornea, the striped appearance being caused by wrinkling of Descemet’s membrane; the condition probably arises from septic infection. As a rule the affection subsides without giving rise to further trouble, but occasionally local suppuration and even panophthalmitis may follow.

A grey horizontal line about the centre of the cornea is sometimes seen after an eye has been too tightly bandaged; this always disappears when the bandage is removed.

7. Erythropsia (red vision) occasionally follows the extraction of the lens, and is probably due to bleaching of the visual purple following the admission to the eye of an unusual amount of light; it usually disappears in a few weeks.

8. Defective vision. Glasses have to be worn after removal of the lens. Usually patients who were previously emmetropic require about + 11 to see clearly for distance and + 15 for near vision.

The section produces some flattening of the corneal curvature at right angles to the line of the incision; this usually amounts to about two diopters.

COUCHING

Couching is the removal of the lens from the pupillary area by depressing it backwards into the vitreous. It is rather a relic of the past than a present-day operation, although it is extensively practised by quacks in India. Under certain circumstances the operation still seems justifiable; it is very simple, and is followed by immediate restoration of vision, but the subsequent risks of irido-cyclitis, retinal detachment, and glaucoma are so great, that, according to some authorities, couching should only be undertaken in preference to extraction when the latter operation has only a chance of one in three of giving satisfactory vision.

Indications. The chief indications for its performance are:—

(i) The presence of a fluid vitreous, the patient having had the lens of the other eye extracted with bad results.

(ii) In the insane, where it would be impossible to carry out the after-treatment of extraction satisfactorily.

Operation. The operation is usually done under cocaine; in the case of the insane a general anæsthetic is usually necessary. It has been performed by simple depression of the lens backwards into the vitreous with a needle passed through the cornea (anterior route). This operation yields unsatisfactory results owing to the lens being liable to return into the pupil; this can be partly overcome by sweeping the needle round the periphery of the lens so as to divide the suspensory ligament, but the operation is not so satisfactory as when the needle is passed in from behind the ciliary body and the lens pressed down from behind (posterior route), to which the following description applies. The capsule of the lens should be torn freely, so that some absorption may subsequently take place and diminish the risk of complications.

Instruments. Speculum, fixation forceps, needle.

First step. The pupil should be dilated with atropine. The patient’s head should be well raised on the table. The needle is passed through the sclerotic about 5 millimetres behind the limbus to the outer side. The posterior capsule of the lens is then freely divided by a sweeping movement.

Second step. The needle is next made to appear in the lower part of the pupil by carrying it round the lower and outer border of the lens. The anterior capsule is then freely divided.

Third step. The shaft of the needle is laid flat on the surface of the lens towards its upper part, and by raising the handle of the needle the lens is displaced backwards into the vitreous. The tearing of the suspensory ligament on the inner side may be assisted by the cutting edge of the needle during depression.

Complications. Immediate. Difficulty may be experienced in making the lens lie at the bottom of the vitreous, and it is only by frequent depression of the lens backwards and downwards, with a sweeping movement of the needle to divide the suspensory ligament, that the desired effect can be obtained.

Remote. The lens nucleus may prolapse through the pupil into the anterior chamber. If this should happen, the patient should be placed on his back and the pupil dilated with atropine; if the nucleus does not go back into the vitreous chamber it should be depressed by means of a needle passed through the cornea.

Glaucoma may result from the dislocation of the nucleus into the anterior chamber and should be treated as described above. It may also be present with a lens which is dislocated backwards. This condition is very liable to end in loss of sight. Probably the only hope of relieving the tension is by the use of eserine or the performance of a cyclo-dialysis.

Cyclitis and retinal detachment may also follow, and usually end in blindness.


CHAPTER III

OPERATIONS UPON THE IRIS

IRIDOTOMY

Indications. Iridotomy is an operation which is performed when the iris has become drawn up after a cataract extraction, so that there is no pupil, or the pupillary area is covered by the upper lid. A long interval should elapse between the extraction and the iridotomy, since these cases have usually suffered from cyclitis following the operation. Iridotomy should not be performed for at least six months after all signs of cyclitis have disappeared, for the frequent failure of the operation is due to the fact that the opening made in the iris and underlying capsule becomes filled with fibrous exudation as the result of cyclitis, which is frequently set up again by the operation if undertaken before a sufficient time has elapsed for the eye to settle down after the inflammation. The ideal operation, therefore, is to make an artificial pupil with the least amount of trauma to the ciliary body.

Instruments. Speculum; fixation forceps; a long, narrow, bent ‘broad needle’; Tyrrell’s hook, iris scissors, iris forceps, and spatula.

Operation. Many operations have been devised for this most troublesome condition, but the following is the one that the author has found to be successful.

The operation is usually performed under a general anæsthetic, but this is not essential.

Iridotomy Fig. 102. Iridotomy. Showing the incision with a long, bent broad needle.
    
Iridotomy Fig. 103. Iridotomy. Showing the method of withdrawing the band of iris and capsule with a Tyrrell’s hook.

First step. The surgeon stands facing the patient on the same side as the eye to be operated on. The long, bent, broad cutting needle is passed into the anterior chamber from the limbus downwards and inwards, and is driven directly through the iris and underlying capsule. The needle is then made to pass in an upward and outward direction behind the iris into the pupillary area above, or if no pupil be present, again through the iris (Fig. 102). The bent broad needle is made to cut laterally by slightly deflecting the handle so as to produce a band of iris and capsule; the cutting needle is then withdrawn.

Second step. A Tyrrell’s hook, bent to the correct angle, is passed beneath the band (Fig. 103), which is drawn into the wound and removed with iris scissors. A large opening is thus obtained with a minimum amount of trauma. If the hook should slip, the band may be seized with iris forceps, withdrawn from the wound, and removed.

Alternative methods. The following methods have been practised:—

Simple incision across the fibres of the iris by means of Graefe’s or Knapp’s knife.

Division with scissors through a wound of the limbus.

By these two methods the opening produced is small, and is very liable to be closed by the subsequent cyclitis. The following operation yields more satisfactory results.

Kuhnt’s operation.

Instruments. Speculum, fixation forceps, Graefe’s knife, iris forceps and scissors.

First step. The surgeon, standing facing the patient, enters the anterior chamber about 2 millimetres inwards from the limbus at the junction of the middle and lower third of the cornea with a Graefe’s knife, the cutting edge directed downwards. The knife is then made to penetrate the iris and underlying capsule, and to travel beneath this to a similar point on the other side, where it is made to come back again into the anterior chamber by again penetrating the iris, and finally out again through the cornea. The knife is then made to cut out in a downward direction.

Iridotomy by Ziegler’s Method Fig. 104. Iridotomy by Ziegler’s Method. Showing the shape of the knife and the position of the first puncture in the iris; the cutting is performed by a sawing movement.

Second step. Iris forceps are inserted and the flap of iris and capsule is withdrawn and as much of it removed as possible. A more or less triangular opening usually results.

Ziegler’s operation.

Instruments. Ziegler’s knife needle, speculum, fixation forceps.

The object of the operation is to cut a V-shaped flap in the iris and underlying capsule, folding the flap backwards on its base so as to form a triangular opening in the iris membrane to serve as a pupil.

First step. The knife needle is entered at the corneo-sclerotic junction with the blade turned on the flat and is passed completely across the anterior chamber to within 3 mm. of the apparent iris periphery. The knife is then turned edge downwards, and carried 3 mm. to the left of the vertical plane (Fig. 104).

Second step. The point is now allowed to rest on the iris membrane, and with a dart-like thrust the membrane is pierced. Then the knife is drawn gently up and down with a saw-like motion, without making much pressure on the tissue to be cut, until the incision has been carried through the iris tissue from the puncture in the membrane to just beneath the corneal puncture. This movement is made wholly in a line with the long axis of the knife, the shank passing to and fro through the corneal puncture, loss of the aqueous being avoided in the manipulation (Fig. 105).

Third step. The pressure of the vitreous will now cause the edges of the incision to bulge open immediately into a long oval. The knife-blade is raised until it is above the iris membrane, and is then swung across the anterior chamber to a corresponding point on the right of the vertical plane. Owing to the disturbance in the relation of the parts made by the first cut, this point is somewhat displaced and the second puncture must be made 1 mm. further over.

Iridotomy by Ziegler’s Method Fig. 105. Iridotomy by Ziegler’s Method. Showing the first incision and the position of the second.
    
Iridotomy by Ziegler’s Method Fig. 106. Iridotomy by Ziegler’s Method. Final step; the triangular flap of iris attached at its base is turned downwards.

Fourth step. With the knife-point again resting on the membrane, a second puncture is made and the incision is carried rapidly forward by the sawing movement to meet the extremity of the first incision at the apex of the triangle, thus making a V-shaped cut. Care must be taken that the pressure of the knife-edge on the tissue shall be most gentle, and that the second incision shall terminate a trifle inside the extremity of the first, in order that the last fibres may be severed and thus allow the apex of the flap to fall down behind the lower part of the iris membrane (Fig. 106). When the operation has been completed the knife is turned on the flat and withdrawn.

IRIDECTOMY

The operation of iridectomy differs widely in its performance, according to the different conditions for which it is used. Hence it is better to prefix the condition for which it is employed, thus: preliminary iridectomy, optical iridectomy, glaucoma iridectomy.

Apart from being one of the stages of removal of a cataract, already described, it is performed as an independent operation in the following conditions:—

1. For optical purposes (optical iridectomy).

2. For the relief of glaucoma, primary and secondary (glaucoma iridectomy).

3. For small growths at the free margin of the iris.

4. For prolapse of the iris through a wound.

OPTICAL IRIDECTOMY

Indications. Iridectomy for optical purposes is performed for a centrally situated nebula of the cornea and in some very rare cases of small central opacities in the lens. In the latter condition it is rarely of much value, as nearly all the rays which enter the eye pass through the central portion of the lens. Further, in this condition the lens may be removed and better sight obtained with glasses. Optical iridectomy should always be performed opposite a clear portion of the cornea, the lower segment of the eye being chosen, otherwise the coloboma may be subsequently covered by the upper lid. The site of election for the operation is downwards and inwards, but in all cases the patient should be carefully examined in the following ways: (1) the vision is tested, any refraction being corrected without a mydriatic; (2) the pupil is then dilated, and the best situation for the iridectomy determined by means of a stenopaic slit. The vision must be definitely improved by the use of these before operation can be advised. The disadvantage of an iridectomy is that it allows more light to enter the eye, and, if the periphery of the lens be uncovered, spherical aberration may result. For both these reasons, therefore, it is advisable to make the iridectomy as small as possible. Tattooing of the central scar in the cornea will often diminish the amount of light entering the eye, but before undertaking the latter operation, the eye should be cocainized and the area covered with a piece of black paper to see if the vision is improved thereby.

Instruments. Speculum, fixation forceps, bent broad needle or small keratome, Tyrrell’s hook, iris forceps, scissors, and spatula.

Operation. The operation is usually performed under cocaine.

First step. The eye is fixed by grasping the conjunctiva directly opposite the spot at which the incision is to be made. The incision is then made by means of a keratome or bent broad needle directly behind the limbus, and enlarged laterally if desired (Fig. 107).

Optical Iridectomy Fig. 107. Optical Iridectomy. The incision being made with a keratome.
    
Optical Iridectomy Fig. 108. Optical Iridectomy. Method of removing the iris to produce a small coloboma.

Second step. A Tyrrell’s hook, bent at the correct angle, is passed on the flat into the anterior chamber. When the margin of the iris is reached the handle is rotated and the hook is made to engage the free border of the iris, which is then withdrawn from the wound; a small portion is removed with scissors, which should be held at right angles to the wound when dividing the iris (Fig. 108).

Third step. The iris should be carefully replaced and the pupil kept under the influence of eserine until the anterior chamber has re-formed, when atropine should be substituted.

Optical Iridectomy Fig. 109. Optical Iridectomy. Showing the coloboma.

Care must be taken to see that the Tyrrell’s hook presents no sharp angle, and great care is required in its manipulation, otherwise the lens capsule may be damaged, and traumatic cataract will result. If the iris slips from the grasp of the Tyrrell’s hook, iris forceps should be used, the iris being grasped near its free margin and as small a portion as possible withdrawn.

Brudenell Carter’s method. The ordinary optical iridectomy divides the sphincter iridis and so inhibits the activity of the pupil. With the idea of obviating this, Brudenell Carter removed a small portion of the iris (button-hole), leaving the pupillary margin intact. On the whole the results of the latter operation are no more satisfactory, and the operation is more dangerous to perform owing to the likelihood of wounding the lens, and to the fact that monocular diplopia occasionally results.

The pupil should be under the influence of eserine. The incision is made as in the previous operation. De Wecker’s iris scissors are inserted open into the anterior chamber, closed, and the piece of iris which bulges up between the blades cut off; this can usually be withdrawn with the scissors; or if not, it should be removed subsequently by forceps.

GLAUCOMA IRIDECTOMY
The Normal Angle of the Anterior Chamber
Fig. 110. The Normal Angle of the Anterior Chamber.

A. Cornea.
B. Ciliary processes.
C. Iris.
D. Ciliary muscle.
E. Pectinate ligament, to the right
of which is the angle of the chamber.
F. Canal of Schlemm.
G. Lens.
H. Posterior chamber.
I. Anterior chamber.

Surgical and pathological anatomy. The fluid in the anterior and posterior chambers of the eye is secreted from the ciliary body by a process of modified filtration. The fluid passes partly direct into the posterior chamber and partly behind the suspensory ligament of the lens, making its way forward into the posterior chamber through the fibres of the suspensory ligament. From the posterior chamber it passes into the anterior through the pupil; from the anterior it filters at the angle of the anterior chamber through the ligamentum pectinatum into the canal of Schlemm; thence it is carried into the blood-stream by the venous anastomosis in that region (Fig. 110).

The essential change found in all cases of primary glaucoma is the blocking of the angle of the anterior chamber owing to the root of the iris being applied to the back of the cornea, and thus preventing the filtration of the fluid into the canal of Schlemm, as a result of which the tension of the eye is raised, either acutely (acute glaucoma) or slowly from time to time (chronic glaucoma) (Fig. 111). The aim of every operation for the permanent relief of glaucoma is the opening up of Schlemm’s canal at the angle of the anterior chamber or the creation of a new lymph channel between the anterior chamber and the subconjunctival tissue (filtrating cicatrix). Although this latter condition is not unattended by the risk of the spread of inflammation from the conjunctiva to the interior of the globe, it is not an inadvisable condition to obtain in some cases of chronic glaucoma if the scar be small and free from iris tissue; in this disease the opening up of the canal of Schlemm by iridectomy is often impossible. (See Sclerectomy, p. 231.)

The Angle of the Anterior Chamber
from a Case of Recent Glaucoma
Fig. 111. The Angle of the Anterior Chamber from a Case of Recent Glaucoma. Showing its occlusion by the base of the iris, A, being adherent to the posterior surface of the cornea, so preventing filtration of the aqueous into the canal of Schlemm, B.

Indications. Since the days of von Graefe, who first performed iridectomy empirically for the relief of glaucoma, the operation has held the first place in its treatment.

(i) In primary glaucoma. Iridectomy should be undertaken as early as possible in the disease. In acute cases, unless the tension is relieved, the disease ends in rapid destruction of the sight. Operation should always be undertaken as quickly as possible, provided the patient has not lost his perception of light for longer than about ten days.

Whilst waiting for the operation, the pupil should be put under the influence of eserine (2 to 4 grains to the oz.) with the idea of reducing the tension by contraction of the pupil. Some surgeons, in addition to using eserine, perform a posterior scleral puncture with the idea of temporarily reducing the tension and allowing the acute symptoms to subside, and do the iridectomy some twenty-four to forty-eight hours later. This method is extremely useful (a) in cases where a general anæsthetic is inadvisable, since the reduction of tension allows cocaine to diffuse into the eye; (b) in cases liable to subsequent intra-ocular hæmorrhage, a more gradual reduction of tension being obtained, rupture of a choroidal vessel is less likely to occur; (c) a deeper anterior chamber is often obtained, and hence there is less risk of wounding the lens during the operation; (d) in cases where the operation has been performed in one eye and the lens has been subsequently extruded on the dressings.

In chronic cases early iridectomy is desirable, since the root of the iris applied to the posterior surface of the cornea becomes atrophic, so that when an iridectomy is performed the iris tears off at the anterior part of the atrophic portion, leaving the angle of the chamber still occluded by its root (Figs. 112 and 113). It is especially in these cases that a filtrating cicatrix, which sometimes follows iridectomy or sclerotomy, is desirable, and indeed some surgeons (Herbert and Lagrange, see p. 231), have recently performed operations with this idea in view, and it is probable that this operation or cyclo-dialysis will prove to be of use in these cases.

The Angle of the Chamber in
a case of Chronic Glaucoma Fig. 112. The Angle of the Chamber in a case of Chronic Glaucoma. The iris, A, has become atrophic at its root. An iridectomy in this case would not free the angle of the chamber, as the iris would separate at the point A.
    
Iridectomy for Glaucoma Fig. 113. Iridectomy for Glaucoma. Failure to relieve the tension owing to the iris not tearing off at its junction with the ciliary body, due to atrophy from prolonged contact with the cornea.

Operation is only contra-indicated in a few very rare cases in which the tension is controlled by the use of eserine.

(ii) In congenital glaucoma (bup[h]thalmos). In this affection the results of iridectomy vary. Without doubt, the tension has been relieved by iridectomy in some cases, and either this operation, sclerectomy, or cyclo-dialysis should be tried if the disease be not too far advanced.

(iii) In secondary glaucoma. For obvious reasons the predisposing causes should always be taken into consideration. Thus it would be of no use to perform an iridectomy in the case of a growth in the choroid. On the other hand, an iridectomy would be unjustifiable for soft lens matter in the anterior chamber, which merely requires evacuation. An early iridectomy in cyclitis is not likely to influence the course of the disease favourably; at the most a paracentesis is required. As the early stages of cyclitis may give rise to tension, it is essential that every case of glaucoma should be examined for keratitis punctata before operation.

In iris bombé and total posterior synechiæ an iridectomy is indicated more to re-establish the communication between the anterior and posterior chambers than to clear the angle, and therefore it need not be so extensive. In cases of iris bombé where iritis is still present, and in cases of cysts of the iris, transfixion is all that is necessary.

It is very doubtful if iridectomy in glaucoma following thrombosis of the central vein is justifiable, for as a rule the tension is not permanently relieved thereby. In secondary glaucoma following cataract extraction or anterior synechiæ, division of the capsule or the anterior synechiæ will often relieve the tension.

Instruments. Speculum, fixation forceps, Graefe’s knife (with a short, stiff, narrow blade), iris forceps, scissors, and spatula.

Operation. With the idea of opening up the angle of the anterior chamber by removing the iris as near its root as possible, the incision should be made somewhat further back behind the corneo-sclerotic junction than in cataract extraction. At the same time, if the incision be placed too far back the ciliary body is liable to prolapse into the wound. The old idea of opening up the canal of Schlemm by dividing it has been abandoned, as to do so would certainly result in prolapse of the ciliary body; and even if this did not happen, no good would result, since the canal would become closed subsequently by cicatricial tissue.

Although von Graefe used a keratome for making the incision, most British surgeons of the present day use a Graefe’s knife, as it gives an incision that is less shelving and more irregular, thus predisposing to the formation of a filtrating scar; a good conjunctival flap is obtained with it and there is less risk of wounding the lens.

When performing the iridectomy it is practically impossible to cut the iris with scissors at its attachment to the ciliary body, and it is better to rely on tearing it off from the ciliary body, as it is in this situation that the iris is thinnest and most likely to give way, provided it has not become atrophic by prolonged contact with the cornea.

In acute cases and in cases of secondary glaucoma where there are many adhesions a general anæsthetic is desirable.

First step. The incision. The position of the surgeon is as for cataract extraction. The eye is fixed by grasping the conjunctiva close to the limbus downwards and inwards. If the patient be under an anæsthetic, two pairs of fixation forceps should be used, one being held by an assistant. Occasionally in glaucoma the conjunctiva tears very easily, and in these cases scleral forceps are of use, or, if the knife be already in the eye, grasping the insertion of the superior or inferior rectus. The Graefe’s knife should be directed downwards and inwards towards the point of fixation, the point being passed through the sclerotic 1.5 mm. behind the limbus to the outer side. Directly the anterior chamber is entered, the handle is depressed towards the patient’s chin. The knife-point is kept superficial to the iris and is passed very slowly across the anterior chamber, close to its periphery until the position of the counter-puncture is reached. The counter-puncture should be situated about 1 mm. behind the limbus in a direct line with the original puncture. Care must be taken in making the counter-puncture that the knife-point does not slip back on the sclerotic and so emerge further back in the eye than is desired. The knife is then made to cut out upwards and a good conjunctival flap is obtained. The incision should be carried out slowly, so that the aqueous escapes gradually, as sudden reduction in the intra-ocular tension is liable to lead to intra-ocular hæmorrhage.

Iridectomy for Glaucoma Fig. 114. Iridectomy for Glaucoma. Showing the position in which the iris should be grasped with forceps.
    
Iridectomy for Glaucoma Fig. 115. Iridectomy for Glaucoma. Showing the irido-dialysis produced before division.
Iridectomy for Glaucoma Fig. 116. Iridectomy for Glaucoma. Division of the iris to form the inner angle of the coloboma. The iris is pulled out as far as possible before removal.

Second step. The iridectomy. The iris forceps are inserted closed into the anterior chamber, opened, and made to grasp the iris near the periphery (Fig. 114) towards the side of the wound on which the iris is first to be divided; then with a slight side-to-side movement of the forceps the iris is withdrawn from the wound until its peripheral attachment to the ciliary body, near where it is held by the forceps, is felt or seen to give way (irido-dialysis) (Fig. 115). The iris is then drawn a little further out from the wound, and one side of the dialysis is divided with the scissors as near the scleral wound as possible. The iris held in the forceps is then pulled over to the other angle of the wound, and as much of it as possible is pulled out and divided close to the scleral incision (Fig. 116). The angles of the incision are freed from iris by means of the spatula and the conjunctival flap is replaced in position. Both eyes are then bandaged.

After-treatment. The patient should be kept in bed for a week, and during the first four days should not be allowed to raise the head from the pillow. After that time the eye not operated upon may be uncovered; eserine should have been instilled into it before the operation and at subsequent dressings to prevent the possible onset of glaucoma owing to the dilatation of the pupil which follows the application of the bandage to the eye. It is not necessary to use any mydriatic or myotic for the eye which has been operated upon.

Complications. These may be immediate or remote.

Immediate. 1. In passing a Graefe’s knife into the anterior chamber to make the section, care must be taken that the cutting edge is directed upwards. If by accident it should be inserted with the cutting edge directed downwards the knife should be withdrawn and the operation postponed for a day or two until the anterior chamber has re-formed.

Care must be taken that the cutting edge is kept on the same plane as the upper edge of the back of the knife, otherwise the incision is liable to pass further back than is intended.

2. Splitting the cornea. The anterior chamber often being little more than a potential space, the knife may be passed between the lamellæ of the cornea and may not enter the anterior chamber at all. The indication that the knife-point is not in the anterior chamber is that there is no diminished resistance, such as is usually felt when the knife enters the chamber; if its point be slightly depressed, the cornea will be seen to dimple in over the position of it, showing that the point is not free in the anterior chamber.

3. Locking of the knife. This is due to the fact that the puncture and counter-puncture are not made in the same plane, the knife being twisted. It is much more liable to occur if a knife be chosen with a blade which is not sufficiently stiff. As a rule the blade can be made to cut out, but failing this, the knife should be withdrawn sufficiently to allow a fresh counter-puncture to be made, or else withdrawn altogether and the operation postponed.

4. Wound of the lens. The great safeguard against wounding the lens is to keep the point of the knife always superficial to the iris and in the periphery of the anterior chamber. If the lens be definitely wounded at the time of the operation it should be extracted immediately after the iridectomy. If the wound be only subsequently discovered (usually about the third or fourth day), provided the lens be not presenting in the wound, the eye should be allowed to settle down and the traumatic cataract extracted some time after the tenth day.

Glaucoma Iridectomy Fig. 117. Glaucoma Iridectomy. Failure to relieve the tension owing to displacement of the lens.

5. Presentation of the lens in its capsule. The lens may present in its capsule at the time of the operation or be found subsequently on the dressings. In the latter instance it is very liable to carry iris into the wound, and a cystoid cicatrix results. This accident is usually due to increased tension in the vitreous chamber; a large incision, especially if placed rather far back in the sclerotic, will also favour its occurrence. If the accident should happen to one eye, and acute glaucoma be present in the other, it is advisable to do a posterior scleral puncture before the iridectomy is performed. Partial dislocation of the lens forward may occur after the wound has healed, leaving the tension of the eye not reduced. This is a condition extremely difficult to recognize, and it is usually only discovered pathologically; if recognized clinically, extraction of the lens should be performed (Fig. 117).

6. Intra-ocular hæmorrhage. Hæmorrhage into the anterior chamber occurs at the time of the operation and is readily absorbed; occasionally it may persist for a considerable time in cases of glaucoma of long standing.

After the operation hæmorrhage may also occur from the cut margin of the iris, which never heals, viz. never becomes covered with endothelium. The hæmorrhage may occur as late as two weeks after the operation and may recur from time to time; it is especially liable to occur in old people with arterio-sclerosis. It is usually absorbed without giving rise to any trouble beyond delay in the convalescence.

Retinal hæmorrhages are frequent and usually small, but a considerable hæmorrhage may take place into the vitreous. As a rule these clear up satisfactorily unless the macular region be involved.

Subchoroidal hæmorrhage. Of all the immediate complications which follow an intra-ocular operation this is by far the worst. The hæmorrhage is due to the giving way of a large choroidal vessel following the sudden reduction of tension, with the result that the choroid and retina are stripped up from the sclerotic, and, with the lens, may be partially extruded from the wound in the globe, from which the hæmorrhage then proceeds. It may occur whilst the patient is still on the operating table, or it may be discovered only after he has been put back to bed, the blood being seen coming through the dressings. Patients who have this condition complain of pain in the ‘corner of the eye’ at the time of the operation. The treatment consists in evisceration or enucleation. It is probable that limited extravasation of blood may also occur, which need not end in disintegration of the eye, but may cause vitreous opacity and defective vision for some weeks after the operation.

Remote. 1. The tension is not reduced by the iridectomy. In acute cases the prognosis with regard to the reduction of the tension and the improvement of vision is very satisfactory. The same cannot be said of chronic cases, especially those which have been operated on rather late in the disease. If iridectomy, which may be repeated downwards or extended from the previous coloboma, fail to reduce the tension, one or more of the following measures should be adopted:—

(a) The use of eserine.

(b) Sclerotomy.

(c) Cyclo-dialysis.

(d) Sclerectomy.

(e) Post-scleral puncture.

It is probably in this order that they should be tried.

2. Prolapse of the iris and irido-cyclitis should be treated as already indicated under cataract extraction (see p. 208).

3. The onset of glaucoma in the other eye may be induced by the dilatation of the pupil caused by bandaging, and is best avoided by the use of eserine. If it should occur, an iridectomy should be performed.

4. Astigmatism produced by the incision is corrected with glasses. This astigmatism is very marked, often amounting to six or eight diopters or more.

IRIDECTOMY FOR SMALL GROWTHS OF THE IRIS

Indications. This is performed—

(i)As a diagnostic measure.
(ii)As a curative measure.

In the latter instance it is obvious that the growth must be very small and situated at the free margin of the iris to yield a satisfactory result, especially if it be of a malignant character.

Operation. The operation is performed under cocaine, eserine having been previously instilled in order to contract the pupil.

First step. An incision should be made with a narrow Graefe’s knife in the limbus in a position most suitable for removing the growth. The incision should be as large as possible so as to avoid wiping off any portions of the growth into the anterior chamber.

Second step. The iris should be seized well in the periphery so as to avoid breaking up the growth; it is then withdrawn with the growth, and the latter removed.

IRIDECTOMY FOR PROLAPSE OF THE IRIS

This operation is usually performed for prolapse of the iris following a wound of the cornea or limbus, and may be attempted up to about the third day after the original injury.

Operation. A general anæsthetic is usually desirable. The prolapsed iris should be seized with the forceps and withdrawn from the wound. A second pair of forceps is used to take a fresh hold on the iris, which can usually be drawn out further (Fig. 118). It is then divided as close to the corneal wound as possible. The iris usually flies back into the anterior chamber clear of the corneal wound by its own elasticity, but if it does not do so it should be freed with a spatula. The pupil should be kept subsequently under atropine.

Prolapse of the Iris through a Punctured Wound of the Cornea Fig. 118. Prolapse of the Iris through a Punctured Wound of the Cornea. Method of withdrawing the iris by two pairs of iris forceps before removal.
TRANSFIXION OF THE IRIS

Indications. This operation is undertaken in cases of iris bombé when iritis is still present and when an iridectomy would subsequently lead to a drawn-up pupil. It is also of service to evacuate the contents of cysts of the iris (local iris bombé).

Instruments. Speculum, fixation forceps, Graefe’s knife (narrow).

Operation. The knife is entered at the limbus from the outer side directly opposite the occluded pupil. The apex of the iris bombé is transfixed and the point of the knife made to appear above the pupillary area; the iris bombé on the other side of the pupil is then transfixed and the knife is withdrawn.

THE DIVISION OF ANTERIOR SYNECHIÆ

Indications. Anterior synechiæ rarely require division unless they are likely to cause tension or the adherent iris is considered a source of danger to the eye on account of its liability to septic infection. If the synechiæ are causing tension, the method of division described under sclerotomy is probably the most satisfactory; otherwise the following method devised by Lang can be used.

Instruments. Speculum, fixation forceps, Lang’s knives—one with a sharp point, and one blunt.

Operation. Under cocaine. The incision is made at the limbus in a favourable situation for the division of the synechia. The sharp-pointed knife is introduced into the anterior chamber and then rapidly withdrawn so as not to lose the aqueous. The blunt knife is then inserted through the incision and, partly by cutting and partly by tearing, the synechia is divided in a direction from the periphery towards the pupil.

The operation is not at all easy to perform, since the iris gives before the knife. Great care should be taken to avoid evacuating the aqueous, as the operation is thereby rendered much more difficult or even impossible.


CHAPTER IV

OPERATIONS UPON THE SCLEROTIC

ANTERIOR SCLEROTOMY

Indications. Sclerotomy is an operation undertaken for the relief of increased intra-ocular tension. It is performed—

(i) Usually as a secondary operation when iridectomy has failed.

(ii) As a primary operation for the division of anterior synechiæ causing tension.

A few surgeons prefer the operation to iridectomy, especially in cases of bup[h]thalmos. When practised after an iridectomy which has been done upwards, the sclerotomy is sometimes performed in a downward direction; otherwise the section is usually made upwards. The intra-ocular tension is probably relieved by the formation of a filtration cicatrix, and it is therefore probable that it may be largely superseded by the operations of cyclo-dialysis and sclerectomy.

When performed for the division of anterior synechiæ the position of the incision should be planned according to the situation of the synechia to be divided.

Instruments. Speculum, fixation forceps, Graefe’s knife with a narrow blade.

Operation. The operation is done under cocaine. Eserine should have been previously instilled in order to contract the pupil and prevent prolapse of the iris.

Graefe’s knife should be passed across the anterior chamber in the same manner and position as for a glaucoma iridectomy (see p. 221). In the complete method the knife is made to cut out through the sclerotic, leaving a band of conjunctiva to hold the flap in position. In the incomplete method a band of sclerotic is left in the periphery. If the operation is done in a downward direction, it is better for the surgeon to stand on the opposite side of the patient to the eye on which the operation is to be performed, operating across the patient.

Complications. Any of the complications which follow an iridectomy for glaucoma may occur (see p. 222). Prolapse of the iris is probably the most frequent.

CYCLO-DIALYSIS

Indications. This operation has only recently come into general use in this country, so that statistical results have at present by no means been worked out, but most satisfactory results have been obtained from it in individual cases; according to German authorities about 30 per cent. are permanently cured. Although at present its performance is largely limited to blind eyes and to eyes that have undergone previous operations for glaucoma, it is probable that it may come into further use as a primary operation in the treatment of chronic glaucoma and bup[h]thalmos. It is also of service in cases of dislocation of the lens backwards, associated with increased tension, where iridectomy would certainly be followed by loss of the vitreous.

Cyclo-dialysis Operation Fig. 119. Cyclo-dialysis Operation. Showing the method of commencing the incision in the sclerotic; it is subsequently deepened with the point of the knife. The dotted lines mark the incision for turning forward the conjunctival flap.

The operation has for its object the separation of the ligamentum pectinatum from its attachment to the sclerotic, with the probable result that the ciliary body and iris root become retracted by the ciliary muscle, so that the canal of Schlemm is opened up and again communicates with the anterior chamber. It also opens up a free communication between the anterior chamber and the suprachoroidal lymph-spaces. The reduction of tension is often not fully manifest for about ten days after the operation.

Instruments. Speculum, fixation forceps, Graefe’s knife, fine pair of straight iris forceps, fine pair of sharp-pointed straight scissors, iris spatula.

Operation. The operation is best performed under a general anæsthetic, as it is attended with considerable pain, although cocaine and adrenalin are frequently used and are always advisable, since the hæmorrhage from the scleral vessels renders it difficult to gauge the depth of the wound in the sclerotic.

First step. By means of the straight iris forceps and sharp-pointed scissors a semilunar conjunctival flap is first raised over the site for the scleral incision. The incision in the sclerotic should be situated about 5 mm. behind the corneo-sclerotic junction over the ciliary region, the outer and upper quadrant of the eye being the easiest position for subsequent manipulation (Fig. 119).

Second step. With a Graefe’s knife the fibres of the sclerotic are carefully divided in an oblique direction forward until the suprachoroidal lymph-space is opened for about 3 mm. The first part of the incision is performed with the blade and completed with the point of the knife, the anterior flap of sclerotic being held forward by straight iris forceps. Heine uses a keratome, dividing the fibres of the sclerotic with the point by stroking it along the line of the incision. The depth of the incision should be carefully gauged from time to time with the iris spatula; the pigment of the ciliary body is usually seen in the bottom of the wound when the sclerotic has been penetrated.

Cyclo-dialysis Operation Fig. 120. Cyclo-dialysis Operation. Showing the spatula separating the ciliary body and ligamentum pectinatum from the sclerotic.

Third step. The iris spatula is directed forwards and inserted between the sclerotic and the ciliary body, keeping close to the former. With a gentle side-to-side movement the spatula is made to separate the ciliary body from the sclerotic for about one-eighth of its whole circumference; then the ligamentum pectinatum is detached from the sclerotic for about the same distance by gently passing the spatula forwards and making the latter appear in the anterior chamber (Fig. 120). If it be desired to evacuate the anterior chamber, the spatula is slightly rotated so as to allow the escape of the aqueous. As a rule this is not necessary or even advisable. The spatula is then withdrawn and the conjunctival flap is replaced in position. Eserine should be instilled.

Complications. (1) Unless the incision be carried carefully through the sclerotic, or the manipulations with the iris spatula be very gentle, loss of vitreous is liable to take place. As a rule, this, if not great, is of little consequence. (2) In passing the iris spatula forward to separate the ligamentum pectinatum the point may pass between the layers of the cornea; this is recognized in the resistance offered to the side-to-side movement of the spatula, which should be withdrawn slightly and the point depressed so as to engage the ligamentum pectinatum. (3) Subchoroidal hæmorrhage has been known to occur after the operation.

SCLERECTOMY

The object of the operation is the production of a filtration cicatrix free from iris tissue for the relief of intra-ocular tension in chronic glaucoma.

Instruments. As for glaucoma iridectomy, with the addition of a small curved pair of scissors.

Operation. Under cocaine.

First step. The incision is performed as for glaucoma iridectomy (see p. 221), except that the incision should be rather smaller and should be carried more obliquely through the sclerotic, so that a long scleral flap is obtained. A large conjunctival flap is very essential to cover the wound.

Second step. An iridectomy is usually performed as for glaucoma; this may be omitted.

Third step. After all the bleeding has ceased, the conjunctival flap is turned forwards on to the cornea so as to expose the scleral flap; with small curved scissors made for the purpose, an elliptical portion is removed from the sclerotic by a single snip (Figs. 121 and 122), and the conjunctival flap is replaced in position. As a result, a hole is made into the anterior chamber, which thus communicates with the subconjunctival tissue, which is bulged forwards in the form of a clear vesicle by the escaping aqueous when the wound has healed.

Lagrange Operation
For the Production of a Cystoid Scar in Chronic Glaucoma. Fig. 121. Lagrange Operation For the Production of a Cystoid Scar in Chronic Glaucoma. Showing the method of removing a piece of the sclerotic.
    
Lagrange Operation For Chronic Glaucoma Fig. 122. Lagrange Operation For Chronic Glaucoma. Showing the piece of sclerotic removed by the scissors (black lines).

The immediate results of this operation are satisfactory provided that enough sclerotic be removed to produce a filtration cicatrix. As yet sufficient time has not elapsed for any statistical results to be obtained, but the cases in which the operation has been performed are reported as satisfactory.

POSTERIOR SCLEROTOMY

Indications. Posterior scleral puncture is performed—

(i) For the relief of tension, the indications for which have already been described under the indications for iridectomy in glaucoma (see p. 218).

(ii) For the evacuation of fluid behind a detached retina.

The operation in the latter instance, although not yielding very satisfactory results with regard to the reattachment of the retina, may be carried out with some hope of success in certain cases. Before performing the operation the pathological cause of the detachment should be carefully investigated, for it is obvious that it would be useless to perform the operation in a case of detachment due to a choroidal tumour or if definite bands of fibrous tissue could be seen in the vitreous pulling off the retina. Undoubtedly it should be undertaken as soon as possible after the detachment has occurred and the puncture should enter the space filled with subretinal fluid. Whether the puncture should penetrate the overlying retina is still a disputed point.

After the operation a pressure bandage should be applied and the patient should be kept on his back and not allowed to raise his head from the pillow for at least three weeks. This latter part of the treatment is most essential; indeed as good results may be obtained with complete rest as by performing scleral puncture. Unfortunately, recurrence is very liable to take place whichever method be used, even if reattachment of the retina be obtained.

Instruments. Speculum, fixation forceps, Graefe’s knife.

Operation. Under cocaine. If no special position be indicated the puncture is best made upwards and inwards. The patient is made to look outwards and downwards. The conjunctiva over the sclerotic, well behind the ciliary body, is drawn down so that when released it shall form a valvular opening to the scleral wound. The Graefe’s knife is driven through the conjunctiva and sclerotic, the incision being made antero-posteriorly in the direction of the fibres of the sclerotic to avoid wounding the choroidal vessels. It is probably better to enlarge the wound when withdrawing the knife than to turn the latter at right angles before it is withdrawn, as has been recommended by some surgeons. A bead of vitreous usually escapes under the conjunctiva. If the tension be not lowered, gentle massage of the globe through the lid should be employed.

PARACENTESIS OF THE ANTERIOR CHAMBER

Indications. Evacuation of the contents of the anterior chamber is performed for several conditions:—

(i) To reduce the tension of the eye when due to an altered consistency of the aqueous, as for instance in cyclitis.

(ii) To evacuate pus from the anterior chamber following metastatic infection.

(iii) To evacuate the anterior chamber in bad corneal ulceration, especially when associated with hypopyon and tension.

(iv) To examine the aqueous for organisms in cases of cyclitis following operation or of metastatic origin.

(v) To evacuate soft lens matter (see p. 194).

Hollow
Needle Used for Paracentesis Of the Anterior Chamber Fig. 123. Hollow Needle Used for Paracentesis Of the Anterior Chamber. This is used when it is desired to examine the aqueous bacteriologically. Care should be taken to see that the cutting blade is sufficiently wide to take the shaft of the needle.

The operation is usually performed through an incision directly behind the limbus. In the case of corneal ulceration it is sometimes performed by dividing the base of the ulcer with a Graefe’s knife (Sämisch’s section). When collecting the aqueous for bacteriological examination, a sterile hollow needle with a point similar to a discission needle, attached to a hypodermic syringe, should be passed into the anterior chamber at the limbus and the fluid withdrawn into the syringe by an assistant (Fig. 123). The spot through which the needle is passed is first touched with the electro-cautery to ensure asepsis.

Instruments. Speculum, fixation forceps, bent broad needle, iris spatula.

Operation. Under cocaine. The puncture is usually made upwards and outwards unless there be some other special indication for its position, such as a mass of pus in the lower angle of the anterior chamber. The eye is fixed opposite the spot at which the puncture is to be made, and the bent broad needle is passed into the anterior chamber through an incision directly behind the limbus. The needle is then withdrawn and is usually followed by a rush of aqueous. The remainder of the aqueous is then evacuated by pressing the lower margin of the wound with an iris spatula. In some cases where a very tenacious hypopyon is present it may be withdrawn with the iris forceps. The only complication liable to occur is prolapse of the iris into the wound, which should be replaced with the spatula, or failing that, removed.

OPERATIONS FOR PENETRATING WOUNDS OF THE GLOBE

Indications. Of all the conditions which a surgeon is called upon to see, penetrating wounds of the globe may present the most difficult problems as to treatment. The most important factors in their treatment and prognosis are—

1. The time at which the patient presents himself for treatment and the condition of the wound are all-important in the prognosis. Thus in the case of a wound which is obviously septic and going to terminate in panophthalmitis the eye should be eviscerated.

2. The position and extent of the wound. Formerly it was taught that if the ciliary body were wounded the eye should be excised. The reason for this was that these injuries were so frequently followed by sympathetic ophthalmia owing to prolapse of the iris and ciliary body. It is now generally recognized that sympathetic ophthalmia only follows if the wound becomes septic, irido-cyclitis with keratitis punctata being present, and it is only after the latter symptom manifests itself that the eye should be excised, provided that the wound be not so extensive as to preclude all chance of recovery from the outset.

In wounds of the sclerotic all portions of the uveal tract and vitreous which prolapse should be removed, and the wound closed with sutures passed through the superficial episcleral tissue. Unless the wound be small the prognosis is not good, as it is liable to be followed by irido-cyclitis, or, if this does not occur, detachment of the retina may ensue, following on organization of the exudates in the vitreous.

Wounds of the cornea usually result in prolapse of the iris, which should be removed in the manner described under iridectomy (see p. 208).

3. If the lens be injured. Unless the wound amounts to little more than a punctured wound of the globe involving the lens, the prognosis is bad. The wound in the lens capsule and the breaking up of the lens mean the presence of soft matter in the anterior chamber—a condition which favours sepsis and is liable to produce increased tension from blocking the angle of the chamber. In patients under thirty the pupil should be dilated with atropine and the lens allowed to absorb—assisted at a later date by needling, when the eye has entirely settled down after the original injury. If the patient be over thirty it is often extremely difficult to decide whether extraction of the lens should be undertaken at the time of the injury or at a later date. The results of both procedures are very unsatisfactory, and the surgeon should be guided partly by the position and extent of the wound. Given these in a fairly favourable position, it is probable that immediate extraction will give the best result.

4. If the eye contain a foreign body. Usually these are pieces of metal or glass. The following points should be investigated to determine whether the foreign body be in the eye:—

(i) The history of these accidents is usually the same. The patient is chipping with a hammer and chisel, and a piece flies off and strikes the globe. In the case of glass it is usually a mineral-water bottle which bursts.

(ii) The position and nature of the wound in the cornea and sclerotic.

(iii) The condition of the anterior chamber—whether evacuated or not.

(iv) The tension of the eye, which may be lowered.

(v) The presence of a hole in the iris.

(vi) The presence of traumatic cataract.

(vii) Whether the foreign body is visible with the ophthalmoscope or by focal illumination.

Author’s Chair for the Localization of Foreign Bodies in The Eye Fig. 124. Author’s Chair for the Localization of Foreign Bodies in The Eye by the X-rays. A is a rifle sight for centring the anode, C, on the cross wire, B, behind which the photographic plate is subsequently placed. P is the screw clamping the head-piece on to the patient’s head. Q is the screw for regulating the height of the tube and the distance from the patient. R is the screw for regulating the height of the head-piece. The inset shows the arm carrying the tube more highly magnified. E is the sliding arm carrying the tube for lateral displacement marked for stereoscopic photographs. F is the pointer for marking the position of the anode. D is the screw for clamping when in position.

(viii) The localization of the foreign body by the X-rays. The latter is the most important factor of all, since the foreign body may pass right through the globe and be embedded in the orbit.

Operative treatment. If the injury be a recent one and the foreign body a metal of magnetizable properties, it is best removed by an electro-magnet after localization by the X-rays (Fig. 124). Sideroscopes have been used, but are not so satisfactory. If the foreign body be non-magnetizable, such as a piece of copper cap or manganese steel, an attempt may be made to remove it with forceps after localization. If the foreign body be embedded in the lens it is often advisable to extract the lens together with it. If the foreign body be of glass, and it be only small, it is usually best left alone, unless capable of easy removal, e.g. if it be situated in the anterior chamber; the eye will often tolerate the presence of glass provided it be aseptic.

The eye should be removed

(i) If the wound be obviously septic.

(ii) If the wound be very large, more especially if the lens be injured.

(iii) If the foreign body be a large piece of metal and cannot be extracted.

(iv) If the eye does not settle down after one of the operations described below, especially if irido-cyclitis with keratitis punctata should have supervened.

If the injury be of long standing. It is of little use as a rule attempting to extract a foreign body from the eye after three days, unless it be loose in the vitreous or embedded in the lens, as it becomes surrounded by lymph. Under these circumstances it is better to leave it alone, or, if it be causing signs of irritation, to enucleate the eye.

ELECTRO-MAGNET OPERATIONS

Magnets for the removal of magnetizable foreign bodies from the eye are of two types—(1) a small magnet, which is inserted into the globe, (2) a giant magnet, which is used to attract the foreign body in the eye from the outside.

Small Electro-magnet for extracting Pieces of Steel from the Eye Fig. 125. Small Electro-magnet for extracting Pieces of Steel from the Eye. It is made to work direct off the electric main.

Surgeons differ as to which is the best method to employ. The statistical results of both are about the same. Many surgeons in this country, and with them the author, prefer the small magnet, especially of the recent more powerful type (Hirschberg), which runs off the main electric current, for the following reasons: it is more accurate (after localization by the X-rays), there is less trauma to the globe involved, it is more portable, and, when the foreign body is in the anterior or the posterior chamber, it is much easier to extract it with a small magnet than with a large one.

With the small magnet. Instruments. Beer’s knife, fixation forceps, magnet (Fig. 125), and suture. The points of the magnet, which are detachable, are sterilized by boiling.

Operation. The foreign body is first localized accurately by means of the X-rays. If it lies near the wound of entrance the magnet point is inserted, the electric circuit completed, and the foreign body withdrawn, the wound of entrance being enlarged if necessary. If the foreign body lies at some distance from the wound, as for instance in the vitreous, an antero-posterior incision is made in the sclerotic, as near to it as possible, by plunging the knife through the conjunctiva and the sclerotic, the former having previously been drawn to one side so as to form a valvular opening. The size of the incision should be such that it will admit the point of the magnet and allow the foreign body to come out, the size of the foreign body being judged by the X-ray photograph. After the knife has been withdrawn, the point of the electro-magnet is inserted and the circuit closed, the magnet being withdrawn with the foreign body attached to it. The conjunctival wound is closed by a suture if necessary. If the foreign body be situated in the anterior or posterior chamber or the lens, an incision should be made into the anterior chamber with a keratome, the point of the magnet inserted, and the foreign body withdrawn. In cases in which the foreign body is deeply embedded in the lens, more especially in patients over thirty years of age, extraction of the lens together with the foreign body should be performed.

Complications. Immediate. Failure to extract the foreign body may arise from—

1. The foreign body being embedded in lymph. It is therefore of the utmost importance that the operation should be performed as soon as possible after the injury.

2. The foreign body being deeply embedded in the sclerotic so that the magnet will not exert sufficient traction to withdraw it.

3. The foreign body being non-magnetic (all steel is not magnetic).

4. Too small a wound being made for its extraction, the metal being wiped off on the edges of the wound as the magnet is withdrawn.

5. Insufficient power in the magnet.

Remote. 1. Panophthalmitis, which must be treated by evisceration.

Large Electro-magnet Fig. 126. Large Electro-magnet. The current is turned on by means of the foot pedal.

2. Irido-cyclitis; if this be prolonged, and keratitis punctata appear, enucleation should be performed.

3. Traumatic cataract; this may subsequently require needling.

4. Detached retina as the result of organization in the vitreous; this may occur months after the original injury.

With the giant magnet. The foreign body should have been previously localized by the X-rays, and its position and size determined, so that it may be removed by the shortest possible route and with the least amount of injury to the eye.

Instruments. Giant magnet (Fig. 126), steel spatula. (Watches and magnetizable metal should be removed from both the patient and the surgeon.)

Operation. Under atropine and cocaine. The patient is at first seated in a chair some three feet in front of the magnet, the eyelids being held apart by the surgeon; the electric circuit is closed. The patient’s head is next gradually advanced towards the magnet. If a foreign body be present in the eye and be magnetizable, the patient will usually withdraw his head or cry out with pain, and the foreign body may be seen bulging forward the iris from the posterior chamber. From this position it may be removed by manipulating the head and eye in relation to the magnet so as to withdraw it into the anterior chamber, from whence it is removed through the entrance wound or an incision at the limbus either by the giant magnet directly applied to the wound or by magnetizing a steel spatula which is inserted into the anterior chamber and connected with the magnet by a flexible steel cable. The small magnet previously described may be used, or the foreign body removed by means of iris forceps.

A piece of steel in the vitreous always travels round the posterior surface of the lens and through the suspensory ligament, and does not injure the lens capsule.

Complications. These are similar to those described under the small magnet operation.


CHAPTER V

OPERATIONS UPON THE CORNEA AND CONJUNCTIVA

OPERATIONS UPON THE CORNEA

REMOVAL OF A FOREIGN BODY FROM THE CORNEA

Removal of a foreign body from the cornea requires a good light (focal illumination). The use of a binocular lens is also of service. Foreign bodies lodged on the surface of the cornea can be removed easily under cocaine with a spud. If the foreign body be deeply embedded in the cornea a fine sterile discission needle should be used. When a foreign body, such as a chip of iron, is deeply embedded, the needle should be inserted slightly to one side of the entrance wound and passed beneath the foreign body so as to lift it from its bed. When the foreign body has partially penetrated the anterior chamber but still lies in the cornea, an incision should be made with a keratome at the limbus and the foreign body pushed back through the entrance wound with the aid of an iris spatula. If the foreign body be iron, the electro-magnet may be of use, and in this case should be tried before resorting to an incision in the anterior chamber. A stain is left frequently after the removal of foreign bodies; this should be removed as far as possible. Subsequently the eye should be bandaged for a few days and bathed with boric lotion. Atropine should be instilled if there be any signs of infiltration around the wound.

CAUTERIZATION OF THE CORNEA

Either a chemical or the actual cautery may be used.

Indications. Corneal ulceration. The cornea being extremely dense, organisms do not penetrate very deeply into its substance, so that destruction of the bacteria is effected by cauterization of the spreading portion of an ulcer; the albumin is also coagulated and so a barrier is presented to their advance.

Operation. The eye is thoroughly cocainized, and the spreading portion of the ulcer is first defined by staining with fluorescine, washing away the excess of stain with boric lotion.

By a chemical caustic. Liquefied carbolic (carbolic acid crystals liquefied in 10 per cent. of water) is applied upon a sharpened match. Any excess should be removed so as to prevent its running on to the cornea. A speculum is inserted and the cornea is dried by blotting with cigarette paper; the stained area is lightly touched with the point of the stick, particular attention being paid to the spreading margin. A dense white plaque is the result; this usually clears up in a few days. Atropine ointment is applied daily to the conjunctival sac.

Electro-cautery Fig. 127. Electro-cautery.

By the actual cautery. The electro-cautery (Fig. 127) point should be extremely fine and only raised to a dull red heat. The stained area should be touched lightly with the point.

The actual cautery is best for serpiginous corneal ulcers, carbolic acid being more satisfactory for those of the vesicular type.

OPERATIONS FOR CONICAL CORNEA

Indications. Since the operation for conical cornea is not without serious risks, it should only be undertaken when the vision cannot be improved with glasses to 6/18; high + or - cylinders will often yield satisfactory results. The object of all forms of operation is the flattening of the cone.

Operation. This may be carried out either by excision of the apex of the cone or by cauterization.

Excision of the apex of the cone is probably the more satisfactory method, although it is somewhat more difficult to perform. The object of the operation is to remove an elliptical portion of the whole thickness of the cornea from the apex of the cone, the long axis of the ellipse being placed horizontally. It leaves the eye with only a minute scar as compared with the nebula produced by the cautery, which is often so great as to require an optical iridectomy to restore vision.

Instruments. Speculum, fixation forceps, a narrow Graefe’s knife, straight iris forceps, and scissors.

The operation is done under cocaine, atropine having been previously instilled.

First step. The apex of the cone is transfixed by the Graefe’s knife with the blade directed slightly upwards and forwards, the knife being made to cut out. The cornea in this situation is extremely thin, being often not more than 1 mm. in thickness. The length of the incision should not exceed 2 mm.

Second step. The flap of corneal tissue thus made is seized with the straight iris forceps and removed with iris scissors, producing a small elliptical opening. The chief difficulty of the operation is the seizing of the corneal flap, which is most difficult to hold; care must be taken not to injure the lens capsule with the iris forceps or scissors when the cornea has collapsed as the result of the evacuation of the anterior chamber. The eye should be firmly bandaged subsequently, and the patient kept in bed until the anterior chamber has re-formed.

Complications. Slow re-formation of the anterior chamber. The anterior chamber will often take two or three weeks to re-form, owing to the hole in the cornea not closing. During this time the eye is open to septic infection and therefore the greatest care should be taken to keep it aseptic when dressing it. For this reason and also because the following complications are due to the same cause, it is desirable to remove as little corneal tissue as possible in performing the operation. It is probable that conjunctivoplasty (see p. 245) would considerably facilitate the rapid closure of the wound.

Anterior polar cataract may result from prolonged contact of the lens with the wound in the cornea. As a rule this seldom interferes much with vision.

Anterior synechiæ from incarceration of the iris in the wound occasionally result and may require subsequent division.

Acute glaucoma is by no means an infrequent complication—indeed the author has seen four successive cases of conical cornea, operated on both by excision and by the cautery, followed by this complication. It is probably due to adhesion of the root of the iris to the back of the cornea during the time the anterior chamber is empty. It can usually be relieved by an iridectomy.

The electro-cautery operation. The operation generally adopted is known as the target operation. It consists in surrounding the apex of the cone with two rings of cautery marks, the outer made at a dull red heat, the inner with the point slightly brighter, whilst the apex is cauterized at a red heat, so that rings of different depth are obtained. Cauterization of the apex should stop just short of perforation, the inner ring being deeper than the outer. With this method secondary glaucoma and anterior synechiæ are not so liable to occur. On the other hand, an optical iridectomy has to be performed more frequently. A few surgeons still cauterize the apex of the cone until a perforation is produced. This latter operation seems to have the disadvantages of both methods and the advantages of neither.

REMOVAL OF TUMOURS INVOLVING THE CORNEA

Tumours which involve the cornea are usually secondary to tumours occurring at the limbus. The chief of these are: simple—dermoid patches, moles of the limbus; malignant—sarcoma, endothelioma, epithelioma. Dermoid patches should be shaved off as close to the cornea as possible; the white area left after their removal can be improved by tattooing.

Malignant tumours in very early stages may be removed locally with scissors and forceps, the cautery being applied to their base, since they do not tend to invade the sclerotic deeply.

TATTOOING THE CORNEA

Indications. (i) To do away with the blinding effects of light through a scar after iridectomy has been performed (see p. 215).

(ii) To simulate a pupil on a white scarred cornea.

The operation is not without risks, as it may light up old inflammation in a previously quiet eye. Panophthalmitis and sympathetic ophthalmia have both been known to follow it. The pricking of the needle may carry in epithelium and implantation dermoids may arise.

Instruments. A fine single needle is generally used, occasionally a bundle of needles (Fig. 128).

Tattooing Needles Fig. 128. Tattooing Needles.

Operation. Under cocaine. Chinese ink, sterilized and prepared by rubbing up with 1–6,000 perchloride of mercury, is smeared over the area to be tattooed. Multiple punctures in an oblique direction are then made into the cornea over the area desired. More paste is then rubbed in over this area. The cornea should be intensely black after the operation, as a certain amount of the ink is carried away by phagocytosis and shedding of the epithelium. Subsequent reaction may be reduced by means of an iced compress. Atropine should be instilled.

SCRAPING CALCAREOUS FILMS

Calcareous films, when not associated with active irido-cyclitis, may be removed with advantage to the vision. Care should be taken to see that no keratitis punctata is present before the operation is undertaken.

Instruments. Speculum, fixation forceps, a spoon which should have rather a blunt edge.

Operation. Under cocaine. The area is very lightly scraped with the spoon. The calcareous changes are in the deeper layers of the epithelium and Bowman’s membrane and hence are easily removed. The scraping should be carried well beyond the apparent margin of the film. The epithelium often takes some time to regenerate. As a rule the results are satisfactory, although the film is apt to recur in the course of years, but it may be removed again if necessary.

OPERATIONS UPON THE CONJUNCTIVA

THE REMOVAL OF FOREIGN BODIES

Foreign bodies lodged in the conjunctival sac, unless embedded in the conjunctiva, are usually found by the surgeon under the upper lid, the sulcus subtarsalis being a favourite situation. They are easily removed with a spud or needle, after the instillation of a drop of 4% cocaine solution. Subsequently the eye should be bandaged for a few hours until the effect of the cocaine has passed off, as in wiping the eye the patient may wipe off the epithelium of the cornea whilst it is insensitive from the cocaine.

In order to evert the upper lid the patient is made to look strongly down, the eyelashes are seized between the thumb and forefinger of the left hand, the skin of the upper lid is pushed down above the tarsal cartilage with the thumb of the right hand, and the lid is everted by pulling it upwards against the point of the thumb.

OPERATION FOR PTERYGIUM

Indications. Pterygium should be removed when advancing across the cornea, especially when the pupillary area is becoming involved. The operation of ablation is the one now generally in use.

Instruments. Speculum, straight iris forceps, small sharp-pointed scissors.

Operation. Under adrenalin and cocaine the neck of the pterygium is seized with the forceps and the body and neck are carefully dissected from the conjunctiva. The body and neck should be very carefully separated right up to the corneal margin by means of forceps and scissors. The head is then stripped off the cornea with a sharp pull. The wound in the conjunctiva should be subsequently closed with fine sutures, otherwise the disease will certainly recur. In stripping the head from the cornea some of the epithelium may be torn off with it. This usually regenerates without impairing the vision.

EXPRESSION

This is an operation for the removal of follicular formations in the conjunctiva, and is used more especially in trachoma.

Instruments. Graddy’s forceps (Fig. 129), fixation forceps.

Graddy’s Forceps Fig. 129. Graddy’s Forceps.

Operation. The operation may be performed under cocaine and adrenalin, a little solid cocaine being rubbed into the area to be expressed. In severe cases in which both eyes are affected, and in small children, a general anæsthetic may be necessary.

Although a number of instruments are in use, perhaps the best, and certainly the least painful, is Graddy’s forceps. In the case of the upper lid it is everted, one blade of the forceps being passed into the fornix, the other being placed over the upper surface of the everted lid. A gentle steady pressure is applied, and the lid is drawn out between the blades. In this way as much of the conjunctiva is gone over as is necessary. The lower fornix is best expressed by picking up the loose fold of the fornix with ordinary forceps and then expressing with Graddy’s.

If only one or two follicles be present they can be picked up with the ordinary fine dissecting forceps and expressed, but when situated on the tarsus the follicles are best enucleated with a spud; a solution of 1 in 50 perchloride of mercury in glycerine is then rubbed into the conjunctiva. The operation may have to be repeated several times as new follicles form.

CONJUNCTIVOPLASTY

Conjunctivoplasty is an operation for the transplantation of a flap of conjunctiva to cover some loss of substance or defect in the continuity of the globe.

Indications. The operation may be necessary—

(i) To close large recent wounds of the cornea.

(ii) To close the wound made by the excision of a cystoid scar.

(iii) To facilitate the healing of a clean ulcer such as Mooren’s ulcer, or to cover the aperture made by an ulcer that has perforated.

(iv) In the treatment of conical cornea by excision of the apex of the cone, it might facilitate the rapid closure of the wound and assist in flattening of the cornea.

Operation. First method. Under cocaine. A flap of conjunctiva is raised from around the limbus, having its base as near the area to be covered as possible; its breadth should be one and a half times the width of the area to be covered. This flap is drawn across the defect in the cornea and stitched to the conjunctiva on the other side; the wound made in raising the flap should be allowed to heal by granulation.

The stitches holding the flap in position cut through in two or three days, but by that time their purpose will have been served. If the flap be still adherent to the wound its base may be divided and any superfluous tissue removed; the remainder will disappear rapidly.

Second method. The conjunctiva is dissected up all round the cornea as close to the limbus as possible, and backwards as far as the insertion of the recti. A purse-string suture is then inserted around its margins and drawn tight so that the whole cornea is covered by conjunctiva. The operation is suitable for cases in which large areas have to be covered.

REMOVAL OF TARSAL CYSTS

The Meibomian glands being embedded in the tarsal plate, cysts in them present both on the conjunctival surface and towards the skin, but the contents are always evacuated from the former.

Instruments. Walton’s iris knife, sharp spoon.

Operation. Under adrenalin and cocaine. The eyelid is everted and a drop of the solution is injected into the cyst with a hypodermic syringe. A vertical stab is made into the cyst with the knife and the contents are then evacuated with a sharp spoon.

Difficulty may arise in fixing the cyst whilst making the incision; this is best obviated by holding the everted lid between the finger and thumb.

In some cases, when the cyst has persisted for a considerable time, the sac-wall becomes so thickened that it has to be dissected out before the mass in the lid will disappear.


CHAPTER VI

OPERATIONS UPON THE EXTRA-OCULAR MUSCLES

SQUINT OPERATIONS

Indications. Operations upon eyes with concomitant squint are undertaken for two purposes:—

(i) For cosmetic reasons, to remedy a deformity due to a squinting eye which is amblyopic.

(ii) To rectify the muscular equilibrium in alternating or latent squints, so that binocular vision may be regained.

When the operation is performed for the latter reason the adjustment will naturally have to be much more accurate than for the former, so as to bring about the superimposition of the images falling on each macula. The muscular balance is interfered with by the administration of a general anæsthetic, and therefore the results cannot be gauged accurately. Thus it is desirable that operations upon the ocular muscles should be performed under local anæsthesia. This is usually possible, except in the case of very small children.

During and after the operation muscular equilibrium is tested by means of an electric light fixed to the ceiling immediately over the head of the patient (see Fig. 74). The room is darkened and the patient is made to look at the light. In a case with an amblyopic eye the reflection of the light should appear in the middle of each cornea if the eye be properly adjusted. In cases where good vision is present in both eyes the Maddox rod test should be used, the rod being placed before the eye not being operated on; the bar of light produced by the rod should pass through or within a few inches of the light if the adjustment has been performed accurately.

The tendons of the recti muscles are inserted into the globe at the following distances from the corneo-sclerotic junction: internal, 5 mm.; inferior, 6 mm.; external, 7 mm.; superior, 8 mm. Each muscle is held in place by expansions on either side of the tendon as well as by the tendinous insertions. Division of these expansions allows a greater retraction of the muscle and is, therefore, to be undertaken when a considerable degree of squint has to be overcome. On the other hand, there will be a danger that the muscle may not regain a proper attachment to the globe if division be too freely performed, and a squint in the opposite direction may result; proptosis also may be caused thereby. It is, therefore, better to combine tenotomy with advancement in high degrees of squint over twenty degrees convergent and in all cases of constant divergence. This is usually better than performing a tenotomy in the other eye, as there still remains the muscle of the other eye in reserve to tenotomize if necessary, if the advancement be insufficient to correct the squint. Further, it is much easier to rectify a muscular error by accurate tenotomy than by advancement. Division of the tendon of the internal rectus only, without its expansion, will usually rectify cases of latent convergent strabismus with a deviation of about 12° prism (Maddox test). Cases of latent divergent strabismus of about 8° prism (Maddox test) require complete division of the tendon of the external rectus, and, in some cases, of the expansion as well. Tenotomy of the superior rectus for hyperphoria should only be undertaken in bad cases; that is to say, of over 12° prism, any lateral deviation being first corrected, as occasionally the correction of the lateral deviation, especially when this is due to the faulty insertion of a muscle, will sometimes correct the hyperphoria present.

Partial tenotomies are performed by some surgeons for the correction of latent muscular errors, but the experience of most in this country is that little benefit is gained unless the tendon be completely divided. Tendon-lengthening by various methods has been performed, but has not come into general use.

After all operations upon the ocular muscles both eyes should be occluded to keep the eyes at rest whilst the muscle is gaining its fresh attachment to the globe; this usually takes about seven days, after which time both eyes should be uncovered, and if there is a tendency to convergence atropine should be used. Glasses correcting any error of refraction should be worn.

TENOTOMY

Tenotomy may be performed by (1) the open, or (2) the subconjunctival method.

Instruments. Speculum, straight blunt-pointed scissors, strabismus hook, needle and silk, needle-holder.

Operation. The operation is performed under adrenalin and cocaine.

1. By the open method. The surgeon stands on the right side facing the patient when dividing the right external or the left internal rectus, but at the head of the table when dividing the right internal or the left external rectus.

Tenotomy Fig. 130. Tenotomy. Showing the method of holding the scissors and the position of the hands.

First step. The speculum is inserted and the patient is made to look away from the muscle to be divided. The conjunctiva is freely divided vertically with scissors directly over the insertion of the tendon into the globe (see Fig. 130) and dissected backwards.

Tenotomy by the Open Method Fig. 131. Tenotomy by the Open Method. The tendon is first button-holed about its centre and the expansions are then divided upwards and downwards to the required extent.

Second step. The tendon of the muscle is then seized with fixation forceps and button-holed about its centre as close to the globe as possible (Fig. 131). The lower blade of the scissors is then passed through the hole in the tendon, and the rest of the tendon and its expansions are divided upwards and downwards to the extent required to bring the eye straight as tested by its appearance or by the Maddox rod test. The strabismus hook may be inserted, both upwards and downwards, to see that the tendon is properly divided, but all pulling on the muscle with a hook should be avoided, as it is painful and disturbs the muscular equilibrium. The conjunctiva is then brought together with a fine silk suture. If the squint be over-corrected by the tenotomy, a deep hold should be taken with the stitch so as to draw the eye back into position.

2. By the subconjunctival method. This is unsatisfactory in that accurate adjustment by division of the expansion of Tenon’s capsule is not possible. It is painful, and is sometimes followed by a troublesome hæmorrhage into the capsule of Tenon. Occasionally it may be of use in some cases of amblyopic eyes where a small wound is desirable. The conjunctiva is button-holed below the tendon, and separated from the surface of the muscle. The capsule of Tenon is then opened below the tendon, a strabismus hook is passed through the opening with its concavity against the globe, and is then rotated upwards beneath the tendon, which is subsequently divided between the hook and the globe.

Complications. These may be immediate or remote.

Immediate. 1. Hæmorrhage into the capsule of Tenon, leading to intense proptosis, only occurs when the subconjunctival method is adopted. As a rule the hæmorrhage ceases on the application of pressure, but occasionally it may be necessary to open up the wound and turn out the blood-clot.

2. Perforation of the globe has been known to occur during the division of a tendon in an obstreperous patient. It should be treated as a wound of the sclerotic (see p. 235).

3. Tenonitis very rarely occurs, but may lead to matting down of all the extra-ocular muscles and defective movements of the globe. Panophthalmitis has been known to follow this condition.

Remote. 1. Failure to correct the muscular error. If the error be large it must be rectified by tenotomy of the corresponding muscle of the other eye or by the advancement of the opposing muscle of the same eye. This should not be undertaken until five or six weeks have elapsed since the previous operation.

2. Over-correction of the muscular error at the time of the operation may be remedied by stitching the tenotomized muscle forward to the extent required to bring the eye straight. Advancement of the tenotomized muscle should be performed if the over-correction be only discovered after the operation. In cases with binocular vision lesser degrees of deviation may be corrected with prisms if they are causing symptoms, while small errors of over-correction, of about 3° prism, often disappear after the first few weeks.

3. Defective movement in the tenotomized muscle is usually present for the first week or two after the operation, but recovery usually takes place after the muscle has regained its attachment to the globe; it may persist, however, to a slight extent; this is most liable to occur after free division of the tendon and its expansion (more especially in the case of the external rectus), or because the tendon has not been divided close enough to the globe. In patients with previous binocular vision diplopia is present after the operation on turning the eyes towards the same side as the tenotomized muscle, but this usually disappears.

4. A granulation may form at the site of the tenotomy wound. It may be due to a tag hanging from the wound or to a portion of a stitch that has been imperfectly removed. It should be snipped off with scissors and the conjunctiva drawn together over its base.

5. Proptosis may result from too free a division of a tendon.

6. Retraction of the caruncle is best avoided by closing the conjunctival wound with a stitch, and thus pulling the caruncle forward.

ADVANCEMENT

Advancement is an operation undertaken to rectify a squint by forming a fresh attachment for one of the ocular muscles nearer the cornea, and at the same time shortening it. There are three main types of operation performed:—

1. The capsulo-muscular, in which the tendon, together with the attachment of the capsule of Tenon to it, is advanced.

2. The tendon only is isolated, shortened, and advanced.

3. The tendon is shortened by folding it upon itself.

The first operation is by far the most satisfactory of these, owing to the fact that a broader new insertion of the muscle is obtained, which is less likely to yield subsequently; it is the operation usually performed in this country.

The chief cause of unsatisfactory results after advancement operations is the cutting through of the sutures holding the tendon in position. The various operations, which are some fourteen in number and have mostly their respective surgeon’s name attached, differ principally in the method of insertion of these sutures. Whichever method of inserting sutures be used, the main factors which aim at preventing the stitches from cutting out are (1) that the stitches should take a good hold in the scleral and episcleral tissues on the corneal side of the wound, for the passing of which it is most essential that the needles should be sharp; (2) that complete rest of the muscles should be ensured by bandaging both eyes for the first seven days after the operation; (3) that the opposing muscle should be tenotomized so as to prevent traction on the sutures.

Of the many operations that have been devised the capsulo-muscular advancement or some modification of it is most frequently used.

Instruments. Speculum, straight scissors, fixation forceps, Prince’s advancement forceps (Fig. 132), four sharp needles and strong silk, needle-holder.

Prince’s Forceps for Advancement Fig. 132. Prince’s Forceps for Advancement. Care should be taken to see that the spring catch holds satisfactorily.

Operation. Under adrenalin and cocaine. First step. The patient is made to look away from the side on which is the muscle to be advanced, and the conjunctiva over the muscle is freely divided with scissors, by a curved incision with the convexity towards the cornea, and dissected back.

Second step. The capsule of Tenon is button-holed by a small incision well above or below the tendon. A tenotomy hook is passed beneath the tendon and its expansion and brought out through a small hole in Tenon’s capsule on the opposite side of the tendon. The smooth blade of Prince’s forceps is then inserted in place of the hook, and the tendon with its expansion is grasped between the blades. The forceps are given to an assistant, who should avoid all traction on the muscle. The eye is then rotated in the direction of the muscle to be advanced, and tenotomy of the opposing muscle is performed by the open method.

Advancement by the Three-stitch Method Fig. 133. Advancement by the Three-stitch Method. Showing the sutures in position. A firm hold on the sclerotic to the corneal side of the wound is essential to the success of the operation.

Third step. The muscle to be advanced and its expansion, which are clamped between the blades of Prince’s forceps, are separated from the globe with the scissors and given again to the assistant to hold. Three strong silk sutures are passed in the following order, middle, upper, and lower, first through the conjunctival and episcleral tissue on the corneal side of the wound and then as far back as possible through the muscle and out through the conjunctiva near the cut margin on the other side of the wound (Fig. 133). Care should be taken that the middle stitch is passed through the episcleral tissue exactly opposite the horizontal plane of the cornea and the central portion of the tendon. The portion of the tendon and capsule within the grasp of the forceps is then removed with scissors by cutting close to the blades of the Prince’s forceps, taking care not to cut the sutures.

Fourth step. The middle suture should be first tightened to the extent required to bring the eye straight. The upper and lower sutures are then tied.

If, on testing with the Maddox rod, the error be found to be slightly over-corrected by the advancement, the eye can be drawn back by taking a firm hold with the conjunctival stitch over the tenotomy wound. The conjunctival stitch may be removed on the fourth day, but the stitches holding the advanced muscle in position should not be removed till after the tenth day. Atropine in both eyes is desirable, especially when there is any tendency to convergence. Glasses should be worn on uncovering the eyes.

Complications. 1. The eyes may not be straight after the operation. No further operation for rectification should be undertaken for at least two or three months. If there be a tendency to convergence, glasses should be worn and atropine used. Small latent errors may be corrected by prisms. If the muscular error be insufficiently corrected tenotomy may be performed on the other eye. If the muscular error be over-corrected it may also require tenotomy on the other eye, the adjustment by tenotomy being more accurate than that by advancement.

2. Thickening over the site of the advanced muscle usually disappears in a few months.

Other complications as described under tenotomy may occur (see p. 250).


CHAPTER VII

ENUCLEATION OF THE GLOBE AND ALLIED OPERATIONS

The principal substitutes for simple enucleation are evisceration, Mules’s and Frost’s operations.

ENUCLEATION

Enucleation is the removal of the globe from Tenon’s capsule.

Indications. Enucleation should be performed in preference to Mules’s operation in—

(i)Malignant tumours.
(ii)Injuries followed by cyclitis.
(iii)Painful blind eyes.

In malignant tumours enucleation should only be performed when there are no signs of extra-ocular extension. If extra-ocular extension be present, evisceration of the orbit should be performed, provided there be no evidence of general metastasis. In cases of glioma of the retina it is especially desirable that the optic nerve should be cut as far back as possible and the cross-section carefully examined for gliomatous tissue, since the disease spreads to the brain along this structure.

In injuries followed by non-suppurative cyclitis enucleation or Frost’s operation is preferable to Mules’s operation, since cases have been recorded of sympathetic ophthalmia following the latter operation, and it is these cases of non-suppurative cyclitis which are especially prone to give rise to that disease.

Blind painful eyes, especially when affected with glaucoma, are best removed, as occasionally the underlying cause, when not known, may prove to be an intra-ocular growth.

Instruments. Speculum, fixation forceps (two pairs), straight scissors, strabismus hook, strong curved scissors.

Operation. Before the anæsthetic is administered the forehead should be marked over the eye to be enucleated, so as to guard against the accident of removing the wrong eye. It is usual, at any rate in the case of hospital patients, to get their written consent for the operation.

First step. The speculum is inserted. In the case of the right eye the conjunctiva is seized with the fixation forceps downwards and outwards, or in the case of the left eye, downwards and inwards. The straight scissors being held with the right thumb and ring finger, the conjunctiva is divided freely all the way round, as close as possible to the cornea, and dissected back.

Second step. The capsule of Tenon is opened below the external rectus by grasping it with forceps and buttonholing it with the scissors. The strabismus hook is passed through the opening made in Tenon’s capsule with its concavity against the globe, turned upwards beneath the tendon, and the latter is pulled well forward and freely divided from above downwards between the hook and the globe. The superior and inferior recti are treated in a similar manner. In dividing the internal rectus a small portion should be left attached to the globe, so that subsequently it can be grasped with forceps to rotate the globe outwards when dividing the optic nerve.

Third step. The globe is dislocated between the lids by opening the speculum widely and pressing it backwards. If the globe will not dislocate, it is either because the tendons are imperfectly divided, or the palpebral aperture is too small to allow of its delivery; the latter is liable to be the case in small children or in those with a staphylomatous globe. In such cases the palpebral fissure should be enlarged by dividing the outer canthus.

The fourth step is the division of the optic nerve. The globe is rotated strongly outwards, either by pulling on the tendon of the internal rectus or by pulling the globe outwards with the finger; the optic nerve is felt for by passing the strong curved scissors behind the globe. When the nerve is defined the blades are opened widely, pressed backwards, and the nerve divided. The globe is then pulled forward with the finger, and the oblique muscles and remaining attachments divided. Hæmorrhage is easily controlled by pressure and the use of adrenalin.

Enucleation Fig. 134. Enucleation. Method of suturing the conjunctiva; the suture requires no knot.

Fifth step. When the bleeding has ceased, the conjunctival wound is united in a horizontal direction by means of a thick silk suture running over and over; no knot is required and the ends are left long, so that it may subsequently be removed easily (Fig. 134). The usual dressings are applied with a firm pressure bandage for the first six hours. The suture should be removed at the end of the seventh day. No artificial eye should be worn for at least six weeks after the operation, and then only for a few hours at a time until the conjunctiva becomes accustomed to it. It should always be taken out at night.

Complications. These may be immediate or remote.

Immediate. Cutting into the globe. This may occur during the division of the optic nerve, and is usually due to imperfect dislocation of the globe. Although of little consequence as a rule, it may be extremely serious, as for instance in the case of an intra-ocular growth, when it is conceivable that a portion of it might be left behind. If this accident should happen, the portion of the sclerotic and choroid left behind should be carefully sought for and removed.

Adhesion of Tenon’s capsule. Eyes that have been the subject of acute inflammation are much more difficult to enucleate, owing to adhesion of the surfaces of Tenon’s capsule. In these cases the globe has practically to be dissected out of that structure.

Remote. Hæmorrhage into the stump may occur, leading to proptosis of the conjunctiva and extravasation into the eyelids and beneath the skin of the face. The use of a firm pressure bandage and the omission of the suture is usually sufficient to prevent this occurring, but the blood-clot may have to be turned out and the bleeding point sought for and ligatured.

Granulations and polypi in the socket are usually the result of leaving some tag of tissue between the margins of the wound, and are therefore more likely to occur when no suture is used to close the wound. They should be removed with forceps and scissors.

Polypoid masses sometimes form in a socket as the result of an imperfect artificial eye causing an œdematous condition of the conjunctiva. They should not be removed, owing to the contraction caused thereby, but the artificial eye should be left out, when they will often disappear.

Contracted socket is usually the result of an imperfectly performed enucleation or loss of large portions of the conjunctiva; for the operations for its relief, see p. 261.

EVISCERATION

Evisceration is the removal of the intra-ocular contents.

Indications. It is the ideal operation for a suppurating globe; in these cases enucleation is contra-indicated because the lymph-space round the optic nerve is opened up by the division of the latter and the inflammation may spread directly to the meninges.

Instruments. Speculum, fixation forceps, Beer’s knife, scissors, scoop and stitches.

Operation. A general anæsthetic is necessary.

First step. The eye is transfixed about 4 mm. behind the corneo-sclerotic junction with a Beer’s knife, which is made to cut out upwards (Fig. 135). The flap of corneal and scleral tissue is then seized with forceps and the cornea removed entirely by completing the incision in the sclerotic round it with scissors (Fig. 136).

Mules’s Operation Fig. 135. Mules’s Operation.
First step. Excision of the cornea.
    
Mules’s Operation Fig. 136. Mules’s Operation. The completion of the excision of the cornea with scissors.

Second step. The contents of the globe are then eviscerated by means of a spoon, and the cavity flushed out with 1 in 4,000 perchloride of mercury lotion. Great care should be taken to remove all portions of the uveal tract; this is best ensured by visual inspection after the hæmorrhage has ceased. The interior of the sclerotic should appear perfectly white.

Third step. Although not absolutely necessary, and inadvisable in the case of a septic globe, a single suture may be passed through the centre of the wound in the conjunctiva and sclerotic.

Complications. As the operation is not infrequently performed for panophthalmitis, much swelling of the lids and discharge from the socket may take place after the operation; these symptoms usually subside in the course of a few weeks without further trouble. The interval which must elapse before an artificial eye can be worn is considerably longer than after enucleation.

MULES’S OPERATION

Mules’s operation is the insertion of a celluloid globe into the sclerotic after evisceration, followed by closure of the scleral wound over it. In both this and Frost’s operation a better stump is formed, so that more movement may be obtained in the artificial eye which is subsequently worn over the inserted globe.

Indications. (i) The operation is especially suitable for anterior staphyloma following ophthalmia neonatorum. In young children the presence of the ball in the orbit assists the development of that structure.

(ii) It is also suitable for large, recently made, fairly aseptic wounds in the globe.

Operation. The first two steps are the same as for evisceration.

Third step. A glass or, better, a celluloid or gold-plated ball is inserted into the sclerotic, which is closed over it by two rows of interrupted sutures, one of catgut passing through the sclerotic, the other of silk closing over the conjunctival wound. To facilitate the closure of the conjunctival wound it is advisable to dissect the conjunctiva back from the limbus before excising the cornea. The ball inserted in the sclerotic should fit the cavity loosely.

Complications. In about 17% of the cases the ball is not retained; this is not infrequently due to too large a size being used, or to the wound being imperfectly closed by the sutures. If two rows be used, as described above, extrusion of the ball is far less frequent than if one only be inserted. If the globe be extruded the patient is in the same position as if he had had evisceration performed.

FROST’S OPERATION

In this operation the eye is enucleated, a celluloid globe is inserted into Tenon’s capsule, and the conjunctiva is closed over it by means of sutures passing through Tenon’s capsule and the conjunctiva.

Operation. The first four steps in the operation are similar to those described under enucleation.

Fifth step. A small, loosely-fitting glass globe is inserted into Tenon’s capsule. A purse-string suture of strong catgut is then inserted into the cut margin of Tenon’s capsule, taking care to include in the sutures the cut ends of the tendons of the recti muscles. The suture is drawn tight and tied so that Tenon’s capsule and the muscles are thereby drawn over the globe. The conjunctival wound is closed over this by a separate suture of silk.

The advantage of this operation over the other substitutes for simple enucleation is that it can be used after any enucleation. The chief disadvantages are that the globe is sometimes extruded unless the wound be carefully closed by sutures, and occasionally it may become dislocated from Tenon’s capsule beneath the conjunctiva, thus preventing an artificial eye from being worn, and requiring removal. These disadvantages are largely done away with if the method of suture described above be used.

OPERATIONS UPON THE SOCKET AFTER THE REMOVAL OF THE EYE

PARAFFIN INJECTION

Indications. Occasionally after an eye has been removed the movements in the socket are not communicated sufficiently to the artificial eye which is placed over it, so that the glass eye has a fixed, staring appearance. As a rule, this can be remedied by the use of a Snellen’s improved eye, which has a rounded posterior surface and fits well on to the stump. If this be not satisfactory, the injection of paraffin into the stump will often improve the movements considerably. The injection should be made by what is known as the ‘cold method’.

The ‘cold method’ of paraffin injection is by far the most satisfactory, for the following reasons:—

(a) The temperature need not be so high, and no damage is therefore done to the tissues.

(b) It is more easily regulated (see Vol. I, p. 682).

(c) Embolism is less likely to occur.

Instruments. Fixation forceps, tenotomy knife, speculum, a large paraffin syringe, and a short needle having a big bore.

Operation. This may be performed under adrenalin and cocaine.

First step. The stump is drawn forwards with forceps. A tenotomy knife, inserted well to the outer side of the stump, is then swept freely round and a pocket is formed in the centre of the orbit into which the injection can be made. The tenotomy knife is then withdrawn.

Second step. The sterile melted paraffin (melting-point 115° F.) should be poured into the syringe, which should have been previously kept in a hot-water bath. The paraffin is then allowed to cool slowly until it just becomes opalescent. The injection should be made through the hole made by the tenotomy knife, sufficient paraffin being inserted to obtain the desired result. The operation is usually followed by considerable swelling of the tissues, which will subside in three or four weeks.

OPERATIONS FOR THE RESTORATION OF A CONTRACTED SOCKET

As the result of wearing badly-formed artificial eyes or of subsequent inflammation in the conjunctival sac, the socket not infrequently becomes so contracted that the prosthesis cannot be retained. Enlargement of the sac may be obtained by two methods:—

(a) Skin-grafting (Thiersch’s method).

(b) Transplantation of skin from the surrounding structures (Maxwell’s operation).

SKIN-GRAFTING

Indications. This procedure is especially suitable for cases in which the base of the socket opposite the palpebral aperture has to be enlarged, and it is usually performed prior to Maxwell’s operation for the restoration of the fornices in severe cases.

Instruments. Scalpel, speculum, skin-grafting razor, probes, and a piece of thick style wire.

Operation. First step. The base of the socket is freely divided in a horizontal direction opposite the palpebral aperture so as to produce a gaping wound.

Second step. This gaping wound is put on the stretch in the following way: A thick piece of style wire is bent round to fit into the fornices of the socket, the ends being brought out over the lid at the inner canthus. The circle of wire is opened out as far as possible so as to put the wound at the bottom of the socket on the stretch to its fullest extent.

Third step. Skin grafts are then cut from the inner surface of the arm (see Vol. I, p. 670), applied by means of probes, and pressed down on to the raw surface. No dressings should be applied directly to the grafts, but a watch-glass may be placed over the palpebral aperture and dressings applied over it. The style wire should be removed on the fourth day.

INCLUSION OF FLAPS. MAXWELL’S OPERATION

Indications. It is especially useful for the enlargement of the socket by the formation of new fornices. As a rule it is performed for the reproduction of the lower fornix, as it is frequently due to the obliteration of this cul-de-sac that the artificial eye cannot be retained. The operation, however, may be modified and applied to the formation of both the upper and outer culs-de-sac.

Instruments. Scalpel, forceps, scissors, and sutures.

Operation. A general anæsthetic is required.

First step. An incision is made in the lower fornix throughout its whole length and carried downwards for a distance of about half an inch (Fig. 137, A).

Maxwell’s Operation for Contracted Socket Fig. 137. Maxwell’s Operation for Contracted Socket. First step. A is the incision through the conjunctiva. The flap of skin from the outer surface of the lower lid is entirely raised from the subcutaneous tissue, except for the pedicle B which holds the new fornix in position.
    
Maxwell’s Operation Fig. 138. Maxwell’s Operation. Final step. Showing the flap of skin from the outer surface of the lower lid turned in to form the new lower fornix. The surface wound has been closed by sutures.

Second step. A crescentic piece of skin is marked out on the lower lid by two incisions which have their concavity directed upwards. The upper one is parallel with the margin of the lower lid and about 5 millimetres below it. This crescentic flap is then dissected up from the deeper tissues all round, except for a small pedicle at its centre (Fig. 137, B).

Third step. The incision forming the upper margin of the crescentic piece of skin is deepened until it meets the incision made in the fornix, so that the lower lid is converted into a band of tissue attached only at each end.

Fourth step. The upper margin of the incision in the fornix is stitched to the upper margin or concavity of the crescentic piece of skin after the latter has been displaced upwards beneath the band of tissue carrying the lashes, and the lower margin of the crescentic piece of skin is stitched to the conjunctival edge of the band, so that the crescentic piece of skin is folded on itself and forms the new lower fornix, being held down in its position by the pedicle (Fig. 138). The sutures should be of catgut, as their subsequent removal is somewhat difficult.

Fifth step. The surface wound is closed by silkworm-gut sutures. The socket should be packed with gauze, or else a piece of style wire should be inserted, as in the previous operation, so as to maintain the groove in the new lower fornix.


CHAPTER VIII

OPERATIONS UPON THE EYELIDS

SURGICAL ANATOMY

The eyelids consist of well-marked planes of tissue, which are, from without inwards—

1. Skin with very little subcutaneous fat.

2. Orbicularis muscle.

3. Tarsal plates, which are attached to the orbital margins by the palpebral ligaments and which thereby form a barrier to the passage of infection backwards into the orbit.

4. Subconjunctival tissue and conjunctiva.

It is most important for successful results that flaps and incisions should be made accurately down to and in the correct layer of the lid.

Along the lid margin, between the eyelashes and the posterior border of the eyelid, is a white line (intermarginal line) formed by the edge of the tarsal plate. In the many operations in which the lid is split the incision is carried along this line.

The blood-supply to the eyelids is derived from arterial arches—two in the top lid, and one in the lower—which run parallel to the margins. As far as possible, therefore, flaps should be planned with their bases at right angles to the course of the vessels. The extreme vascularity of the lid, together with the small amount of subcutaneous fat, allows of almost complete detachment of flaps of skin without fear of necrosis, but at the same time every care should be taken to avoid injuring these flaps when manipulating them. Hæmorrhage is controlled during the operation by means of clamps or by direct pressure of the lid between the finger and thumb. As a rule a general anæsthetic is required for most of the operations.

SUTURE OF WOUNDS OF THE EYELIDS

Wounds which involve the skin only are brought together in the ordinary way with a few fine sutures. In wounds of the upper lid care should be taken to suture the levator palpebræ, if divided, as otherwise traumatic ptosis may result.

Suture of wounds involving the lid margin.

(a) In simple division the margins of the lids are brought together by means of a fine suture; the conjunctival surface is first approximated, and then the skin by a deep suture which includes the tarsal cartilage. Accurate apposition of the lid border is very essential. Unfortunately a certain amount of ectropion frequently follows, which may require for its relief one of the operations given below (see p. 284).

(b) Occasionally the lid margin carrying the lashes may be torn off. As a rule, the strip remains attached to the lid. It should then be accurately sutured in position, taking care that the lashes take their correct turn outwards. In cases where the strip is torn off entirely, the skin and conjunctiva should be sutured together. When large portions of the lid are lost, some form of plastic operation, such as is performed for making a new lid, is required (see p. 287).

(c) When the canaliculus has been divided the end attached to the lachrymal sac should be sought for and divided for a short distance inwards from the wound (see p. 291), the entrance being kept open daily by a probe to prevent traumatic stricture.

OPERATIONS FOR ANKYLOBLEPHARON

Fusion of the eyelids together is either a congenital condition or the result of injury, and may take the form of bands or firm fibrous union. It is rarely complete and is often associated with symblepharon. The union should be divided on a director, or by careful dissection, taking care not to wound the underlying globe. The raw surfaces are kept apart by daily dressing until they are covered by epithelium. No externa[l] dressing should be applied.

OPERATIONS FOR SYMBLEPHARON

Partial adhesion of the lid to the globe in which a few bands pass from the lid to the globe are best treated by division followed by union of the ocular conjunctiva over the raw surface; no external dressing should be applied. Any tendency to fresh adhesion may be prevented by daily inspection.

In extensive adhesion of the lid to the globe, where the lids are entirely adherent to the globe and the cornea is destroyed, interference is inadvisable. In less extensive adhesion, the lid is first separated from the globe, reunion being prevented by covering the denuded area on the globe with a flap of bulbar conjunctiva transplanted from an area that does not come in contact with the raw surface on the eyelid (Teale’s operation), or by Thiersch’s grafts from a situation where there are no hairs; or by grafting mucous membrane from the mouth of the patient or a frog. Teale’s operation, or some modification, is by far the most satisfactory, but unfortunately it cannot always be carried out when the loss of conjunctiva is large.

OPERATIONS UPON THE PALPEBRAL APERTURE

CANTHOPLASTY

Indications. In contraction of the palpebral aperture, either due to a congenital condition, or the result of a wound, trachoma, or other cicatricial contraction.

Instruments. Speculum, forceps, scissors, and three sutures.

Operation. The speculum is inserted and opened as widely as possible. One blade of the scissors is passed into the cul-de-sac at the outer angle of the lid and the palpebral aperture enlarged by dividing the outer canthus horizontally. The external tarsal ligament which is split longitudinally is then cut across with scissors passed into the upper and lower wound. The conjunctiva is drawn up into the wound and stitched to the skin at the margin to prevent reunion. The stitches should be removed about the sixth day.

CANTHOTOMY

Canthotomy is simple division of the outer canthus without stitching the conjunctiva into the wound. It is useful in some cases of blepharospasm associated with fissure at the outer canthus.

CANTHORRHAPHY

Union of the eyelids, usually at the outer canthus.

Indications. (i) When the eyelids do not cover the globe as the result of—

(a) Cicatricial contraction of wounds, burns, &c., about the lid.

(b) Long-standing facial paralysis.

(c) Exophthalmic goître.

(ii) To help maintain the lid in position after ectropion operations.

Instruments. Beer’s knife, fixation forceps, spatula, and sutures.

Operation. First step. The position for the new external canthus is determined by holding the lids together at the outer canthus, and is marked on the upper and lower lids. From these points incisions are carried outwards to the external canthus along the intermarginal line in the top and bottom lids. These incisions are deepened to about 5 millimetres.

Canthorrhaphy Fig. 139. Canthorrhaphy.

Second step. From the inner end of the incision in the lower lid a vertical one is made downwards for about 5 millimetres, and is then carried out to the external canthus. The tissue thus marked out, bearing the lashes, is then removed.

Third step. A corresponding, slightly larger, area is similarly removed from the under or conjunctival surface of the upper lid (Fig. 139).

Fourth step. These two areas are brought into apposition by means of a strong suture passed through their centre. The suture should have a needle at either end, and these should be passed from the conjunctival surface and brought out through the middle of the raw area in the lower lid, about 2 millimetres apart, and then through the middle of the raw area in the upper lid and out through the skin. The suture is tied so that the two raw areas are brought into accurate apposition. The margins of the wound may then be brought together by sutures if necessary. The main suture should be left in for at least ten days.

TARSORRHAPHY

Indications. (i) Complete union of the eyelids may be required when an eye has been removed and for some reason an artificial one cannot be worn.

(ii) Partial union is effected in cases of paralysis of the first division of the fifth nerve when corneal ulceration threatens. A similar union is also useful in keeping the lower lid in position during the process of cicatrization in many of the operations for ectropion described below. The adhesions produced can be subsequently divided when contraction has ceased.

Instruments. Knife, forceps, scissors, spatula.

Operation. Complete. As narrow a strip of tissue as possible is removed from the lid borders behind the eyelashes. This is best performed by everting the upper lid and shaving off the posterior margin with a sharp knife; the lower lid is then treated similarly. The raw areas are brought into apposition with fine sutures.

Partial. When only a temporary adhesion is required, as after ectropion operations, it is sufficient to make raw corresponding areas of about 2 millimetres on the posterior margins of the top and bottom lids on either side of the central position of the cornea and unite them with sutures, which may be removed about the end of the first week.

PTOSIS OPERATIONS

The following operations are usually only undertaken for congenital ptosis, but they are occasionally required for the paralytic and traumatic varieties. All the operations are far from satisfactory, and should only be undertaken when the lid covers the pupil completely or so nearly that the head has to be thrown back to see objects directly in a line with the eyes. The relative value of the various operations apart from their indications is a matter of opinion amongst ophthalmic surgeons; therefore the various types of operations which are performed are given below.

There are four types of operation, which respectively aim at—

1. Shortening the eyelid by excision of a portion of the tarsal plate.

2. Attachment of the lid to the occipito-frontalis muscle.

3. Advancement of the levator palpebræ muscle.

4. Grafting of part of the superior rectus muscle into the lid to take the place of the levator palpebræ superioris.

SHORTENING THE EYELID BY EXCISION OF A PORTION OF THE TARSAL PLATE

Fergus’s operation (modified). The object of this operation is to shorten the eyelid by removing the upper portion of the tarsal plate, the cut margin of which is subsequently sutured to the tendon of the levator palpebræ and the palpebral ligament.

The results of the operation are satisfactory, especially in cases in which there is some movement in the eyelid. The author, who has performed most of the ptosis operations on several occasions, has had most uniform results by this method, the modification of which was first suggested to him by Mr. Treacher Collins.

It has the advantage that the amount of retraction required may be more easily estimated, the corneal complications are of much rarer occurrence, and the resulting scar forms a natural fold in the lid. It is obviously not applicable to cases in which the eyelid is already short, as in the cases of ‘Chinese eye’ in which little can be done beyond enlarging the palpebral aperture.

Instruments. Spatula, scalpel, artery and dissecting forceps, scissors, and sutures.

Operation. First step. The spatula is inserted into the superior fornix. A curved incision is made directly below the orbital margin throughout its whole length. The skin and orbicularis muscle are divided and dissected downwards so as to expose the upper surface of the tarsal plate. A suture is then passed through this flap so that it may be drawn down by an assistant.

Second step. A narrow strip about 3 millimetres broad is excised from the whole length of the tarsal plate; in doing this care must be taken not to button-hole the conjunctiva or flap of skin.

Third step. The cut margin of the tarsal plate is sutured to the levator palpebræ and palpebral ligament by two sutures passed in the following manner: A thick catgut suture armed with a curved needle is passed through the upper cut margin of the orbicularis palpebrarum, palpebral ligament, and levator palpebræ (if the latter be present) at about the junction of the middle and inner thirds of the wound, a firm hold being taken on these structures. The needle is then passed through the tarsal cartilage parallel to the lid border for a distance of about 3 millimetres and out again on to its anterior surface. The needle is then again carried through the levator palpebræ, palpebral ligament, and orbicularis in the upper part of the wound. A similar suture is passed about the junction of the middle and outer thirds of the wound. When both sutures are in position they are tied sufficiently tightly to produce the retraction of the lid desired, slight over-correction being necessary. The skin wound is then closed with sutures.

ATTACHMENT OF THE LID TO THE OCCIPITO-FRONTALIS MUSCLE

There are three chief methods of affecting this attachment:—

(a) By cicatricial bands (e.g. Hess’s operation).

(b) By a suture left permanently in position (e.g. Harman’s operation).

(c) By the attachment of the skin of the lid to the muscle (e.g. Panas’ operation).

Indications. In the majority of the cases of congenital ptosis the levator palpebræ is completely absent, as shown by the want of upward movement in the lid, and it is for this condition that one of the operations of this type is performed. In rare cases the occipito-frontalis muscle is also absent or imperfectly developed, and in these cases these operations should not be undertaken.

Hess’s operation. The object of this operation is to insert silk stitches between the eyelid and the occipito-frontalis muscle, and to leave them in long enough for a fibrous band of union to form along the stitch tracks.

Instruments. Scalpel, dissecting forceps, needle and holder, spatula, artery forceps.

Operation. First step. The eyebrow having been shaved, an incision 2 inches long is made about in the line of the brow, and the skin is dissected down almost to the lid margin.

Second step. Three sutures are passed, one in the middle, and one at each end of the lid; each suture carries two needles. The needles are inserted in the intermarginal line of the lid about 3 millimetres apart and brought out into the wound above, so that the lid margin is held by the loops. These threads are then carried deeply beneath the upper edge of the wound into the substance of the occipito-frontalis muscle, brought out through the skin well above the eyebrow and tied over a piece of drainage tube. The sutures should be drawn tight enough to produce an undue amount of retraction of the lid, as this tends to drop again after removal of the sutures. The skin wound is then closed and a small dressing is applied to cover the drainage tube on the forehead. The eye itself should be covered with a celluloid shield, as it is usually impossible for the patient to close the palpebral aperture, and the cornea is liable to be injured by exposure. The deep sutures should be left in for at least three or four weeks, so that they may bring about a fibrous band between the muscle and the eyelid by their irritation. The immediate result of the operation is usually excellent, but the lid is very apt to drop again in the course of six months or a year after removal of the stitches.

Harman’s operation. The aim of this operation is to insert a fine metal chain between the occipito-frontalis and the lid, the chain being left permanently in position. The operation has not yet been performed sufficiently often to allow any definite statement about the final results to be made.

The results have not been very satisfactory in three cases in which the author has performed this operation.

Instruments. A 4-inch straight surgical needle, to which is attached the fine wire chain such as is used by spectacle makers to attach glasses to the dress. It measures about O.75 millimetre in diameter. It is attached to the needle by a soldered ring or by means of a piece of silk doubly looped through the needle without a knot.

Operation. Under a general anæsthetic. ‘The method of implanting the chain will be followed readily by reference to Fig. 140. The chain-needle is inserted above the external angular process at A, is passed inwards, and with a slightly upward inclination deeply beneath the tissues of the forehead, to be withdrawn at B; as much of the chain is drawn through as desired. The needle is reinserted at B, passed beneath the brow close to the orbital margin and through the tissues of the lid to C, where it is withdrawn and the chain after it. In like manner it is passed from C to D through the substance of the tarsus and withdrawn. It is now returned from D to E above the brow and withdrawn, and a final length embedded above the brow from E to F, which is just above the internal angular process. The chain should be buried completely and stretched evenly between the points A, B, C, D, E and F; and by traction the loop BCDE should be adjusted at B and E; when the lid is at the desired height the slack at B and E is taken up by traction on A and F.

Harman’s Operation for Ptosis Fig. 140. Harman’s Operation for Ptosis.

‘The position of the points E and B is of importance; they must be situated in the region of the most effective elevation of the brow by contraction of the frontalis muscle, as determined by experiment before the commencement of the operation (and they should be placed well above the eyebrow).

‘The lengths of chain lying buried above the brows from A to B and E to F, and the angles A B C and D E F, are arranged so that there is sufficient holding power to prevent the subsequent drop of the lid, but will not prevent adjustment to forcible traction on the lid until the links of the chain have become interwoven and surrounded by the growth of connective tissue. This growth should be sufficiently vigorous by the end of a week to securely fix the chain against all the force of traction of the orbicularis muscle. (In one case in which the author removed the chain after two weeks there was no connective tissue in the links and it was easily withdrawn.) Until this time the free ends of the chain should be turned towards each other over the skin of the brow and cemented in position by a cotton-wool and collodion dressing, after which time the free ends, A and F, are cut off and the free extremities pushed beneath the skin.’

Panas’ operation. In this operation a direct adhesion of the skin of the lid to the occipito-frontalis muscle is aimed at.

Instruments. Lid spatula, scalpel, dissecting forceps, scissors, sutures.

Ptosis Operation. Panas’ Fig. 141. Ptosis Operation. Panas’.

Operation. Under a general anæsthetic.

First step. An incision, 2 inches long, is made in the line of the brow, and an incision of a similar length is made into the skin of the lid about half an inch below it. The tissue between these two incisions is undermined so as to produce a band of skin and subcutaneous tissue. From the ends of the lower wound vertical incisions are made into the lid, running slightly outwards and inwards respectively towards the outer and inner canthus (Fig. 141).

Second step. The flap, C (Fig. 141), thus produced is raised, and doubly armed sutures, D D, are passed through its upper margin and are carried beneath the band of skin and subcutaneous tissue. The needles are then carried deeply beneath the upper margin of the wound A into the substance of the occipito-frontalis muscle and brought out on to the forehead. Outer and inner sutures, E E, are passed deeply into the substance of the tarsus both ends are then passed beneath the band and brought through into the upper wound, whence they are passed beneath the upper margin of the wound into the occipito-frontalis muscle and are tied over a piece of drainage tube. They hold the lid in position during the process of cicatrization. Considerable over-correction should be employed as the lid tends to drop subsequently. No dressings should be applied over the open palpebral aperture. The stitches are removed on the tenth day. A small depression is usually seen where the skin of the lid passes beneath the band.

ADVANCEMENT OF THE LEVATOR PALPEBRÆ MUSCLE

This is especially suitable for cases in which the levator palpebræ has some power, that is to say, when there is some movement of the lid present. It is also suitable for cases of traumatic and paralytic origin. The movement of the lid by the levator palpebræ is best estimated by eliminating the action of the occipito-frontalis by holding down the brow and asking the patient to raise the lid.

Instruments. Lid spatula, knife, forceps, scissors, sutures.

Operation. Under a general anæsthetic.

First step. A spatula is inserted into the upper conjunctival fornix. An incision is made just below the eyebrow over the upper margin of the tarsal plate throughout its length. The skin, especially of the lower margin of the wound, is dissected up and the orbicularis muscle divided, the tarsal plate, with the superior palpebral ligament attached to it, and the orbital margin being exposed. The superior palpebral ligament is then divided carefully high up near the orbital margin and directly below, in a small quantity of fat, will be found the tendon of the levator palpebræ superioris. The tendon can usually be distinguished from the palpebral ligament by the fact that it is elastic when pulled on.

Ptosis Operation
Fig. 142. Ptosis Operation. Advancement of the Levator Palpebræ. Showing the suture passed through the tendon; the difficulty of the operation is to find it. (Diagrammatic.)
    
Ptosis Operation
Fig. 143. Ptosis Operation. Advancement of the Levator Palpebræ. Showing the sutures in position. The tendon is shortened by folding it on itself.

Second step. The advancement of the muscle is then performed in one of the three following ways: (a) by excising a portion of the tendon and suturing the divided ends together; (b) detaching the tendon from the tarsal plate and bringing it from behind forward through a hole made in the upper margin of that structure and suturing it on its anterior surface towards the lower margin; (c) by folding the tendon on itself. The last method is the one most usually performed. Two sutures with a needle at each end are passed through the substance of the muscle and tied (Fig. 142). The ends of these sutures are then carried downwards between the tarsal cartilage and the orbicularis palpebrarum and out in the intermarginal line of the eyelid. The sutures are then tied tightly so as to secure rather more than the amount of retraction required (Fig. 143). The palpebral ligament and orbicularis palpebrarum are then united and the wound in the skin is closed.

GRAFTING A PORTION OF THE SUPERIOR RECTUS INTO THE LID

Motais’ operation. Indications. This operation is performed for cases of ptosis in which there is partial or complete loss of upward movement of the lid. In cases of congenital ptosis the superior rectus is not infrequently absent or imperfectly developed, as is shown by the defective upward movement of the eye. It need hardly be said that it is most important to see that the superior rectus is well developed before undertaking the operation. Vertical diplopia always follows the operation, and therefore it is advisable only to undertake it when the ptosis is bilateral, a similar operation being performed on both sides. Another somewhat hypothetical objection is that during sleep the eyelids are rolled upwards by the superior recti so that the lids are slightly open, but this occurs in almost all successful ptosis operations. Occasionally there is some defective upward movement of the eye after the operation.

Instruments. Speculum, straight strabismus scissors, lid retractor, needle holders and stitches.

Operation. A general anæsthetic is desirable in all cases.

First step. The superior rectus is exposed through a horizontal incision in the conjunctiva, as in the first stage for advancement. The tendon is defined in the wound and a strabismus hook passed beneath it; its middle portion is isolated and two silk sutures, with a needle at each end, are passed through it and tied.

Second step. The speculum is removed and the eyelid everted and pulled upward by means of a retractor or two silk stitches passed through the substance of the lid. Starting from the middle of the wound the conjunctiva of the fornix is divided backwards and the under surface of the tarsal plate is exposed.

Third step. An incision is carried through the tarsal plate parallel to and near its upper border well into the substance of the orbicularis muscle on the other side. The needles on each end of the doubly armed sutures holding the isolated portion of the superior rectus muscle are passed through the hole in the tarsal plate and are carried downwards between the orbicularis muscle and the tarsal plate to near the lid margin, where they are brought out through the skin and tied over a piece of drainage tube. The conjunctival wound is closed by sutures.

Complications. Ulceration of the cornea is more likely to occur after those operations in which the lid is much over-retracted, such as Hess’s, Panas’ operation, and the advancement of the levator palpebræ. It usually affects the lower corneal margin and may be merely roughening and opacity of the epithelium or deep septic ulceration. If the ulceration be severe, the sutures holding the lid in position should be taken out and the eye treated as for corneal ulceration; on the other hand, slight abrasion of the epithelium will often heal without taking out the sutures.

Sepsis. The difficulty of keeping the wound aseptic after these operations is considerable, and not infrequently inflammation may take place; provided it does not go on to suppuration, the final result is improved thereby; should suppuration take place the sutures must be removed.


CHAPTER IX

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

The operations commonly performed for entropion and trichiasis are of three types:—

1. Operations for the destruction of the individual hair follicles.

2. Rectification of a faulty curvature of the tarsus.

3. Transplantation of the lash-bearing area.

ELECTROLYSIS

Indications. In cases of trichiasis where a few eyelashes turn in on the conjunctiva or cornea they may be removed by this method.

Operation. A platinum electrolysis needle (negative pole) is passed alongside each lash into the follicle, and a constant current of about 5 milliampères allowed to pass for a half to one minute. There is usually some bubbling seen around the hair, which will fall out when touched if the operation has been properly performed. It is a comparatively painless operation and free from scarring if the hair follicle be not penetrated by the needle. This is best ensured by using a rather blunt point and not turning on the current until the needle is in position.

SKIN AND MUSCLE OPERATION

Indications. This operation is especially suitable for the senile or spastic forms of entropion of the lower lid, not infrequently seen after much bandaging in old people, which has failed to yield to treatment by pulling the lid outwards with strapping.

Instruments. Straight scissors, fixation and entropion forceps.

Treacher Collins’s Entropion Forceps Fig. 144. Treacher Collins’s Entropion Forceps.

Operation. Adrenalin and cocaine solution is injected beneath the skin of the lower lid. A horizontal strip of skin as near the lid margin as possible is seized with the entropion forceps (Fig. 144) and removed by one snip of the scissors. The underlying orbicularis muscle is then removed over the same area and the wound closed with sutures. If a more pronounced result is required, a vertical piece of skin is removed at the outer end of the previous wound and allowed to granulate.

RECTIFICATION OF A FAULTY CURVATURE OF THE TARSUS

DIVISION OF THE TARSAL CARTILAGE FROM THE CONJUNCTIVAL SURFACE OF THE LID

Burow’s operation. The object of this operation is to restore the inverted tarsal edge of the lid by dividing the cartilage from the conjunctival surface, and it is especially suitable for those cases in which the whole of the upper lid border is buckled inwards to a slight extent owing to cicatricial contraction such as is often seen in the late stage of trachoma and occasionally as a congenital deformity in the lower lid.

Instruments. Lid spatula and Beer’s knife.

Operation. The operation is performed under a general anæsthetic.

First step. The lid is everted over the lid spatula. An incision is then made along the white line, the result of cicatricial contraction, seen in the sulcus subtarsalis about 3 millimetres behind the upper lid margin; the incision should extend throughout the whole length of the lid and completely divide the tarsal plate. Care should be taken that the cut is made at right angles to, and not obliquely through the tarsal cartilage. When the eyelid is replaced the lid margin will be found to lie in its proper position.

Second step. If the skin of the upper lid be very lax or a more marked result be desired an elliptical piece of skin may be removed from the upper lid above the site of the underlying incision and the wound stitched together so as to exaggerate the outward curve of the lashes; this is usually desirable in most cases, since there is a strong tendency for the lid to become inverted again owing to the contraction of the wound, which is allowed to heal by granulation.

DIVISION OF THE TARSAL CARTILAGE FROM THE ANTERIOR SURFACE OF THE LID

Streatfield’s operation. The object of this operation is the removal of a wedge-shaped piece of the tarsal cartilage directly behind the lashes throughout the length of the upper lid. The division is made from the outside, and the wound is subsequently sutured so that the margin of the lid is everted. It has the advantage over the previous operation that no granulating area is left to cicatrize; it is especially suitable for cases in which there is much buckling inwards of the upper tarsal plate, and yields most satisfactory results even when the deformity is great.

Lid Clamp Fig. 145. Lid Clamp.
Streatfield’s Entropion Operation Fig. 146. Streatfield’s Entropion Operation.

Instruments. Beer’s knife, fixation forceps, lid clamp (Fig. 145), spatula, and sutures with a glass bead threaded on each.

Operation. The operation is performed under a general anæsthetic.

First step. The lid is fixed in a clamp. The surgeon makes an incision in the skin directly above the lash-bearing area throughout the whole length of the lid and parallel to its margin. A second incision is made about 3 millimetres above this, and its extremities are curved downwards to join the first. The piece of skin and orbicularis muscle between them is removed and the tarsal cartilage is exposed.

Second step. A wedge-shaped strip is removed from the tarsal cartilage throughout the whole length of the lid, the apex of the wedge reaching just through the cartilage, but not the conjunctiva on its under surface.

Third step. Mattress sutures are then inserted. Each suture should have a needle at either end. A bead may be threaded on the stitch to prevent it cutting into the lid margin. The needles are passed from the margin of the lid directly above the eyelashes, about 3 millimetres apart, and brought out through the lower margin of the wound. They are then passed from within outwards through the tarsal plate and the upper margin of the wound, being brought out through the skin about half an inch above it and tied (Fig. 146). A few points of suture in the skin may be added if necessary.

THE TRANSPLANTATION OF THE LASH-BEARING AREA

Arlt’s Operation for Trichiasis Fig. 147. Arlt’s Operation for Trichiasis.

Arlt’s operation. Indications. The operation is suitable for cases of trichiasis in which part or the whole of the lashes of the upper lid turn inwards and rub on the surface of the cornea.

Instruments. Beer’s knife, forceps, scissors, sutures, lid clamp.

Operation. First step. A lid clamp is applied to the upper lid. An incision is made in the intermarginal line and the tarsal cartilage is split behind the lash-bearing area for a depth of about 5 millimetres throughout the whole extent of the lid (Fig. 147).

Second step. An incision through the outer surface of the lid above the lashes is made to meet the other at right angles, so that the lashes are carried on a band of tissue attached at each end.

Third step. A semilunar piece of skin is then removed by a curved incision above the last, joining it at the outer and inner ends, and the band carrying the lashes is stitched to the upper margin of this incision; the line of the incision along the intermarginal zone behind the lashes is allowed to heal by granulation. The subsequent contraction caused thereby pulls down the band carrying the lashes to a certain extent. It is, therefore, desirable to pull the band of lashes upwards at the time of operation to a greater extent than is required for the final result in order to overcome this tendency for the condition to re-form as a result of cicatricial contraction of the granulating area. In order to obviate the cicatricial contraction some surgeons cover the area with a graft of mucous membrane.

ECTROPION OPERATIONS

Ectropion may affect the upper lid, but it occurs far more frequently in the lower. Operations undertaken for its relief vary very considerably for the following reasons:—

1. The cause of the ectropion. The active or cicatricial form requires different and more extensive operations than the passive form, such as occurs after facial paralysis, senile ectropion, or that occurring after blepharitis.

2. The degree of ectropion, whether it is partial, affecting merely the lid margin; or complete, affecting the whole lid.

Ectropion of the lower lid is always accompanied by epiphora, owing to the want of application of the canaliculus to the lacus lachrymalis. The canaliculus is also apt to become obliterated as the result of marginal blepharitis. Before undertaking any of the operations described below this condition must be remedied, either by dilating the canaliculus or by slitting it inwards for a short distance (see p. 290), otherwise, even if the operation be successful in restoring the deformity, the overflow of tears causes the patient to pull down the lower lid constantly in wiping them away, and this tends to reproduce the condition.

After many of the operations a temporary tarsorrhaphy is required to keep the lid in position during the process of cicatrization. The temporary bands produced by this operation are so placed on either side of the cornea as not to interfere with vision altogether. Canthorrhaphy is also desirable in some cases, especially when the ectropion affects the outer end of the lid.

The deformity to be overcome in ectropion is not only the turning outwards of the lid; in cases which have existed for any length of time the lid border becomes permanently elongated and requires to be shortened before it will keep in position. The exposed conjunctiva, especially in cases secondary to blepharitis, becomes thickened near the lid margin, and, though it may regain a more or less normal appearance after the lid has been replaced in position, the thickened margin frequently prevents the proper apposition of the canaliculus, and in these cases it is often desirable to remove this tissue (see Fergus’s operation).

OPERATIONS FOR PASSIVE ECTROPION
Snellen’s Sutures Fig. 148. Snellen’s Sutures.

A. A suture in position.

B. The suture tightened.

Snellen’s suture method. The object of this operation is to pass sutures through the lower lid from rather above the apex of the eversion out on to the cheek, so that when tightened they draw the lid up into position. The inflammation which occurs around the sutures leaves a permanent band of cicatricial tissue which continues the action of the sutures after they have been removed.

Indications. Snellen’s sutures are useful in moderate degrees of the senile form of ectropion in which there is not much thickening of the lid margins. Although the results are satisfactory in carefully selected cases, the operation is attended with considerable pain and is very liable to be followed by a marked inflammation along the stitch tracks; indeed, the final results are not very satisfactory unless some inflammation does occur.

Instruments. Two, and occasionally three, sutures of thick silk armed at either end with 3-inch straight needles.

Operation. A general anæsthetic is desirable, although not absolutely necessary. The needles belonging to each stitch are inserted about 3 millimetres apart, from the conjunctival surface above the apex of the everted lid, and after passing deeply near the lower cul-de-sac on the posterior surface of the tarsus, they are brought out on the cheek low down and tied over a piece of drainage tube. The loops, when drawn tight, draw the lid margin inwards (Fig. 148). Two of these sutures are usually required at such a distance apart as to divide the lower lid into thirds. They should be left in place some two or three weeks.

Fergus’s Operation for Slight Ectropion of the Lower Lid Fig. 149. Fergus’s Operation for Slight Ectropion of the Lower Lid. Showing the lines of the incision.

Fergus’s operation. This operation consists in excision of the apex of the everted lid.

Indications. It is a most satisfactory operation for cases in which the lid margin has undergone thickening from blepharitis and for cases of slight senile ectropion.

Instruments. Beer’s knife, fixation forceps, and sharp-pointed scissors.

Operation. Under adrenalin and cocaine, a little solid cocaine being rubbed into the conjunctiva. A strip of thickened conjunctiva and subconjunctival tissue corresponding to the apex of the eversion is removed along the whole length of the lid (Fig. 149). The wound produced is united with sutures. The pull of the conjunctiva, which is stitched to the lid margin, is sufficient to draw that structure inwards into position.

Kuhnt’s operation (modified). The object of this operation is the removal of a triangular piece of conjunctiva and tarsal cartilage from the centre of the lower lid, the base of the triangle being placed towards the free margin of the lid so as to produce sufficient shortening of the elongated lid border to hold it in position. The skin of the lid is also shortened by removal of a triangular portion at the external canthus.

Indications. It is especially suitable for cases of paralytic ectropion (lagophthalmos) and severe degrees of senile ectropion of the lower lid.

Instruments. Lid spatula, Beer’s knife, scissors, forceps and sutures.

Operation. A general anæsthetic is required.

First step. The lower lid being held between the finger and thumb is split in the intermarginal line along the outer two-thirds of its length, and the incision deepened till the lower border of the tarsus is reached. For this purpose some surgeons use a broad keratome instead of a Beer’s knife.

Second step. A triangular piece of conjunctiva and the whole thickness of the tarsus are removed from the centre of the lower lid, the base of the triangle being towards the free margin of the lid and being of sufficient length to produce the shortening desired to bring the lid up into position (Fig. 150); this is best estimated by making the incision forming the inner limb of the V and overlapping the outer flap until the lid is pulled upwards into position.

Third step. A triangular piece of skin with its base upwards is excised from the outer canthus in the following manner (Fig. 150). An incision is made outwards and slightly upwards from the canthus. A vertical incision, twice the length of the preceding one, is made directly downwards from its outer end to the outer canthus, and the lower end of this is then joined by an incision completing the triangle. The skin marked out by this triangle is then dissected up and removed. The undermining of the flap formed by the skin and subcutaneous tissue of the outer part of the lid is continued inwards until the flap, when pulled up into place, restores the lid to its proper position.

Modified Kuhnt’s Operation for Severe Ectropion Fig. 150. Modified Kuhnt’s Operation for Severe Ectropion. Second step. The outer half of the lid is split and a V-shaped portion of the tarsal plate removed. The triangular piece of skin at the outer canthus is entirely removed.
    
Modified Kuhnt’s Operation Fig. 151. Modified Kuhnt’s Operation. Fourth step. Showing the sutures in position. The outer part of the lid has been undermined and dissected up. The V-shaped gap in the tissues is sutured first.

Fourth step. The lid is sutured into position. The V-shaped wound in the conjunctiva and tarsus is sutured, the knots being placed on the conjunctival surface with the exception of the suture at the lid border, which is turned the other way, the ends being brought out through the skin of the outside flap, after the latter has been sutured in position, and the two ends tied over a bead. The outside flap of skin is brought up into position by a suture at its upper angle. As the result of this a few eyelashes project beyond the outer canthus; these should be excised. Additional sutures to hold the flap in position are then inserted. Both eyes should be bandaged after the operation, otherwise the knots in the conjunctiva may rub on the cornea.

Argyll Robertson’s operation. The operation aims at shortening the border of the lower lid and at the same time pulling it upwards into position by means of a strap of skin and subcutaneous tissue cut from the outer side, the attached end of the strap being formed by the outer portion of the skin of the lower lid.

Indications. It is especially useful for paralytic cases, and as a subsequent measure to the VY operation described below for cicatricial ectropion. The operation is likely to be successful if a marked reduction in the deformity is effected by pulling the skin at the side of the outer canthus upwards.

Instruments. Scalpel, dissecting forceps, artery forceps, scissors, sutures.

Operation. First step. An incision, 2 millimetres below the lid margin and opposite its outer third, is carried through the skin parallel to the border of the lower lid outwards to the canthus; having reached this point the direction of the incision is changed and it is carried more upwards and outwards till the upper end is on a level with the upper orbital margin. The incision is then carried outwards for about 6 millimetres and again downwards, slightly diverging from the former incision, until it is opposite the lower orbital margin. This flap of skin and subcutaneous tissue is dissected up from above downwards (Fig. 152).

Argyll Robertson’s Operation for Ectropion Fig. 152. Argyll Robertson’s Operation for Ectropion. Second step. Showing the method of shortening the lid and the strap of skin reflected. The upper convex line shows the piece of skin to be removed so that the lid may be pulled upwards into position.
    
Argyll Robertson’s Operation for Ectropion Fig. 153. Argyll Robertson’s Operation for Ectropion. Final step. The strap of skin has been sutured in position after pulling it upwards sufficiently to reduce the deformity and enlarging the raw area upwards to allow this to be done.

Second step. A V-shaped portion is removed from the margin of the lower lid near the outer canthus, the base of the V being of sufficient length to produce the shortening of the lid required when the edges of the incision are brought together.

Third step. The strap of skin is pulled upwards to the extent required to replace the lid in position, and sutured there. The raw area must be enlarged upwards so as to accommodate the upper end of the strap. It is better to do this than to shorten the strap, since a firm hold is thus obtained (Fig. 153).

OPERATIONS FOR THE ACTIVE OR CICATRICIAL FORM OF ECTROPION

The numerous operations which have been devised for this condition are divided into two groups: (1) the transplantation of flaps in the neighbourhood of the lesion, and (2) the grafting of skin flaps from other parts of the body. The latter method is usually only undertaken when the employment of flaps from the neighbourhood of the deformity is impossible, as the cicatricial contraction which follows the grafting of flaps from other parts of the body is usually attended by considerable shrinkage and therefore does not yield such satisfactory results.

BY THE TRANSPLANTATION OF FLAPS

VY operation (Wharton Jones). Indications. This operation is useful for cases of ectropion affecting the middle parts of the lower lid, generally due to a scar such as would result from a healed sinus after tuberculous periostitis of the lower orbital margin.

Instruments. Dissecting forceps, scalpel, artery forceps, sutures.

VY Operation for Ectropion of the Lower Lid Fig. 154. VY Operation for Ectropion of the Lower Lid due to a Scar. First step. Showing incision.
    
VY Operation for Ectropion Fig. 155. VY Operation for Ectropion. Final step. Showing the lid in position.

Operation. The operation is performed under a general anæsthetic. A V-shaped incision, with the apex downwards, is made to embrace the whole margin of the lower lid. The upper ends of the V should skirt the outer and inner canthus and roughly lie over the lower orbital margin, enclosing the scar, the apex of the V falling rather below the orbit. The incision should include the skin and subcutaneous tissue. The V-shaped flap is dissected up and the lid liberated from the underlying scar tissue. The incision is then sewn up in the form of a Y (Fig. 155). Temporary tarsorrhaphy (see p. 266) is always desirable. Subsequent shortening of the lid margin by the Argyll Robertson method is sometimes necessary.

Denonvillier’s operation. This procedure is useful to remedy an ectropion of the outer portion of the lower lid by the transposition of flaps at the outer canthus.

Instruments. Scalpel, dissecting and artery forceps, scissors, sutures.

Operation. The operation is performed under a general anæsthetic.

First step. An oblique incision (Fig. 156), starting from below the inner end of the deformity, A, is carried outwards and slightly upwards for 12 mm. to the point B. From the point B a curved incision B C is carried upwards to and along the orbital margin. This marks out a triangular flap. From C the incision is carried outwards and downwards in a curved direction to D, which is situated about 2 cm. from the external canthus, thus marking out another triangular flap B C D.

Denonvillier’s Operation for Ectropion of the Lower Lid Fig. 156. Denonvillier’s Operation for Ectropion of the Lower Lid. By reversed flaps at the outer angle. First step. The flap B C D is brought down to form the outer part of lower lid.
    
Denonvillier’s Operation for Ectropion Fig. 157. Denonvillier’s Operation for Ectropion. Showing the operation completed after transposition of the flaps.

Second step. Both flaps are dissected up, and, when all bleeding has ceased, the apices of the triangles are transposed and sutured in position, the incision thus forming a Z-like figure (Fig. 157). A canthorrhaphy is generally required.

Fricke’s operation. This has for its object the transplantation of flaps from the side of the forehead or face into the lid to remedy a loss of tissue resulting from operation or cicatricial contraction.

Indications. The operation is usually performed for cicatrices about the upper lid, the flap being turned down from the side of the forehead. A flap may be turned in from the inner side in addition if necessary. The operation may also be applied to ectropion of the lower lid.

Fricke’s Operation Fig. 158. Fricke’s Operation. To replace the loss of portions of the skin of the upper lid.

Operation. When planning the flaps the following points must be taken into account:—

(i) The flap must be cut so that its base contains the main blood-supply of the part made use of.

(ii) It should be at least one-third larger than the area to be covered. This is estimated by cutting a piece of protective the size of the area to be covered and laying it on the skin before the flap is cut.

(iii) The base of the flap should consist of a considerable amount of subcutaneous tissue as well as skin, but the apex may be little more than the skin itself.

(iv) The direction of the subsequent contraction should be taken into account so as to assist the final result.

First step. The lid is first freed by dividing all the cicatricial bands, or, if only a small cicatrix be present, by excising that. The lid is then pulled down into position and put fully on the stretch. This is best performed by stitching the margin of the lid to the cheek.

Second step. The flap is marked out at least one-third larger than the size required to cover the raw area. The base of the flap should be placed a little below the raw area to be covered, so that the rotation of the flap into position is easily performed without danger of constriction to the base (Fig. 158).

Third step. The flap having been raised and all bleeding stopped, it is rotated and sutured in its new position, the wound made by the removal of the flap being brought together by sutures or, if it be too large for this, covered by skin grafts (see Vol. I, p. 670).

BY THIERSCH’S SKIN-GRAFTING METHOD

Indications. As has already been pointed out, this method is not so satisfactory as the method by flaps described above, but it is frequently the only one available when the surrounding skin has been destroyed, as after extensive lupus of the face.

Instruments. Scalpel, forceps, skin-grafting razor, probes.

Operations. First step. As for the previous operation.

Second step. Grafts are cut from a situation free from hairs, such as the inner side of the upper arm (see Vol. I, p. 671).

Third step. After all bleeding has been stopped, the grafts are applied, straightened with probes, and pressed firmly down on to the raw surface. The edges of each graft should slightly overlap the one next to it. Great care should be taken in applying the dressings not to disturb the grafts (see Vol. I, p. 673).

If the whole thickness of the skin be used (Wolff’s method), care should be taken to see that the under surface is free from fat.

THE REPAIR OF LARGE LOSSES OF SUBSTANCE FROM THE EYELIDS

Losses of portions of the lid margins usually result from operations for malignant growths. When the loss is in the upper lid, some modified form of Fricke’s operation is the best method of remedying the deformity. When a large area is to be covered, transplantation of a flap from the arm by the Tagliacotian method has to be performed (see Vol. I, p. 679).

Fricke’s operation is also applicable to the outer portion of the lower lid. When the inner end of the lower lid is affected, De Vincentiis’ operation yields satisfactory results. When the whole lower lid has been lost, a modified Dieffenbach’s method with the use of the ear cartilage is indicated.

De Vincentiis’ operation. The operation aims at shifting the remains of the lid bodily inwards to cover the gap left by the removal of the growth.

Instruments. Scalpel, dissecting forceps, artery forceps, scissors, sutures.

Operation. First step. The portion of the whole thickness of the lid together with the growth is excised by a V-shaped incision (Fig. 159).

De Vincentiis’ Operation Fig. 159. De Vincentiis’ Operation to replace the Loss of the Inner Portion of the Lower Lid. Showing the inner portion of the lid removed by a V-shaped incision and the relief incision made outwards from the external canthus.
    
De Vincentiis’ Operation Fig. 160. De Vincentiis’ Operation Completed. The lower lid has been pulled inwards and united to the opposite side of the gap left by the V-shaped incision. The incision outwards from the outer canthus, now much diminished in length, is also sutured.

Second step. The outer canthus and orbito-tarsal ligament are divided with the scissors. The incision is then carried outwards and upwards with a scalpel, in a line with the lower margin of the lid, the incision being long enough to free the lower lid sufficiently to slide it inwards and to enable the edges of the V-shaped wound to be united (Fig. 160).

Dieffenbach’s operation (modified with the use of ear cartilage). This operation consists in shifting inwards a flap of skin and subcutaneous tissue derived from the outer side of the face to take the place of the eyelid which has been removed, the conjunctiva and tarsal plate being represented by a piece of skin and cartilage taken from the posterior surface of the ear and stitched to the inner surface of the flap.

Operation. First step. The growth, together with the eyelid, is first removed by a V-shaped incision, the base of the V being formed by the margin of the lower lid.

Second step. An incision is carried directly outwards from the external canthus. The length of this incision should be 1¼ times the length of the lid margin. An incision is then carried downwards from its outer end parallel to the outer limb of the V by which the lower lid has been excised. This flap is then raised freely (Fig. 161).

Modified Dieffenbach’s Operation Fig. 161. Modified Dieffenbach’s Operation to replace the loss of the whole lower lid. First step. The whole lower lid, together with the growth, is removed by the V-shaped incision and the flap to form the new lid is dissected up from the outer canthus. The diagram shows the incision marking out the flap.
    
Modified Dieffenbach’s Operation Fig. 162. Modified Dieffenbach’s Operation. Third step. Showing the flap turned down, to the free border of which is attached the flap of skin and ear cartilage. The inset shows the proportion of skin and cartilage (light area) to be removed from the back of the ear.

Third step. The ear is turned forward and a semilunar portion of the skin is marked out and deepened down to the cartilage. The base of this semilunar portion should be equal in length to the upper margin of the flap that is to form the new lid (Fig. 162). The skin is then dissected up for about 3 millimetres from the crescentic part of the incision back towards the straight one forming the base of the semilune. When this part of the skin has been raised the cartilage is divided, first by a curved incision, 3 millimetres behind that through the skin, and then along the straight incision joining the ends of the curved one. It is separated from the skin on the anterior surface of the ear, and the semilunar piece of skin and cartilage is thus removed. The portion of cartilage removed with the skin is smaller than the latter; the two portions coincide in length along their straight margins, but the depth of the crescent of cartilage is considerably less than that of the skin (Fig. 162). The cartilage is usually too thick to form the new tarsus and must be pared down until the right thickness is obtained. It is then applied to the inner surface of the flap to form the new lid, the skin surface being directed inwards to help to form the lower conjunctival sac. It is fixed firmly by sutures at its margin, which are passed through the whole substance of both flaps, and tied on the outer surface of the new lid.

Fourth step. The flap forming the new lower lid is sutured in position. The surface from which the flap is taken is closed as far as possible with sutures after undermining the edges, any raw area being covered by skin grafts taken from the arm.


CHAPTER X

OPERATIONS UPON THE LACHRYMAL APPARATUS

Operations upon the lachrymal apparatus are divided into—

I.Operations upon the lachrymal canals.
II.Operations upon the lachrymal gland.

The majority of operations are undertaken for the relief of obstruction to some portion of the canal which leads from the conjunctival sac to the nose, obstruction to which causes an overflow of tears (epiphora)—a condition which must be distinguished from hypersecretion (lachrymation).

The obstruction may occur in any part of the canal, that is to say, in the puncta, canaliculi, lachrymal sac or duct; and it is most important to determine the cause and position of the obstruction in every case before undertaking an operation for its relief. Hence it need hardly be said that the nose should be carefully examined in every case unless the cause is obvious. The operations are divided into two classes:—

1. Those which are undertaken for the relief of the obstruction.

2. Those which are undertaken for the obliteration of the canals.

Except under exceptional circumstances, the latter operations are only undertaken when a cure cannot be brought about by the former.

The presence of a septic focus, such as a distended lachrymal sac, apart from the irritation and increased lachrymal secretion caused thereby, is a source of grave danger to the eye if not relieved, as it is a frequent cause of serpiginous corneal ulceration.

OPERATIONS FOR THE RELIEF OF LACHRYMAL OBSTRUCTION

DILATATION OF THE CANALICULUS

Indications. (i) Contraction of the puncta following marginal blepharitis, especially when associated with ectropion.

(ii) Preparatory to syringing or probing.

(iii) To dilate a stricture of the canaliculus.

Instruments. Nettleship’s canaliculus dilator (Fig. 163).

Canaliculus Dilator Fig. 163. Canaliculus Dilator

Operation. The operation is performed under adrenalin and cocaine, a little solid cocaine being rubbed in over the canaliculus.

The lid is slightly everted and put on the stretch by pulling it downwards and outwards with the thumb. The depression caused by the punctum is seen on the top of a small elevation. The point of the dilator is entered vertically into the punctum and then turned parallel with the lid margin and passed onwards with a steady pressure. At the same time it should be rotated between the finger and thumb, until the inner bony wall of the lachrymal sac is felt. The only difficulty which may be experienced is in entering the dilator into the punctum, owing to the small size of the latter. For this reason the fine point of Nettleship’s dilator is more suitable than the form modified by Lang. Even Nettleship’s dilator is too large in a few cases, and here a large sharp-pointed pin is sometimes of use in defining the punctum before using Nettleship’s dilator.

SLITTING THE CANALICULUS

Indications. To enlarge the punctum and direct the entrance to the canaliculus inwards. This is especially desirable before ectropion operations and for the removal of concretions (leptothrix) from the duct. In former days the canaliculus used to be slit with the idea of passing very large probes down the lachrymal duct; this has now been abandoned, since slitting the canaliculus throughout its whole length, as is required for this treatment, does away with the capillary attraction.

Canaliculus Knife Fig. 164. Canaliculus Knife.

Instruments. Dilator, canaliculus knife (Fig. 164), straight iris forceps, sharp-pointed scissors.

Operation. It is usually performed on the lower canaliculus. The eye is cocainized as in the previous operation and the patient is made to look up.

First step. The canaliculus is first dilated. The knife is inserted for a short distance with the handle parallel to the lid margin. The lower lid being held on the stretch by the thumb, the handle of the knife is raised towards the brow, thus dividing the canaliculus. The blade of the knife should be directed upwards and slightly backwards.

Second step. As the lips of the wound are liable to reunite, it is better to remove the posterior lip of the groove. This is performed by seizing the latter with forceps and dividing it with scissors. The entrance to the canaliculus should be kept open by means of the dilator passed twice a week for a month.

SYRINGING THE LACHRYMAL DUCT

Indications. (i) To test whether the lachrymal canals are patent.

(ii) By constantly cleansing the sac and washing away all purulent discharge the mucous membrane may regain a more healthy condition, and so an obstruction due to an alteration in the mucous lining may be relieved. In cases with a purulent discharge a small quantity of protargol (10% solution) may be left in the sac after syringing.

(iii) The injection of adrenalin and cocaine into the sac before its excision.

Lachrymal Syringe Fig. 165. Lachrymal Syringe.

Operation. The eye is cocainized and the patient made to look up. The punctum is everted by pulling down the lower lid. The canaliculus is then dilated. The nozzle of the lachrymal syringe (Fig. 165) should be passed until it is felt to impinge on the bony outer wall of the sac. Withdraw the syringe slightly and apply gentle pressure to the piston. The fluid will either regurgitate through the upper canaliculus or, if the duct be patent, pass down into the nose and so into the throat.

Complications. If too forcible syringing be used extravasation of the fluid may take place. This is accompanied by pain and swelling in the lachrymal region. It usually subsides under hot fomentations, but suppuration and even cellulitis of the orbit have been known to occur.

PROBING THE LACHRYMAL DUCT

Indications. (i) In cases of congenital lachrymal obstruction due to débris blocking the duct.

(ii) When syringing has failed to bring about a cure, a probe may be passed once or twice to see if dilatation causes any improvement. It is especially useful in children.

(iii) As a preliminary to the insertion of styles.

Various forms of probes are employed, those of Bowman being in general use. Too fine a probe should not be used, otherwise a false passage is liable to be made.

Operation. This is performed under adrenalin and cocaine, which should be injected into the lachrymal sac.

The lower punctum is dilated and the probe passed parallel to the lid margin until it is felt to impinge upon the lachrymal bone. Keeping the point applied to the bone, the handle of the probe is rotated upwards through rather more than a quarter of a circle and passed by a gentle pressure downwards and slightly outwards into the duct, keeping the point of the probe close to the bone the whole way. The direction of the probe after entering the duct should be downwards, outwards, and backwards in the direction of the first molar tooth on the same side. The backward direction of the duct is much more marked in young children than in adults.

Complications. A false passage may be made into the antrum of Highmore. If such an accident should occur, no further attempt should be made to pass a probe for a few days until the wound has healed.

THE INSERTION OF STYLES

A few surgeons still insert styles into the lachrymal duct with the idea of continuous dilatation. The hollow styles used by Bickerton are the ones most frequently employed.

Instruments for dilating, slitting the canaliculus, probing, and styles. Also Stilling’s knife.

Operation. A general anæsthetic is desirable.

First step. The canaliculus is dilated and slit up, the posterior lip being removed (see p. 29).

Second step. The duct is dilated by probing (vide supra) or enlarged by passing Stilling’s knife down it.

Third step. A style is passed down the dilated duct. The lower end of the style should rest upon the floor of the nose, otherwise there is a tendency for the style to slip into the duct and disappear. Care should be taken that the upper end does not rub on the globe. Styles should generally be left in position from three to six months. A style should at first be made of lead wire and moulded until a suitable pattern is obtained, from which a hollow gold style can be made subsequently.

Complications. 1. Dacrocystitis may follow the insertion of a style, which should then be removed until the inflammation has subsided.

2. The style may slip down the duct. If this should occur an attempt should be made to grasp it through the slit canaliculus. The lower end may present in the nose and the style can then be withdrawn with forceps. Occasionally styles lodge in the antrum of Highmore, in which case they must be removed after localization by the X-rays through an opening from the mouth above the canine tooth.

OPERATIONS FOR THE OBLITERATION OF THE CANALS

When syringing and probing have failed to relieve the lachrymal obstruction, one of the following operations for the obliteration of the lachrymal passages may be employed.

OBLITERATION OF THE CANALICULI

Indications. In cases of lachrymal obstruction in which an immediate operation upon the globe is required.

Operation. Under cocaine. Fine sutures armed with a small curved needle are passed beneath both the upper and lower can[al]iculus and tied so as to include them in the ligature. Permanent obliteration may be caused by the destruction of the lining membrane with the actual cautery.

EXCISION OF THE LACHRYMAL SAC

Indications. (i) For mucocele in cases of lachrymal obstruction which have failed to yield to other treatment.

(ii) In all cases of tuberculous disease of the sac.

(iii) For a recurrent lachrymal abscess after subsidence of the acute inflammation.

(iv) For hypopyon ulcer associated with lachrymal obstruction.

(v) Before operation on the globe in cases of lachrymal obstruction.

(vi) For lachrymal fistula.

Instruments. Small scalpel, forceps, Muller’s speculum (Fig. 166), Axenfeld’s retractor (Fig. 167), straight scissors, horsehair sutures.

Muller’s Retractor for Excision of the Lachrymal Sac Fig. 166. Muller’s Retractor for Excision of the Lachrymal Sac.
    
Axenfeld’s Retractor for Excision of the Lachrymal Sac Fig. 167. Axenfeld’s Retractor for Excision of the Lachrymal Sac.

Operation. Hæmorrhage is the most troublesome part of this operation; it is best controlled by injecting adrenalin (made from the dried gland, ʒj, and ℥j of water) and cocaine, 10%, into the sac a quarter of an hour before operating. Swabs on the end of a glass rod dipped in adrenalin and cocaine may also be used during the operation. A general anæsthetic is desirable, but many surgeons perform the operation under local anæsthesia, produced by injecting 5% cocaine with 1 in 1,000 adrenalin into the tissue surrounding the sac; but the latter plan has the disadvantage that the mixture may cause severe toxic effects, and the patient usually experiences some pain while the upper portion of the incision is being made and the lower end of the sac is being divided.

First step. The internal tarsal ligament is first defined by putting the lids on the stretch. An incision should be made, 15 millimetres in length (5 millimetres of which should fall above the tarsal ligament), backwards and inwards directly over the lachrymal sac. Muller’s retractor is then inserted to retract the wound laterally, the hooks being made to engage the margins of the incision by means of forceps. The superficial fascia and the fibres of the orbicularis muscle are then divided. The internal tarsal ligament in the upper part of the wound, together with the glistening deep fascia, is exposed and divided carefully so as not to injure the lachrymal sac, which is found directly beneath it (Fig. 168).

Excision of the Lachrymal Sac Fig. 168. Excision of the Lachrymal Sac. Showing the internal tarsal ligament in the upper part of the wound with the sac lying beneath.
    
Excision of the Lachrymal Sac Fig. 169. Excision of the Lachrymal Sac. Showing the method of defining the upper end of the sac. The internal tarsal ligament has been divided and the sac is well pulled forward with forceps.

Second step. With scissors the sac-wall is then separated from the deep fascia which encloses it, first externally and then internally, the canaliculi being divided. Axenfeld’s retractor is then inserted in the longitudinal axis of the wound (Fig. 167). The middle of the sac is grasped with forceps and pulled forward, and the top of the sac is defined and detached. This is frequently difficult owing to the troublesome hæmorrhage which often occurs. The sac is pulled well forward, and the posterior wall is separated, the neck of the sac being divided as far down the duct as possible by means of scissors. A large probe is passed down the duct into the nose. Some surgeons remove the periosteum of the lachrymal bone as well as the sac, which is unnecessary. The wound is closed by three sutures, the middle one including the divided ends of the internal tarsal ligament. A firm dressing should be applied so as to keep the walls of the cavity in contact. In tuberculous cases it is desirable to curette the lower end of the duct after removal of the sac. The stitches are removed on the seventh day.

Complications. These may be immediate or remote.

Immediate. 1. Inability to find the sac. This may happen to a beginner, and is generally due to the fact that the dissection is carried too much inwards towards the nose. It should not occur if the guides to the sac carefully borne in mind, namely, the internal tarsal ligament and, on the inner side, the lachrymal crest, which can easily be felt with the finger or forceps in the wound.

2. Opening the conjunctival sac. This may take place when dividing the canaliculi. It is more likely to occur if the deep fascia has been imperfectly divided before carrying out the dissection to the inner side. As a rule the opening heals readily.

3. Opening of the orbit, due to the division of the fascia attached to the posterior lip of the lachrymal groove. It is recognized by the fact that orbital fat presents in the wound, and for this reason it makes the operation more difficult. It is most likely to happen when the lower end of the sac is being divided. It lays the orbit open to the possibility of septic infection. The internal rectus has been divided, no doubt due to the fact that the fascia, which passes from the outer surface of this muscle, is attached to the posterior lip of the lachrymal groove, and the muscle has been thereby pulled up into the wound; with ordinary caution such an accident is impossible.

4. Injuries to the cornea. Corneal abrasions by the clumsy insertion of retractors may lead to severe corneal ulceration.

Remote. 1. Epiphora. Normally the lachrymal secretion is largely removed from the conjunctival sac by a process of evaporation. It is only when the hypersecretion of tears takes place that the lachrymal apparatus is called much into use. As a rule, patients who have had the lachrymal sac excised do not complain of epiphora, except in a cold wind. Occasionally this epiphora may be so troublesome that removal of the palpebral portion of the lachrymal gland is desirable for its relief. There is no fear of the conjunctival sac becoming dry after this operation, since there are numerous accessory lachrymal glands (glands of Waldeyer and Krause) opening on to the superior fornix.

2. A sinus. The wound may break down and a sinus may form at the site of the incision. These cases are nearly always of tuberculous origin and not infrequently have underlying bone trouble. They can usually be made to heal by the use of iodoform and scraping.

3. Recurrence of the mucocele or lachrymal abscess. Occasionally the mucocele may re-form, or an abscess result after removal of the sac. This is due either to a piece of sac-wall being left behind, or to the relining of the cavity with epithelium from the cut end of the duct. It is particularly liable to occur in cases of a tuberculous nature. Firm pressure with the dressings after the operation is the best method of preventing the cavity relining with epithelium. If the condition has arisen, the pseudo-sac should be excised.

OPENING A LACHRYMAL ABSCESS

Indications. Lachrymal abscess is due to an inflammation around the sac-wall through which infection of the cellular tissue has taken place. The abscess should not be opened until pus is present, as even considerable swelling and œdema will often subside without suppuration; this is usually about the end of the third day. Further, if the opening be made too soon, the inflammation takes considerably longer to subside.

Instruments. Beer’s knife, forceps, and probe.

Operation. Usually performed under gas. An incision is made over the lachrymal sac and is carried downwards and inwards to the bone by a single puncture of the knife. The pus is evacuated, and the cavity stuffed with gauze, which should be changed daily for the first three days. Hot fomentations should be applied. As soon as the swelling has subsided, the lachrymal obstruction should be treated by one of the methods previously described.

OPERATIONS UPON THE LACHRYMAL GLAND

REMOVAL OF THE PALPEBRAL PORTION
Excision of the Palpebral Portion of the Lachrymal Gland Fig. 170. Excision of the Palpebral Portion of the Lachrymal Gland. The lid is doubly everted and the gland is dissected out from within outwards.

Indications. For obstinate epiphora after removal of the lachrymal sac.

Instruments. Fixation forceps (two pairs), two sharp hooks, strabismus scissors, suture.

Operation. Usually performed under adrenalin and cocaine.

First step. The upper lid is doubly everted. The eversion is best carried out by holding the singly everted lid between forceps and then re-everting it; the forceps are then given to an assistant to hold. With a syringe a few drops of 5% cocaine are injected through the conjunctiva into the area to be operated upon.

Second step. The gland is seen beneath the conjunctiva at the outer part of the upper fornix, seized with forceps, and drawn forwards. A horizontal incision is made with scissors through the conjunctiva, which is dissected backwards. The edges of the wound are then held apart by means of sharp hooks (Fig. 170).

Third step. The gland, which is seen as a nodule, is drawn forward with forceps. By means of the scissors the gland is separated from its attachments along its whole length, starting on the inner side, the wound being subsequently closed with a few points of catgut suture.

REMOVAL OF THE ORBITAL PORTION

Indications. It is usually undertaken for tumours (endotheliomata, &c.) and retention cysts.

Instruments. Knife, artery and dissecting forceps, retractors, ligatures.

Operation. Performed under a general anæsthetic.

First step. An incision, three inches long, is made through the skin immediately below the outer third of the orbital margin. The underlying orbicularis palpebrarum is divided, and the orbital fascia covering the gland is defined and incised.

Second step. The gland is first separated from the periosteum of the depression in the bone in which it lies, and is drawn forward and carefully dissected out from the lid. The wound is then closed with sutures.

An abscess in the lachrymal gland should be opened by an incision similar to, but not so long as that in the above operation.

OPERATIONS UPON THE ORBIT

EXPLORATION OF THE ORBIT (KRÖNLEIN’S METHOD)

In this operation the bony outer wall of the orbit is divided above and below, and turned outwards so as to expose the orbital contents without interfering with the globe; the bony wall, being kept attached to the overlying tissue, can be replaced subsequently without fear of necrosis.

Indications. The operation is performed in cases of a suspected tumour of the orbit, which, if small and non-malignant, can be removed, the eye being left in situ. If doubt exists as to the nature of the tumour a piece can be removed and examined microscopically, either at the time of the operation or later. It is especially suitable for tumours of the optic nerve and for orbital cysts behind the globe.

Instruments. Scalpel, dissecting forceps, artery forceps, scissors, periosteum detacher, chisel and hammer, or preferably, a motor rotary saw, and retractors.

Operation. Performed under a general anæsthetic.

First step. A slightly curved incision with the convexity forwards is made so as to expose the outer margin of the orbit and carried down to the bone. The periosteum is separated from the inner surface of the outer wall of the orbit by means of a periosteum detacher and divided horizontally, the finger is inserted, and the orbit explored. If a small tumour or cyst be found it can sometimes be shelled out through this incision without enlarging the wound further.

Second step. The eye and orbital contents are carefully protected with a large flat retractor. The bone is first divided above, by means of either a chisel or a saw. The upper incision should pass through the base of the external angular process of the frontal bone, and run backwards and slightly downwards to the posterior end of the spheno-maxillary fissure. The lower incision should run directly backwards from the lower orbital margin into the spheno-maxillary fissure. The triangular wedge of bone attached by its outer surface to the soft tissues in the temporal fossa is then forced outwards. In doing this care must be taken not to fracture the orbital wall anteriorly, otherwise the space to work in will be much reduced.

Third step. Consists in the removal of the tumour. Care must be taken to displace the external rectus to one side so as to avoid injury to it as much as possible. If the case should be one of an optic nerve tumour, for which the operation is most frequently performed, the optic nerve is divided close behind the globe. The tumour is freed from the surrounding ciliary nerves and the ophthalmic artery and brought up into the wound as much as possible. The optic nerve is then divided at the apex of the orbit and the tumour removed. The wound in the periosteum of the outer wall of the orbit is closed with a catgut suture, the bone, together with the soft parts, replaced in position and the skin wound closed by sutures. A drainage tube should be inserted for at least twenty-four hours.

Complications. 1. Proptosis. The operation is liable to be followed by great proptosis as the result of hæmorrhage into the orbit. If the optic nerve has been removed, the globe may be dislocated forwards between the lids and come in contact with the dressings.

2. Corneal ulceration. As the cornea is frequently anæsthetic from division of the ciliary nerves, ulceration is very liable to follow. It is, therefore, desirable in many cases to stitch the lids together after closing the skin wound.

3. Defective outward movement in the globe is of frequent occurrence, owing either to injury of the external rectus or the sixth nerve, or to involvement of them in the scar tissue. Stitching the periosteum together obviates the latter to a certain extent.

4. As the wound cicatrizes a certain amount of enophthalmos is very liable to result.

EVISCERATION OF THE ORBIT

Indications. This operation is usually performed for some form of new growth originating either in the eye or the orbit.

Operation. This may be modified (1) according to the position of the growth. In severe cases of rodent ulcer and sarcomatous growths, which involve the lids, it is desirable that the lids should be removed with the tumour; but in cases of tumour of the optic nerve, or disease situated far back in the orbit, and not involving the lids or conjunctiva, these structures may be retained, since a much better socket is thus obtained. (2) The nature of the growth. In simple tumours, such as nævi and some cases of arterio-venous aneurism which have failed to yield to other treatment, the incomplete method, in which the lids are retained, is all that is necessary, but in malignant cases they should be removed.

The Complete Method. An incision down to the bone is first made, completely encircling the orbital margin and including any growth that may be involving the skin. The periosteum is then separated completely, as near to the optic foramen as possible. Care must be taken in dealing with the periosteum over the lachrymal bone, as the bone is liable to be fractured and an opening made into the nose if undue force be used. The apex of the cone formed by the periosteum is divided, as far back as possible, with curved scissors, and the whole orbital contents are removed. The wound is packed with gauze, and skin-grafting is subsequently performed when the bone has become covered with granulations; this usually occurs about the end of the second week.

The Incomplete Method. The globe is first enucleated and the outer canthus divided. The lids are well retracted and an incision is carried down to the bone along the orbital margins. The periosteum is then stripped up from the walls of the orbit and the apex of the cone divided as far back as possible, as in the previous operation. The conjunctiva and outer canthus are then united with sutures. As a rule, skin-grafting is not necessary after this operation.

OPENING AN ORBITAL ABSCESS

Orbital abscesses should be incised where they point. In the upper lid care should be taken not to divide the levator palpebræ muscle; the incision should be placed well to one side. In making an incision over the inner side of the orbit care should be taken not to detach the pulley of the superior oblique. The cause of the abscess should be ascertained if possible. Suppuration in the ethmoidal sinuses coming through from the nose is the commonest cause, and should be treated appropriately (see Section V).


SECTION III

OPERATIONS UPON THE EAR

BY
HUNTER F. TOD, M.A., M.D. (Cantab.), F.R.C.S. (Eng.)
Aural Surgeon to the London Hospital

CHAPTER I

EXAMINATION OF THE EAR: GENERAL CONSIDERATIONS
WITH REGARD TO OPERATIONS

In order to perform successfully the various operations upon the ear, it is essential that the surgeon should be familiar with the technique of its examination, which, for the sake of convenience, will first be briefly described.

EXAMINATION OF THE EAR

Clar’s Lamp Fig. 171. Clar’s Lamp.

For this purpose it is necessary to make use of certain instruments in order to obtain a clear view of the deeper parts of the auditory canal and tympanic membrane. Most important amongst these are the following:—

Mirror. A head-mirror, such as the ordinary laryngological mirror with a focus of eight inches, is to be preferred to the hand-mirror, as it leaves both hands free for manipulation.

Sources of illumination. Although the light reflected from the sky on a bright cloudless day is excellent, it can seldom be made use of, and so for practical purposes the source of light is usually artificial. It is wiser always to use the same kind of light—for instance, electric—as in this way a more accurate comparison can be made of the various pathological conditions seen on examination. In the consulting room, the lamp recommended by Dr. Greville Macdonald, furnished either with a thirty-two candle-power frosted burner or with a Nernst light, is most suitable. As a portable lamp, it is useful to have an electric bull’s-eye lamp, run off from a dry-celled battery: it can be held in the position of the ordinary lamp, the light being reflected into the ear by means of the head mirror. The ordinary surgical head-lamp, although not well adapted for inspection of the deeper parts of the auditory canal, is eminently suited for obtaining good illumination during the performance of the mastoid operations; or in its stead a head-mirror with lamp attached may be used, as recommended by Clar (Fig. 171).

Aural specula. Of the various aural specula employed, Gruber’s is very good (Fig. 172). A special speculum in which a portion has been removed from the narrow end is sometimes useful in order to facilitate operative procedures within the external meatus.

Forceps. The best are angular spring forceps with bulbous points (Fig. 173).

Gruber’s Aural Speculum
Fig. 172. Gruber’s Aural Speculum.
    
Angular Spring Forceps Fig. 173. Angular Spring Forceps.

Position of the patient. The patient should sit upright in a chair with the side to be examined turned towards the surgeon. To prevent movement, the head should be supported by an assistant or by a head-rest fixed to the back of the chair. The lamp is placed a little behind and to the left of the patient’s head, on a level with the head of the examiner.

Technique of examination. To convert the external meatus into a straight canal, the auricle has to be pulled backwards and downwards in an infant, backwards in a child, and backwards and upwards in an adult. The speculum should be warmed and inserted gently into the meatus by the thumb and index-finger of the left hand, whilst the pinna is held between and pulled back by the second and third fingers (Fig. 174). This leaves the right hand free for manipulation. The largest possible speculum should be used, in order to give the maximum amount of room and illumination. It should only be introduced into the meatus as far as the adaptable cartilaginous portion permits—about half an inch in the adult—and not forced into the bony portion. The utmost gentleness is essential in order to obtain the confidence of the patient; this is absolutely necessary for the performance of the various small operations upon the auditory canal and tympanic cavity under local anæsthesia.

Examination of the Ear Fig. 174. Examination of the Ear.
    
Aural Forceps holding Cotton-wool Fig. 175. Aural Forceps holding Cotton-wool.

Method of cleansing the ear. Except when the auditory canal is completely blocked by inspissated pus, cerumen, or epithelial débris, it is sufficient to mop out the ear with small pledgets of cotton-wool. To prevent injury to the walls of the meatus and to the tympanic membrane, the pledget is held between the blades of the forceps in such a fashion that it partially projects beyond its points (Fig. 175). The forceps is passed through the lumen of the speculum along the auditory canal and then quickly withdrawn. This is repeated with fresh pledgets until the meatus is cleansed. If there is much purulent discharge, only a brief moment may be given (after the withdrawal of the forceps) in which to inspect the deeper parts. Such a view, however, should always be obtained in order to form an accurate diagnosis. If this method fails to cleanse the ear, syringing becomes necessary.

Technique of syringing. The patient should be sitting down, as syringing may cause giddiness. The fluid should be aseptic, and at a temperature of 100° F. The patient’s head is inclined to the affected side, and the auricle is pulled upwards or backwards. The syringe is inserted a short distance within the meatus, and applied to the upper posterior wall so that the stream of lotion flows along the roof of the canal to the drum, and returns along the floor, thus washing out the contents. The best syringe is one with a metal plunger, as it can be easily sterilized. After syringing, the auditory canal should be dried and again inspected. If the inspissated pus or epithelial débris cannot be removed by simple syringing, an ear-bath of warm hydrogen peroxide (10 vols. %) should be given, and the ear again syringed after ten minutes.

Milligan’s Intratympanic  Syringe Fig. 176. Milligan’s Intratympanic Syringe.

Syringing out of the attic. In certain cases of chronic attic suppuration, it is advisable to syringe out the attic. For this a special syringe is necessary. It consists of a fine canula whose point is turned up almost at right angles to its shaft (known as Hartmann’s canula), to which is fitted a piece of india-rubber tubing and a ball syringe. Milligan’s modification of this instrument is now generally used, as it permits of the canula being held in the hand, and instead of having a ball syringe, is connected by rubber tubing to a small irrigator (Fig. 176).

The patient sits upright in a chair in the ordinary position for examination of the ear; a speculum is inserted into the meatus, and held in position with the left hand; the canula, together with the ball syringe (if Hartmann’s is used), is held in the right hand. Under good illumination the canula is passed inwards along the auditory canal, and its point inserted through the perforation. By gently pressing on the syringe, the fluid is forced into the attic, which is thus washed out.

With Milligan’s instrument, the irrigator is fixed about two feet above the level of the ear. While the canula is being inserted, the escape of lotion is prevented by compressing the tube against the shaft of the instrument by means of the thumb. After the canula has been inserted into the opening, relaxation of this pressure permits of flow of the lotion. Milligan’s method is better than Hartmann’s, as the surgeon has more control over the instrument. Pain due to the introduction of the canula may be greatly minimized by previously inserting within the margins of the perforation either a pledget of cotton-wool soaked in a saturated solution of cocaine, or a crystal of cocaine.

After the cavity has been thoroughly washed out, the auditory canal is carefully dried as a final step, gentle inflation by Politzer’s method may be performed in order to expel any fluid still remaining within the attic.

GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS

In this connexion two points must be borne in mind: (1) The surgeon must have a good view of the part operated upon. For this reason when operating upon the auditory canal, the tympanic membrane, and tympanic cavity, he will usually require to work by reflected light.

(2) There must be no movement of the patient’s head during the operation. If the operation is performed under a local anæsthetic, it is therefore very important that the patient’s head should be kept fixed by means of an assistant.

Preliminary surgical toilet. If there be no existing suppuration, the ear should be cleansed, some twelve hours before the operation, by first giving an ear-bath of hydrogen peroxide lotion. This is done by making the patient incline the head to the opposite side so that the affected ear is uppermost. The warm solution is then poured into the meatus. After ten minutes the ear is syringed out with a 1 in 5,000 aqueous solution of biniodide of mercury, and a strip of sterilized gauze is then inserted into the auditory canal. The auricle and surrounding parts should also be surgically cleansed, and afterwards protected by a simple aseptic compress. If, as in furunculosis of the external meatus, syringing or cleansing of the ear is very painful, drops of a 10% solution of carbolic acid in glycerine may be instilled frequently into the meatus instead. If there is an existing otorrhœa, it is obviously impossible to render the field of operation absolutely aseptic. The ear, however, should be cleansed, but the auditory canal should not be plugged with gauze. The existence of a purulent discharge is no excuse for lack of cleanliness. Failure of such precautions may lead to disaster; for example, to perichondritis of the auricle as a sequel of the mastoid operation.

Before the actual operation takes place, if necessary after the anæsthetic has been given, the ear and surrounding parts should again be carefully cleansed, and the auditory canal syringed out with biniodide of mercury solution.

In intrameatal operations the head should be wrapped in a sterilized towel, and a square of sterilized lint, having an aperture in the centre so as to expose only the auricle and meatus, should be placed over the side of the head and face. In operations on the mastoid process, and in those involving a post-auricular incision, the head should also be shaved for at least two or three inches beyond the region of the ear.

Anæsthesia. Both local and general anæsthesia are used. Unless contra-indicated for some special reason, and unless the operation is a very trivial one, it is wiser to give a general anæsthetic. Of these, chloroform is the most suitable in adults and infants, and the A. C. E. mixture in children. Ether, although it may be safer, is frequently a source of annoyance to the operator, as it tends to increase the hæmorrhage.

In order to produce local anæsthesia two methods may be employed: (1) The instillation of fluids into the meatus; (2) subcutaneous injection of fluids beneath the lining membrane of the meatus and into the surrounding parts of the auricle.

The solution usually employed is a sterilized aqueous solution of cocaine hydrochloride in varying strengths up to 20%, to which may be added equal parts of 1 in 1,000 adrenalin chloride solution; the latter not only increases its analgesic properties, but also acts as a powerful hæmostatic.

Instillation. As the auditory canal and the tympanic membrane are lined with epithelium which is very resistant to the absorption of fluids, complete anæsthesia is almost impossible to obtain. This method, therefore, is practically limited to such trivial operations as the curetting away or snaring off of granulations or polypi from the external or middle ear. To render anæsthesia more complete, the affected part may be finally rubbed over with a crystal of solid cocaine hydrochloride just before the operation—is begun. On the other hand, if the raw surface is large—for example, the wound left after a recently performed complete mastoid operation—the cocaine employed should not be stronger than a 5% solution in order to minimize the risk of poisoning. Gray of Glasgow has suggested, as a more penetrating anodyne solution, a mixture consisting of a 10% solution of cocaine hydrochloride in equal parts of aniline oil and absolute alcohol, a solution which he especially advocates in order to produce anæsthesia of the tympanic membrane before doing paracentesis.

Subcutaneous injection. This is a modification of Schleich’s method, and was first introduced by Neumann of Vienna. It consists in injecting a very weak solution of cocaine and adrenalin chloride subcutaneously beneath the periosteum lining the auditory canal. By this method even the complete mastoid operation has been performed, and in certain clinics it is used continually in the minor operations of paracentesis of the tympanic membrane, division of intratympanic adhesions, extraction of polypi, and ossiculectomy. A solution of beta-eucaine or novocaine may be used in preference to cocaine, as being less dangerous. According to Neumann, three solutions are necessary: (a) a 1 in 2,000 solution of adrenalin chloride containing a 1% solution of beta-eucaine; (b) a 1 in 3,000 solution of adrenalin chloride containing a 1% solution of cocaine; (c) a 20% solution of cocaine.

Neumann’s Syringe for Subcutaneous  Injection Fig. 177. Neumann’s Syringe for Subcutaneous Injection.

The syringe for injecting the solution has a capacity of 1 cubic centimetre, and for convenience its needle is fixed at an obtuse angle to the body of the syringe (Fig. 177). The technique of the injection depends on whether the operation is to be limited to the auditory canal and tympanic cavity, or is to involve the mastoid process.

If the complete mastoid operation is going to be performed, the needle of the syringe, now filled with the eucaine solution, is thrust through the skin about the middle point of the mastoid process, and a few drops of the solution are injected. The needle is then forced upwards towards the temporal ridge, at the same time being thrust in deeply until it touches the bone, so that a syringeful of the solution is injected beneath the periosteum. The needle is then withdrawn and reinserted at the same point, but in a backward direction, the solution being injected along the posterior portion of the mastoid process; in a similar manner the solution is injected downwards towards the tip of the mastoid. The ear being now pulled well forward, the needle is made to pierce the fold between the auricle and the mastoid process, just above the posterior ligament, and is pushed inwards between the anterior border of the mastoid process and the cartilage of the meatus, and a further syringeful of the solution is injected. A large speculum is now inserted into the ear, so that by pressing it against the wall of the meatus the skin, at the termination of the cartilaginous portion, is made to project in folds. The needle of the syringe, filled with cocaine solution, is pushed into this fold, and a few drops of the solution injected. By degrees the needle is still further pushed inwards, keeping it in close contact with the bony wall so that the fluid is injected beneath the periosteum. If the injection has been successful, a white bulging of the superior wall of the auditory canal will be noticed. To render anæsthesia complete, further injections may be made into the inferior and anterior walls of the auditory canal. Finally, a pledget of cotton-wool soaked in a 20% solution of cocaine is pushed into the tympanic cavity.

In the case of simple opening of the mastoid, subcutaneous injections into the auditory canal are not necessary. On the other hand, if the operation is limited to the auditory canal and tympanic cavity, the injections into the mastoid process are not required, but a primary injection of a small quantity of eucaine solution into the auriculo-mastoid fold considerably diminishes the pain produced during the act of injection into the auditory canal. Fifteen minutes should be allowed to elapse before the operation is begun. The anæsthesia lasts about half an hour.

Difficulties. It is by no means easy to inject fluid beneath the periosteum of the auditory canal, owing to its close adherence to the bone. The needle by mistake may repierce the skin at a point farther in, so that the fluid, instead of being injected beneath the periosteum, is injected into the auditory canal itself. In these cases anæsthesia will not be obtained, and the operator may possibly blame the principle of subcutaneous injection, rather than his own faulty technique.

In favour of subcutaneous injection it is urged that most of the minor operations within the tympanic cavity, including ossiculectomy, may be performed with the patient sitting up in the chair in the consulting room, and further, that the patient can afterwards go home; that the operation is rendered more easy owing to there being practically no bleeding; and that in the case of the more severe operations, such as opening of the mastoid antrum, the surgeon, in a case of emergency, may make use of this method if he cannot possibly obtain the services of an anæsthetist.

Against subcutaneous injection is the pain of the injection, which may be so great that the patient will not submit to it, and in consequence the proposed operation may have to be postponed.

In the case of the mastoid operation, it is difficult to believe that local anæsthesia, however efficient, will be looked upon with favour either by the surgeon or by the patient, except when a general anæsthetic is absolutely contra-indicated. The discomfort produced by retraction of the parts, the jarring caused by chiselling, and the consciousness of what is taking place, are far more unpleasant and more of a shock to the patient, than a general anæsthetic carefully given. Further, it is not always possible to foretell the extent of the operation, and if repeated injections become necessary, there is danger of eucaine or cocaine poisoning being produced.

Position of the patient and the surgeon

1. In the minor operations the patient may be operated on whilst in the sitting posture, whether a local anæsthetic or a general one of gas and oxygen is employed. The relative positions of the patient and the surgeon are then the same as for the ordinary routine examination of the ear. Special care, however, should be taken that the patient’s head is supported by the anæsthetist or assistant in order to prevent involuntary movements.

2. If the patient is operated on in the recumbent position, the head may rest comfortably on an ordinary pillow, but if chiselling is going to take place, the best support is a loosely filled sand-bag. The head should be turned towards the opposite side so that the affected ear is uppermost, and the surgeon stands at the side to be operated on. The lamp, the source of reflected light, should be held about six inches above the patient’s shoulder on the opposite side.


CHAPTER II

OPERATIONS UPON THE EXTERNAL AUDITORY CANAL

OPERATIONS FOR FURUNCULOSIS

The operative treatment consists in incising the furuncles and, if necessary, curetting out their contents.

Indications. (1) If, in spite of palliative treatment for two days, the pain be so intense as to prevent sleep, and be accompanied by pyrexia.

(2) If there be accompanying œdema of the auricle and surrounding parts.

(3) If the furuncles occur during the course of a middle-ear suppuration, and occlusion of the external meatus prevents free drainage of the purulent secretion.

When possible, it is always preferable to operate under a general anæsthetic, such as gas and oxygen. If, however, the patient objects to a general anæsthetic, it should be explained that, in spite of the application of anodynes, the operation, although of momentary duration, will be excessively painful.

Operation. After the ear has been thoroughly cleansed, a large aural speculum is inserted within the meatus and the auditory canal dried with pledgets of cotton-wool.

The instrument usually used for this operation is a small and narrow sharp-pointed knife known as Hartmann’s furunculotome (Fig. 178, C). Equally suitable, however, is a fine bistoury; or, if necessary, a small tenotome or the ordinary paracentesis knife.

Burkhardt-Merian’s Aural Instrument Fig. 178. Burkhardt-Merian’s Aural Instrument.

A. Curette. B. Myringotome. C. Furunculotome.
D. Hook for removal of foreign body.

The surgeon holds the speculum in position within the meatus with the left hand, and with the right inserts the knife through the lumen of the speculum along the meatus until its point passes the innermost limit of the furuncle. It is then quickly withdrawn, at the same time incising the furuncle freely down to its base. Another method is to transfix the furuncle by passing the knife through its base and making it cut outwards through the skin. In a similar manner any other furuncles that may be present are incised or transfixed.

If the inflammatory process, instead of being localized as a furuncle, extends to the subcutaneous tissues, and especially if it is accompanied by much pain, pyrexia, and occlusion of the external meatus, linear scarification may become necessary.

After incision, the contents of the furuncle are rapidly scooped out with the curette (Fig. 178, A). Slight hæmorrhage may occur, but can be arrested at once by plugging the meatus for a minute with a strip of sterilized gauze. The auditory canal is finally syringed out with a warm aqueous 1 in 5,000 solution of biniodide of mercury and firmly plugged with gauze soaked in a 10% solution of carbolic acid in glycerine; a hot fomentation being afterwards applied to the side of the head.

If the operation has been performed under a local anæsthetic (and this should only be done if a solitary furuncle is present), the pain is usually too great to permit of firm packing of the auditory canal. This after-packing, however, should be carried out, if possible, for the following reasons: firstly, it presses out the contents of the furuncle; secondly, it prevents auto-infection from one hair follicle to another; and thirdly, it tends to dilate the auditory canal.

After-treatment. If the furuncles have occurred during the course of a middle-ear suppuration, the gauze plugging must be removed within a few hours after the operation. The ear is then syringed out once or twice daily with a warm solution of lysol or carbolic acid, a small wick of gauze soaked in a 10% solution of carbolic acid in glycerine being afterwards inserted along the meatus.

If there be no accompanying middle-ear suppuration, the packing should not be removed for at least twenty-four hours. The pain produced by the first dressing may be severe, but can be usually avoided by first soaking the gauze with 5% solution of cocaine for a few minutes before removal and then gently withdrawing it whilst the ear is being syringed with a warm aseptic lotion. For the next two or three days it is sufficient to insert a drain of gauze soaked in a 1 in 3,000 alcoholic solution of perchloride of mercury.

Results. Although cure may be expected, it is not uncommon for further furuncles to occur in crops at repeated intervals. This is due to auto-infection of the hair follicles, which to a large extent may be prevented by painting the surface of the auditory canal daily, for at least two or three weeks, with an oil containing a drachm of nitrate of mercury to the ounce.

In the case of diffuse inflammation, although relapses are uncommon, superficial necrosis of a portion of the bony meatus may afterwards occur as a result of involvement of its periosteal lining. If this takes place, stenosis of the auditory canal may afterwards occur from subsequent cicatrization.

Dangers. With ordinary precautions no accident should occur, but the following may be mentioned: (1) if the furuncles are deeply placed, the tympanic membrane may be incised inadvertently, and a middle-ear suppuration may result; (2) a too violent incision may cut through the meatal cartilage posteriorly, and, as a result of septic infection, may give rise to perichondritis of the auricle. This, fortunately, is rare.

REMOVAL OF EXOSTOSES FROM THE EXTERNAL MEATUS

Indications. The indications vary, depending on whether there is a coexisting middle-ear suppuration or not.

If there be no middle-ear suppuration. Operation is not urgent, but is justifiable under the following conditions:—

(i) When one ear only is affected. (a) If there be complete deafness due to obstruction of the auditory canal. The question of operation, however, should be decided by the patient, because it may be postponed indefinitely so long as no symptoms occur.

(b) If there be recurring attacks of discomfort or of pain in the ear as a result of eczema, of otitis externa, or of actual pressure of the growth itself. The patient may desire operation to obtain permanent relief.

(c) If there be deafness of the opposite side from other causes, and the presence of the exostoses is causing deafness of the functionally good ear.

(ii) When both ears are affected. In addition to the indications already given, operation is advisable on the worse side if there be almost complete obstruction on both sides, accompanied by recurrent attacks of deafness, owing to the narrowed passage of the auditory canal becoming repeatedly blocked from accumulation of cerumen or epithelial débris.

Operation is contra-indicated if previous examination indicates that the deafness is due to a chronic middle-ear catarrh or internal-ear disease, as in these cases restoration of hearing, which is the primary object of the operation, will be impossible.

If middle-ear suppuration be present operation is generally advisable.

(i) In acute middle-ear suppuration operation is urgent if there are signs of retention of pus, provided it is impossible to dilate the lumen of the auditory canal. Before resorting to operation an attempt should always first be made to obtain free drainage, as the obstruction may be due merely to inflammatory swelling of the tissues lining the auditory canal. With cessation of the acute inflammation, this swelling may subside and the lumen of the auditory canal again become patent; and if recovery with healing of the tympanic membrane takes place the hearing may again become normal, rendering the operation no longer necessary.

(ii) In chronic middle-ear suppuration operation is always indicated if there are symptoms of retention of pus. It is also advisable as a prophylactic measure, although not urgent, even although no acute symptoms are present.

Operation. When there is no middle-ear suppuration.

The operation may be performed either (a) through the external meatus or (b) by reflecting the auricle forward by a post-auricular incision.

Through the external meatus. This method is only indicated if the exostosis is situated at the entrance of the meatus and is pedunculated.

A general anæsthetic is given, the patient being in the recumbent position. The surgeon works by reflected light. After the ear has been thoroughly cleansed a large-sized aural speculum is inserted into the meatus and the outlines of the exostosis are defined with a probe. A small gouge or chisel is used. It is inserted into the meatus in such a fashion that its point presses between the pedicle of the exostosis and the wall of the bony meatus. With successive sharp taps of the mallet, the gouge is made to cut through the pedicle, care being taken that the instrument is not driven in too deeply, on to the tympanic membrane.

The growth, which can now be felt to be movable within the meatus, can usually be removed by grasping it between the blades of forceps, or can be expelled by syringing the ear. After its removal the auditory canal should be plugged for a few minutes with a solution of cocaine and adrenalin chloride. This checks all hæmorrhage, and at the same time enables the surgeon to get a good view of the deeper parts to see if further growths are situated more deeply within the meatus. Such growths, provided they are pedunculated and do not abut on the tympanic membrane, can sometimes also be removed by the same method; much depends on their shape and situation. If sessile or too deeply placed, the operation may have to be completed by reflecting forward the auricle. Before terminating the operation a clear view of the tympanic membrane should always be obtained.

The meatus is finally syringed out with a 1 in 5,000 aqueous solution of biniodide of mercury and dried, a strip of sterilized gauze being inserted into the auditory canal. A simple dressing is then applied to the side of the head.

Other methods of operation through the external meatus.

(a) Perforation of the exostosis, or enlargement of the small passage existing between multiple exostoses, by means of the burr.

Although successful results have been recorded, this method is not advised, as cicatricial tissue almost invariably causes closure of the opening made. To keep the opening patent it is necessary to insert a small lead or silver canula, frequently a source of great discomfort.

(b) If the exostosis has a very fine pedicle, it may be possible to nip through its base with a pair of forceps, but it is not so sure a method as the employment of a gouge and mallet.

(c) Such methods as attempts to destroy the growth by means of the galvano-cautery or by the pressure of laminaria tents should be avoided; they are useless and unsurgical.

By reflecting the auricle forward. This is indicated if the exostoses are multiple, have a broad base, and are deeply situated.

The position of the patient, and the anæsthetic, are the same as in the previous operation. Reflected light may not be necessary.

The ear and the surrounding parts are carefully cleansed and the head is shaved for a short distance over and beyond the mastoid process. A curved incision is made close behind the auricle (Fig. 226), beginning at the upper level of its attachment and extending downwards along the retro-auricular fold. The incision goes down to the bone. The auricle is reflected forward and the soft tissues are separated from the bone until Henle’s spine and the posterior upper margin of the auditory canal are brought into view. Any bleeding, chiefly from branches of the posterior auricular artery, is at once arrested by pressure forceps, ligatures being afterwards applied. The assistant’s duty is to hold the auricle well forward and at the same time to keep the wound dry by swabbing.

The fibrous portion of the canal is carefully separated from the bony portion with the periosteal elevator, the growth, if possible, being exposed without tearing through the thin layer of skin which covers it.

The method of procedure now depends on the character and number of the exostoses present.

(a) If situated superficially, they are removed by chiselling through their base with a gouge. They should be thoroughly removed, if necessary cutting through the normal bone well behind their base.

(b) If deeply placed, they are more easily removed by first chiselling away a part of the upper posterior wall of the external meatus. This is done in the same manner as in the early stage of the complete mastoid operation (see p. 397). If possible the antrum should not be exposed, and care should be taken not to cut too deeply for fear of injuring the tympanic membrane.

(c) If the exostoses spring from the anterior wall, it is necessary to make a T-shaped incision through the posterior membranous portion of the auditory canal in order to bring them into view clearly. This is done with a tenotomy knife, the flaps being held apart by means of forceps. The growths can now be removed by means of the gouge and mallet.

(d) If the obstruction is due to multiple small exostoses forming an annular stricture within the bony canal, it is better to separate the membranous portion completely from the bony meatus. In doing so the skin over the exostoses tears through, so that the membranous portion can be reflected outwards as a finger-like process. To give greater room for the operation, the auricle and fibrous portion are pulled well forward by means of a loop of gauze passed through the lumen of the cartilaginous meatus.

If necessary, reflected light should now be used. To reach the exostoses it may be necessary, as in the previous case, to remove part of the posterior bony wall. With the gouge and mallet the exostoses are carefully chiselled away. They frequently abut on the tympanic membrane, so that their removal without injuring it may be well-nigh impossible. It is of the utmost importance that the field of operation should be kept dry, if necessary by repeatedly mopping out the canal with pledgets of cotton-wool soaked in adrenalin solution. The chief difficulty is to determine the situation of the tympanic membrane. A fine probe is used to discover any existing chink between the growths; this will be a guide to show the direction in which to work. As soon as a small passage has been made, sufficient to allow of a view of the deeper-lying parts, the ear should be syringed out and dried, and a thorough inspection made. The tympanic membrane can usually be seen as a greyish-blue membrane; at other times it can be recognized by touching it with a probe. After making certain of the position of the membrane, the rest of the operation is easy. A small seeker (Fig. 219), such as is used in the mastoid operation, is passed through the opening already made, and with it the deeper limits of the exostoses can be felt. The opening is gradually enlarged by removing the growths piecemeal with the chisel or gouge.

Although the burr is contra-indicated when operating through the external meatus, it is frequently of great service in these cases in rendering the walls of the canal smooth. The disadvantages of using a burr are, that it is less easy to control (unless the surgeon has had considerable experience in using it), and that it destroys all the epithelial lining of the auditory canal with which it comes in contact. It should, therefore, only be used in those cases in which there is a complete ring of exostoses, but should be avoided if the exostoses are limited and if it is still possible to leave untouched a portion of the epithelial lining of the auditory canal.

When the surgeon considers he has successfully removed the obstruction, he should verify this fact by syringing out and drying the ear, and again obtaining a clear view of the tympanic membrane.

The fibrous portion is now replaced by inserting a finger into the cartilaginous meatus and pressing it back into the bony canal, the auricle being meanwhile pulled back into its normal position. The edges of the posterior wound are sutured together and the auditory canal is gently packed with gauze which should be inserted right down to the tympanic membrane. It is not necessary to make special meatal skin flaps, as careful packing of the auditory canal should be sufficient to keep the parts in apposition.

When middle-ear suppuration is present. In acute middle-ear suppuration the chief difficulty is to decide what operation to perform. As operation is only indicated if there is retention of pus, it is wiser to open the mastoid antrum; the exostosis, if superficial and pedunculated, can also be removed at the same time. If, however, the obstruction is due to multiple and deeply placed exostoses, this part of the operation should be deferred to a later date, that is, after the acute symptoms have subsided.

In chronic middle-ear suppuration the only operation to be recommended is the complete mastoid operation (see p. 392).

After-treatment. The after-treatment is practically the same whatever operation has been performed. The first dressing need not be done until the third day. The gauze plugging is then withdrawn and the auditory canal is syringed out and dried. If only a single exostosis has been removed the wound surface is small, and it is usually sufficient to puff in some boracic powder and again insert a piece of gauze. This may be repeated every second day, healing usually taking place within two or three weeks. In the case of deeply situated multiple exostoses, especially if removed from the anterior wall, considerable swelling of the soft parts lining the auditory canal may occur as a result of the manipulations. In such cases, after syringing out any existing blood-clots, some cocaine and adrenalin solution should be instilled into the meatus. An aural speculum is then gradually worked into the auditory canal, which is gently mopped out with small pledgets of cotton-wool, and the deeper parts are carefully inspected. Sometimes the torn ends of the fibrous portion, instead of covering the bony walls, are found to project into the auditory canal and to cause considerable narrowing of its lumen. By careful manipulations with the probe or by stroking the edges with tiny pledgets of cotton-wool, these rough surfaces may be smoothed down. It is very important, in the early days of the after-treatment, to prevent any narrowing at the site of the operation. This is one of the chief causes of subsequent failure. The gauze should always be reinserted right down to the tympanic membrane, and if there is not much secretion it should be packed firmly against the posterior and outer portion of the canal in order to prevent subsequent stenosis from the tendency of the cartilage to prolapse forward owing to the soft parts having been separated from the bony canal at the time of the operation.

The wound behind the ear heals very quickly and the stitches can generally be removed on the third or fourth day. Subsequent treatment consists in preventing the formation of granulations over the wound area. This is best accomplished by keeping the auditory canal aseptic and dry. If granulations occur they should be touched from time to time with a saturated solution of trichloracetic acid. If healing has not taken place within two weeks, it will frequently be advantageous to discontinue the gauze packing and, in its stead, to instil drops of pure rectified spirit.

If a middle-ear catarrh with secretion of fluid occurs, owing to the tympanic membrane having been injured, it may be impossible to continue the gauze packing. In these cases only a fine drain of gauze should be inserted into the meatus, the dressing being changed as frequently as may be necessary.

Provided asepsis is maintained, the middle-ear inflammation usually subsides rapidly with healing of the membrane. After healing has taken place, inflation of the middle ear is recommended twice a week, for two or three weeks, in order to aid recovery and to prevent adhesions forming within the tympanic cavity.

Dangers. 1. If the exostoses be deeply situated, the tympanic membrane may be injured.

2. If much of the anterior wall of the auditory canal be removed, the temporo-maxillary joint may be opened.

3. It is possible that the tympanic membrane may not be recognized, and, by working too deeply, the labyrinth or the facial nerve may be injured.

Prognosis. Provided no accident has occurred during the operation, a successful result should be obtained. Stenosis, however, may occur from cicatricial contraction if the operation has been incompletely performed.

REMOVAL OF FOREIGN BODIES

Before considering the question of removal of foreign bodies, the following points cannot be emphasized too forcibly:—(1) No attempt should be made to remove a foreign body until it is certain that one really exists. (2) Provided there is no middle-ear suppuration, a foreign body left in the ear will very rarely cause any immediate harm. (3) The most serious complications are due almost invariably to ill-advised haphazard attempts to remove the foreign body; as a rule from working blindly in the dark without making use of reflected light.

If a foreign body be suspected, the surgeon should first carefully examine the auditory canal in order to determine its character and position and the condition of its walls. On this will depend the treatment to be employed.

If the object be a living insect it should be killed at once by the instillation of warm oil, rectified spirit, or chloroform. This will cause immediate relief of the intense pain and tinnitus which may have been set up by its movements against the sensitive tympanic membrane.

The methods employed for the removal of a foreign body are syringing, extraction by instruments through the external meatus, and removal by operation by making a post-auricular incision and reflecting forward the auricle.

By syringing. In the vast majority of cases syringing is successful, and therefore should always be tried except under the following conditions:—(a) If the foreign body be of such a nature that it may be driven inwards; for example, a percussion cap for a toy pistol, lying with its concavity outwards.

(b) If there be much inflammation and swelling of the walls of the external meatus, unfortunately frequently due to previous unsuccessful attempts at extraction by instruments. In such cases forcible syringing may cause considerable pain, and in addition immediate removal of the foreign body may be impossible owing to the temporary occlusion of the meatus.

Unless urgent symptoms of retention of pus behind the foreign body are present, it is wiser to wait for a few days until the inflammation has subsided, in order that the canal may become more patent and permit of a more favourable opportunity for removal of the foreign body. The auditory canal, in the meanwhile, may be mopped out two or three times a day with pledgets of cotton-wool, and a 1 in 5,000 alcoholic solution of biniodide of mercury afterwards instilled into the ear.

The method of syringing has already been described (see p. 308). The syringe should be a large one with its tip protected by some india-rubber tubing. The point is inserted within the meatus up against the foreign body and the stream of lotion is directed towards any chink which may exist between it and the auditory canal. It may be necessary to use many syringefuls with considerable force before the foreign body can be expelled, but the syringing should be stopped if pain or giddiness are caused.

If the foreign body cannot be removed at the first attempt, drops of rectified spirit may be instilled into the ear several times a day, provided there are no urgent symptoms. This will tend to diminish any swelling of the soft tissues of the external meatus and of the foreign body if it is a vegetable substance. The ear should again be syringed after two or three days. In many cases this will now be successful; if not, the foreign body may be moved gently with a probe (using a speculum and reflected light), great care being taken not to push it further into the auditory canal, and another attempt may be made to remove it by prolonged syringing. If this fails it may be left in situ for a still longer period, provided there are still no symptoms requiring its immediate removal. In some cases, instead of the instillation of alcohol, a 5% solution of carbolic acid in glycerine or olive oil proves more effectual.

In the case of a hard substance, repeated attempts may be made to dislodge it before resorting to further measures; but in the case of a soft vegetable substance like a pea, it must not be forgotten that moisture tends to make it swell and perhaps will necessitate almost immediate extraction by instruments.

Crocodile Forceps Fig. 179. Crocodile Forceps. Two-thirds size.

A, Points of crocodile forceps, full size.
B and C, Aural punch-forceps.
D, Aural scissors.

Extraction by instruments.

Indications. (i) If inspection shows that the foreign body can at once be removed by a suitable instrument: for example, a percussion cap the edge of which may be grasped by a pair of forceps (Figs. 179 and 193); or a small boot button whose shank, if it faces outwards, may be caught by a small hook.

(ii) If repeated attempts have failed to remove the foreign body by syringing.

(iii) If previous attempts by others have failed, and the foreign body has been pushed in beyond the isthmus, and cannot be removed after prolonged syringing.

(iv) If syringing produces violent giddiness, showing the probable presence of a perforation of the tympanic membrane.

(v) If there be symptoms of acute inflammation of the middle ear or of pus being pent up behind the foreign body.

Operation. An anæsthetic may not be necessary in adults if the foreign body is not too deeply placed within the ear, if its removal appears to be a simple matter, and if the patient is of a placid temperament. Otherwise, unless contra-indicated for some special reason, a general anæsthetic should always be given in children, and it is also preferable in adults for the following reasons:—(1) Inability to remove the foreign body after repeated attempts by syringing usually means that its extraction by instruments will be a somewhat difficult matter. (2) The risk of injury to the meatal walls or tympanic membrane from involuntary movements of the patient during the operation is far greater than the risk of the anæsthetic. (3) If the foreign body cannot be removed through the meatus by means of instruments, the post-meatal operation is indicated. This, if necessary, can be done at once if the patient is under a general anæsthetic.

If no anæsthetic is given the patient may sit up in a chair; otherwise, the recumbent position is advised.

It is usually necessary to use an aural speculum, but if the foreign body be situated near the entrance of the meatus a sufficient view may be obtained by pulling the tragus forward and the auricle backward. Good illumination is essential.

(i) If the body be a soft substance, such as a pea, the core of an onion, or a fragment of wood, it is best removed by fixing into it some form of sharp hook (Fig. 178, D). These hooks vary in shape. They may be curved, or shaped like a crochet-hook, or have the sharp point placed at right angles to the shaft of the instrument.

In the case of a round substance like a pea, especially if it is tightly impacted within the meatus, its removal is sometimes facilitated by first slicing it into pieces by means of a small bistoury.

As a rule, the foreign body is impacted at the junction of the cartilaginous and bony portion of the auditory canal; sometimes, however, it is more deeply situated within the osseous meatus, usually the result of previous attempts to extract it.

In the former case, the instrument is passed along the upper posterior wall of the canal between it and the foreign body, the point of the hook being kept upwards or downwards so as not to project into the auditory canal. The instrument is first passed well beyond the foreign body, and then the shaft is twisted round so that the hook projects into the auditory canal. With a quick movement it is drawn outwards a short distance so that the point of the hook pierces the impacted substance. Gentle traction is now used and in the majority of cases the foreign body can be extracted.

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

If this fails, a slightly curved fenestrated scoop (Fig. 180) or curette should be passed, if possible, between the foreign body and the anterior wall of the auditory canal. The hook already fixed into the foreign body prevents it from being driven further within the meatus, whilst the scoop, if it can be got beyond the foreign body, can usually lever it out.

If the foreign body has been pushed in beyond the isthmus and lies deeply within the osseous canal, it is better to pass the hook along the anterior inferior wall of the meatus, because owing to the inclination of the tympanic membrane its anterior inferior margin is much more deeply placed than its upper posterior part.

(ii) In the case of a hard substance, such as a piece of stone, coal, or a bead, blunt hooks may be used instead of sharp ones. They should be passed into the meatus beyond the foreign body in the manner already described.

(iii) In other cases, depending on its shape and position, the foreign body is better removed by means of a snare, the loop of which is manipulated round it and then drawn tight in the same manner as in the extraction of a polypus.

The chief points to observe in these manipulations are (a) not to push the foreign body farther in and (b) not to injure the walls of the meatus or the tympanic membrane.

Other methods of extraction are—(1) Drilling through the foreign body, if it is a hard substance, and then inserting a fine hook into the opening so made. (2) The agglutinative method, which consists in dipping a small paint-brush into a concentrated solution of seccotine or glue and then inserting it into the meatus until it comes in contact with the foreign body. The brush is left in this position for several hours in the hope that it may become adherent to the foreign body; if so, on withdrawing the brush from the ear, the foreign body should be extracted with it. This method can only be used provided the ear is kept dry.

These procedures, although said to be successful in a few cases, are not recommended.

After-treatment. If the tympanic membrane and auditory canal have not been injured, it is sufficient to dry the meatus and puff in a little boracic powder. If there be abrasions of the canal, a small strip of gauze should be inserted and changed as frequently as it becomes moist with secretion, the meatus, if necessary, being also syringed out with an aseptic lotion. If there be acute inflammation of the walls of the canal, accompanied by much swelling and purulent discharge, drops of glycerine of carbolic (1 in 10) may be instilled frequently. After the inflammation has subsided, an alcoholic solution of 1 in 3,000 biniodide of mercury may be employed. If the tympanic membrane has been injured, either from the presence of the foreign body itself or from the attempts at extracting it, the treatment is similar to that for an ordinary middle-ear suppuration.

Removal by operation. This may be done in the following ways:—

By means of a post-aural incision.

Indications. (i) If prolonged attempts to remove the foreign body by instruments have failed. This operation becomes imperative if there are signs of retention of pus within the middle ear.

(ii) If the foreign body has been pushed into the tympanic cavity and cannot be removed otherwise. In such cases, if the perforation is large and the foreign body is small, an attempt may first be made to dislodge the substance by injecting fluid into the middle ear through the Eustachian tube by means of the catheter and syringe (see p. 372). This method, however, is rarely successful.

Operation. The procedure is the same as for the removal of exostoses (see p. 318). After separating the fibrous from the bony portion of the canal, an incision is made through it and the cut edges are held aside with forceps. Usually the foreign body can now be seen lying within the canal. It is best removed by passing a small fenestrated curette beyond it and levering it out. In some cases one of the hooks already mentioned will be found to be more suitable. Forceps should not be used, as they may inadvertently push the foreign body farther in. If the foreign body be very deeply placed, removal of the upper posterior portion of the bony meatus may be necessary. The subsequent steps of the operation and its after-treatment are similar to that already described in the case of an exostosis.

By means of an operation upon the mastoid.

Indications. (i) If the above measures fail to remove the foreign body.

(ii) If there be symptoms of inflammation of the mastoid process, or of internal-ear or of intracranial suppuration.

(iii) If there be facial nerve paralysis the result of pressure from the foreign body.

Operation. The operation performed depends on the condition found. Simple opening of the mastoid antrum may be sufficient in a case of recent middle-ear suppuration, although it is usually necessary also to remove a considerable portion of the posterior wall of the auditory canal before the foreign body can be extracted. If these measures fail, an attempt may be made to dislodge the foreign body by forcibly syringing through the aditus, or by the insertion of a probe through it, into the tympanic cavity. If this likewise ends in failure, it will then be necessary to perform the complete operation. These cases fortunately are rare.

If it be certain that chronic middle-ear suppuration already exists, the complete mastoid operation is indicated.

If it becomes necessary to operate on the mastoid process, owing to other means having failed to dislodge the foreign body, it is wiser, as a rule, to perform the complete operation at once, because, under these circumstances, irreparable destruction must have taken place within the tympanic cavity.

The technique of these operations and their after-treatment are described in the chapter on operations upon the mastoid process (see p. 390).

OPERATIONS FOR STENOSIS OF THE EXTERNAL MEATUS

Stenosis, or stricture of the auditory canal, is practically always the result of traumatism or inflammatory conditions; it is only very rarely congenital.

Indications. (i) If there be deafness of the other ear, and the functionally good ear periodically becomes deaf from obstruction of the narrow passage by cerumen or epithelial débris, and the patient is weary of conservative treatment.

(ii) If there be recurrent attacks of otitis externa.

(iii) If there be retention of pus, the result of inflammation of the external or middle ear, which is not relieved by conservative treatment.

The operation is contra-indicated if there is accompanying deafness, due to chronic middle-ear or to internal-ear disease, provided there is no suppuration within the external or middle ear.

Operation. The method of operation depends on whether the stricture is membranous, fibrous, or bony in consistence, or whether it is limited or is causing a general narrowing of the auditory canal. It may take one of the following forms:—

Dilatation. This method is not very satisfactory, and is limited to recent cases of membranous or fibrous stricture of the annular variety. After cleansing the meatus, a small laminaria tent is inserted through the stricture, and if the pain is not too severe it is left in situ for at least twenty-four hours and then withdrawn. The ear is again carefully cleansed, and if possible a larger laminaria tent is substituted. This procedure is repeated until the maximum amount of dilatation has been obtained.

Incision of the stricture. This also is limited to membranous or to fibrous strictures of the annular variety.

The operation, if necessary, may be performed under a local anæsthetic, produced by subcutaneous injections, although usually a general anæsthetic is preferable.

The ear and surrounding parts are surgically cleansed by the ordinary methods. The surgeon works by reflected light. The patient may be in either the sitting or the recumbent position, depending on whether a local or general anæsthetic is given. In the latter case the auditory canal should be filled with cocaine and adrenalin solution before the anæsthetic is administered in order to diminish bleeding as far as possible.

The ear having been dried, a conveniently large aural speculum is inserted, and with a tenotome or a furunculotome radiating incisions are made through the stricture. One of the small flaps thus made is grasped with a fine pair of tenaculum forceps, and the surgeon cuts through its base, keeping the knife as close as possible to the wall of the auditory canal. Each flap is treated in a similar fashion. Instead of making radiating incisions, the tissue forming the obstruction may be transfixed through its base, the knife being made to cut in a circular fashion right round the auditory canal, keeping as close as possible to its wall.

On completion of the operation, a piece of india-rubber tubing, of as large a size as possible, is inserted into the dilated canal. It should only be removed for the purpose of cleansing and should be at once reinserted. A silver canula, if necessary, can afterwards replace the india-rubber tubing. This canula may have to be worn for months.

This operation is often most unsatisfactory, as the stricture, instead of being annular as first supposed, may be found, on operation, to extend a considerable distance along the auditory canal and, in addition, to be partially due to a general thickening of the underlying bone.

Excision of the stricture. The auricle is reflected forward and the preliminary steps of the operation are performed as already described for removal of a deep-seated exostosis (see p. 319). The surgeon makes a transverse incision with a knife through the fibrous portion of the auditory canal, just external to the stricture, and carries it right round the meatus, thus separating the outer portion of the membranous from the bony canal. The fibrous portion is now pulled outwards by means of a retractor, and the thickened tissue, forming the stricture, is peeled off from the surrounding bony meatus with a small periosteal elevator and so removed. If the stenosis is partially due to thickening of the walls of the canal itself, it may also be necessary to chisel away a considerable portion of its upper posterior part. After completion of the operation a clear view of the tympanic membrane should be obtained.

In this operation a considerable portion of the bony canal is denuded of its epithelial lining membrane, so that there is a special tendency to the re-formation of cicatricial tissue. To prevent this taking place two methods may be employed:—(1) If much of the upper posterior wall of the bony meatus be removed, a post-meatal flap should be made and kept in position by means of a catgut suture carried through the skin behind the auricle. The formation of such a flap is described as a step in the complete mastoid operation (see p. 401).

(2) If no bone be removed, the membranous portion is replaced in situ, the posterior auricular wound closed, and as large an india-rubber tube as possible is inserted into the meatus. A week or ten days later, as soon as granulations begin to form, skin-grafting may be undertaken (see p. 410).

If grafting be not successful, the india-rubber tube or silver canula must be kept constantly within the meatus (only being removed for cleansing purposes) until healing takes place.

The complete mastoid operation is indicated in the case of stenosis occurring in chronic middle-ear suppuration if symptoms of retention of pus occur.

In acute middle-ear suppuration, however, every attempt should be made to avoid operation, as the lumen of the auditory canal may again become patent after the acute inflammation has subsided.

OPERATIONS FOR ATRESIA

Atresia of the external meatus may be either congenital or acquired.

Indications. (i) In congenital cases operation is only justifiable if the atresia is due to a membranous web situated in the outer part of the auditory canal and if, as a result of tuning-fork tests and of inflation through the Eustachian tube, it is fairly certain that the middle ear is normal.

Operation is contra-indicated in cases of bony atresia. Although attempts have been made to make an artificial canal in order to restore the hearing power, a successful result has not yet been obtained. Apart from the difficulty of retaining the patency of any canal so made, the accompanying malformation of the middle ear renders a successful result impossible (Paper by author, Journal of Laryngology, &c., March, 1901). Although the tympanic membrane is said to have been exposed by operation in a few cases, experience has shown that the supposed tympanic membrane was really the capsule of the temporo-maxillary joint.

(ii) In acquired cases operation is indicated if the other ear is deaf; if the site of the occlusion of the auditory canal is in its outer part and is due to membranous or fibrous tissue, and if there is no previous history of middle-ear disease, and if the labyrinth is still intact.

Operation is not advised if the other ear is normal, unless the patient particularly desires it.

Operation is contra-indicated if there is internal-ear deafness on the affected side and if the other ear is normal; or if there is a definite history of the closure of the auditory canal having been the result of a previous middle-ear suppuration. In the latter case the destructive changes within the tympanic cavity will be so marked that the chances of improving the hearing will be very slight in spite of the most successful operation.

Operation. If the obstruction be due to a fibrous band, an attempt may be made to remove it by excising it by the intrameatal method. In other cases the post-auricular method is necessary.

The chief point to remember is to make a large opening. For this reason the post-auricular method is to be preferred, as a considerable portion of the upper posterior wall can be removed and a large meatal flap fashioned (see p. 401).

Results. If the stricture or point of occlusion of the auditory canal is limited and composed of membranous and fibrous tissues, a good result can be usually obtained, and there is no reason why complete recovery of hearing should not take place if the labyrinth and tympanic cavity are normal.

Unfortunately, as in all cases of stricture, there is a tendency for it to recur.

OPERATIONS FOR AURAL POLYPUS

In this section only the aural polypi which project from the tympanic cavity into the external auditory meatus will be considered; whereas the treatment of granulations, and with them the minute polypi which are still limited to the tympanic cavity, will be discussed in the chapter on operations within the middle ear.

Indications. An aural polypus should always be removed because, apart from the fact that it is a symptom of underlying disease, it may obstruct free drainage of the purulent discharge, and therefore become a source of danger.

Operation. The simplest and the best method is removal by the snare.

In the case of small and soft polypi, the polypus is removed by traction—formerly called avulsion—after the snare has been tightened round its pedicle; with a large, tough, fibrous polypus considerable force may be required to tear through its pedicle. This procedure in the case of polypi arising from the region of the tegmen tympani has been known to give rise to fatal meningitis. In such cases the pedicle of the polypus should be cleanly cut through by the snare—so-called excision.

As aural polypi are always associated with suppuration, it is especially necessary that the ear should be thoroughly cleansed before operation.

A local anæsthetic (see p. 310) is sufficient in the case of smaller polypi, but if the polypus be large and tough, it is wiser to give a general anæsthetic, such as gas and oxygen. Or a 3% solution of cocaine may be injected into the growth, which, according to Frey of Vienna, renders removal absolutely painless; this, however, has not always been my experience.

Aural Probe Fig. 181. Aural Probe.

The size of the polypus and the origin of its pedicle should be determined before operating, if necessary by using a probe (Fig. 181); also it must be diagnosed from a bulging congested tympanic membrane, or from the inner surface of the tympanic cavity, which may be exposed to view owing to complete destruction of the membrane having already occurred.

Wilde’s Aural Snare Fig. 182. Wilde’s Aural Snare. The snare is held in the usual position for extraction of a polypus.
    
Wilde’s Snare being passed round an Aural Polypus Fig. 183. Wilde’s Snare being passed round an Aural Polypus. (Semi-diagrammatic.)

A Wilde’s snare is generally used. It is a fine angular snare fitted with soft copper wire. The loop of the snare should be bent downwards and forwards and should be of such a size as to just surround the growth. The snare is held between the thumb and the first and second finger of the right hand (Fig. 182). Under good illumination, and using the speculum and reflected light if necessary, the shaft of the snare is passed along the upper portion of the auditory canal until the edge of the polypus is reached. The loop is made to encircle the polypus (Fig. 183), the snare is gradually pushed inwards with a gentle sinuous movement until it reaches the point of attachment of the growth. The loop is then tightened until it firmly grasps the neck of the polypus (Fig. 184). The friable tissue is torn through by gentle traction and the polypus is withdrawn in the snare. Care must be taken not to injure the tympanic membrane through which the polypus may be projecting; it is for this reason that the loop is bent at an angle to the shaft of the snare so that it may lie parallel to the tympanic membrane whilst in the act of grasping the polypus. If the polypus be very small its pedicle may be clearly defined before operation, and the snare passed round it directly (Fig. 185).

Wilde’s Snare gripping the Neck of Polypus Fig. 184. Wilde’s Snare gripping the Neck of Polypus. (Semi-diagrammatic.)
    
Polypus arising from the Attic Region Fig. 185. Polypus arising from the Attic Region. The snare is in position for the extraction of the polypus. (Semi-diagrammatic.)

If the polypus be very large and tough, the snare is made to cut clean through its pedicle as near to its attachment as possible, instead of employing traction. The snare is then withdrawn, the polypus being afterwards grasped and removed by means of forceps. In this latter case it may be necessary to use a stronger snare fitted with piano steel wire instead of the ordinary copper wire. On removal of the polypus there may be considerable hæmorrhage. After it has ceased the ear is syringed out and dried. The auditory canal is then inspected, and if it is found that the growth has not been removed completely, this can be done now by reapplication of the snare.

After final cleansing of the meatus, a strip of gauze is inserted, and the ear protected with a pad of cotton-wool and a bandage.

After-treatment. The dressing should be removed within twenty-four hours, and the ear cleansed by syringing. After mopping it dry drops of rectified spirits should be instilled.

On removal of the first dressing, any polypoid tissue which remains may be cauterized under cocaine anæsthesia by the actual cautery, or by a bead of chromic or trichloracetic acid (see p. 348).

Further treatment consists in keeping the ear clean and dry. For the first few days it should be syringed daily, dried, and spirit drops instilled. As the secretion becomes less the syringing should be diminished. If the perforation be large, instead of instilling drops, some finely powdered boric acid may be puffed in.

Other methods of removal. These are not recommended, but merely mentioned for the sake of completeness.

By forceps. The rough and ready method of extracting a polypus forcibly from the ear by means of forceps, although practised formerly, has now been discarded as being unsurgical and dangerous.

Ligation. The operation consisted in passing a snare over the polypus and grasping it tightly as near to its base as possible. The snare was then twisted round its axis in order to tighten the loop further and so obliterate the blood-supply of the growth, the wire of the snare being afterwards cut through with pliers and the snare withdrawn. After a few days the polypus became gangrenous from want of blood-supply, and separated from its deep attachments.

Curetting. This method, which should only be made use of in the case of small multiple polypi within the tympanic cavity, will be considered when discussing the treatment of granulations within the middle ear (see p. 398).

Dangers. Hæmorrhage is seldom profuse, but if it is, it can always be arrested by packing the meatus with cocaine and adrenalin solution.

The chief dangers are injury to the contents of the tympanic cavity, such as dislocation or removal of the ossicles; or subsequent meningitis. These mishaps are usually the result of forcible extraction, or of blindly curetting the ear after this has been done. Meningitis, however, has been known to occur, in spite of every precaution being taken, if, owing to caries of the tegmen tympani, the polypus has its origin from the dura mater of the middle fossa.

Prognosis. If the polypus be single and of recent origin, the result probably of acute inflammation of the middle ear, its removal may cause complete recovery and cessation of the middle-ear suppuration.

In the case, however, of multiple polypi associated with chronic middle-ear suppuration and usually signifying underlying bone disease, recurrences may be frequent and further operations may become necessary.

It may here be emphasized that a polypus in itself is not a disease, but merely a symptom of disease.

After removal of a large polypus, the patient should always be kept under observation for a day or two in case of symptoms of acute inflammation of the mastoid process arising and necessitating further operation.


CHAPTER III

OPERATIONS UPON THE TYMPANIC MEMBRANE AND
WITHIN THE TYMPANIC CAVITY

SURGICAL ANATOMY OF THE TYMPANUM

The tympanic membrane. The chief points to notice when operating on the tympanic membrane are its inclination and its relation to the inner wall of the tympanic cavity.

The normal membrane is inclined obliquely downwards and forwards so that it forms an obtuse angle of 140 degrees with the roof and an acute angle of 27 degrees with the floor of the external meatus. In infants the inclination is even greater.

Its relation to the tympanic cavity varies in its different parts. It lies nearest to the inner wall in the region of the umbo, being only 2 millimetres distant from the promontory, and is furthest from it in the posterior quadrant.

Running backwards, just below the posterior fold, is the chorda tympani nerve, which may be cut through in the act of paracentesis and in division of the posterior fold.

The tympanic cavity. For the purpose of description the portion of the tympanic cavity above the level of the tympanic membrane is known as the attic or epitympanic cavity; whilst the part below its level is called the cellar or hypotympanic cavity (Fig. 186).

Anatomical Preparation of the  Middle Ear Fig. 186. Anatomical Preparation of the Middle Ear. 1½ nat. size. 1, Antrum; 2, Aditus; 3, Attic, containing head of malleus and body of incus; 4, Chorda tympani nerve; 5, Middle fossa of intracranial cavity; 6, Eustachian tube; 7, Carotid canal; 8, Jugular vein in jugular fossa; 9, ‘Cellar’ or floor of tympanic cavity; 10, Canal of facial nerve; 11, Sigmoid groove for lateral sinus. (From the Author’s Diseases of the Ear.)

The attic contains the head of the malleus and the body and short process of the incus, and communicates posteriorly with the antrum by a variable sized opening—the aditus. Its roof, the tegmen tympani, a plate of bone frequently of extreme thinness, separates the cavity of the middle ear from the middle fossa of the cranium. The facial canal extends backwards along the inner and upper border of the tympanic cavity, passing above the vestibule and the fenestra ovalis to curve downwards posteriorly beneath the external semicircular canal, which at this point forms the inner and inferior boundary of the aditus.

The ossicles form a movable chain fixed at three points: namely, the attachment of the handle of the malleus to the tympanic membrane; the posterior ligament of the incus, a feeble structure, binding its short process to the entrance of the antrum; and the strong annular ligament connecting the footplate of the stapes to the margins of the fenestra ovalis.

In addition, the anterior, external, and superior ligaments of the malleus also tend to keep it in position and limit its movements.

The tensor tympani muscle, extending from the processus cochleariformis, crosses the tympanic cavity to be inserted into the inner margin of the neck of the malleus; and the stapedius muscle emerging from the apex of the eminentia pyramidalis is inserted into the head of the stapes.

These ligaments and muscles partially divide the cavity into smaller compartments, such as the outer attic and Prussak’s space, so that in some cases inflammation may be limited to only a part of the tympanic cavity; a fact to be remembered in considering the question of operative procedures.

OPERATIONS UPON THE TYMPANIC MEMBRANE

PARACENTESIS

Indications. The chief object of paracentesis (myringotomy or simple incision) is to permit of escape of fluid from the tympanic cavity.

(i) In acute inflammation of the middle ear, if the acute symptoms continue in spite of palliative treatment, and the following conditions are present:—(a) An increasing congestion and bulging of the tympanic membrane, especially if accompanied by earache and pyrexia. (b) The obvious presence of pus within the tympanic cavity, shown by a circumscribed, angry red or yellow protuberance on the tympanic membrane. (c) Accompanying cerebral symptoms, such as drowsiness, vomiting, vertigo, and convulsions. (d) Tenderness over the mastoid process. (e) Paroxysms of pain acute enough to prevent sleep.

Paracentesis should be done early in infants and in specific fevers. In the former case even a slight middle-ear inflammation may give rise to all the cardinal symptoms of meningitis, which frequently subside rapidly as the result of simple paracentesis; in the latter, there may be rapid destruction of the drum, which a timely incision may possibly prevent.

(ii) In middle-ear catarrh with exudation. Paracentesis is justifiable in order to remove the secretion, if the hearing does not improve after a month’s treatment, owing to the existence of exudation within the tympanic cavity.

(iii) As a preliminary to intratympanic operations.

Operation. The auricle and surrounding parts are surgically cleansed (see p. 309), the preliminary toilet, if possible, being carried out at least half an hour before the operation is performed.

Although apparently a trivial matter, it is of the utmost importance to render the auditory canal as aseptic as possible in order to prevent secondary infection of the tympanic cavity from without.

Paracentesis Knife held in  position in the Hand Fig. 187. Paracentesis Knife held in position in the Hand.

It is wiser to give a general anæsthetic, such as gas and oxygen, as the pain of the operation may be intense. If this is refused, local anæsthesia by Gray’s solution (see p. 310) or by a subcutaneous injection of cocaine and adrenalin may be employed. In infants an anæsthetic is not necessary.

The patient may be sitting up or lying down. If a general anæsthetic has not been given, the patient’s head must be held firmly by an assistant in order to prevent sudden movement. The surgeon works by reflected light in order to obtain a clear view of the tympanic membrane.

The point of election for the incision is through the posterior part of the membrane, excepting when it is obvious from the bulging and appearance of the membrane that the incision must be made in the anterior inferior quadrant.

The incision is made by means of a paracentesis knife, which is shaped like a tiny bistoury set at an angle to its handle (Fig. 187). The double-edged spear-shaped knife is now seldom used, as with it there is a tendency to puncture rather than to incise the membrane.

The tympanic membrane is pierced by the paracentesis knife at its inferior posterior margin. With a quick movement the drum is incised freely, the incision being carried in an upward direction midway between the malleus and the circumference of the membrane posteriorly, until it reaches Shrapnell’s membrane (Fig. 188). In making this incision the inclination of the membrane must not be forgotten. Owing to its lower margin being more deeply placed than the upper, there is a tendency for those who have not had much practice in doing a paracentesis to begin their incision too high up, as they fail to realize the greater depth of the canal at this point. The soft tissues of the upper posterior wall of the external meatus close to the membrane, if much congested, may be incised also in the act of withdrawing the knife. In doing this the chorda tympani nerve may perhaps also be cut, resulting in loss of taste on the affected side for a time; this is a matter of no importance. As a result of this free incision, drainage is given to the contents of the tympanic cavity, attic, and antrum.

In order to prevent rapid closure of the perforation and to give better drainage, some authorities advise making a flap-shaped incision. To do this, the membrane is incised upwards, nearly to its upper border; the knife is then carried backwards and downwards before it is withdrawn from the wound.

Tympanic Membrane showing Incision in Acute Suppuration of the Middle Ear Fig. 188. Tympanic Membrane showing Incision in Acute Suppuration of the Middle Ear. Usual line of incision; dotted line shows continuance of incision to make a flap opening for drainage.
    
Line of Incision in Acute Suppuration of the Attic Fig. 189. Line of Incision in Acute Suppuration of the Attic.

Occasionally the acute inflammation is limited to the attic, Shrapnell’s membrane appearing deeply congested and bulging outwards so as to cover the processus brevis, whilst the rest of the membrane may be only slightly injected. In such cases it is sufficient to incise the bulging area, beginning the incision just above the region of the processus brevis and carrying it horizontally backwards to its posterior extremity (Fig. 189).

After-treatment. In acute middle-ear inflammation, after the first rush of blood and discharge has been mopped away, a small drain of sterilized gauze should be inserted into the auditory canal and the ear protected with a pad of sterilized gauze. The dressing and gauze drain should be changed as often as may be necessary, depending on the amount of discharge. The ear should not be syringed out unless the discharge becomes very profuse and thick.

In acute middle-ear catarrh with exudation, a Siegle’s speculum (Fig. 194) should be inserted into the meatus after free incision of the membrane, and as much fluid as possible extracted by suction. In addition, gentle inflation by means of Politzer’s method will help to expel from the middle ear the fluid, which should then be mopped out of the external meatus. This should be repeated daily.

Difficulties and dangers. The usual fault is to mistake the congested posterior wall of the external meatus for the membrane.

If the patient is not under an anæsthetic, the incision may be made too timidly, the membrane being only scratched. The pain thus inflicted will cause the patient to jerk away the head and probably prevent the membrane from being incised freely. The incision, therefore, must be made in a bold and rapid manner. It is better to make the incision too free than too small.

Care must be taken not to plunge in the knife too deeply for fear of wounding the mucous membrane of the inner wall of the tympanic cavity. This may result in adhesions between it and the membrane.

Further, cases have been recorded in which a too violent incision has injured or dislodged the ossicles, or in which severe hæmorrhage has occurred, presumably from puncturing the bulb of the jugular vein, which was projecting abnormally through the floor of the tympanic cavity.

The two chief causes of failure are insufficient drainage from too small an incision, which may necessitate a further operation, and secondary infection from without.

Results. In the majority of cases, provided free drainage is established, the discharge ceases and healing of the membrane takes place from within a day or two to four weeks, depending on the character of the case. If the symptoms continue it may become necessary to perform the mastoid operation (see p. 373).

ARTIFICIAL PERFORATION OF THE TYMPANIC MEMBRANE

The object of the operation is to equalize the pressure within the tympanic cavity and external meatus so as to enable vibrations of sound to be transmitted more readily by the membrane and chain of ossicles to the inner ear.

Indications. (i) In the case of an extremely calcified membrane which apparently cannot vibrate.

(ii) To relieve tinnitus or vertigo which appears to be due to an alteration of tension within the tympanic cavity, the result of an impermeable stricture of the Eustachian tube.

(iii) As a means of diagnosis. If the hearing be improved or the subjective symptoms relieved as a result of the artificial opening, then, if the perforation closes (as it probably will do), the surgeon is in a position to suggest some more radical measure, such as ossiculectomy (see p. 351).

Operation. Two methods are employed: (i) The knife; (ii) The galvano-cautery. The perforation should be made in the postero-inferior quadrant.

In favour of the galvano-cautery is the fact that the perforation does not tend to close so rapidly. On the other hand, considerable damage may be done unless it is applied with extreme care. For this reason it is wiser to operate under a general anæsthetic, such as gas and oxygen.

If the paracentesis knife be used it is not sufficient to make a simple incision; a small triangular flap must be excised. The operation should be performed under good illumination. The paracentesis knife is inserted boldly through the membrane a little behind and above the umbo. The membrane is incised in an upward and slightly backward direction towards its margin; then downwards parallel to its posterior border; then horizontally forward, meeting the original point of the incision. The excised portion of the membrane is removed by seizing it with a fine pair of crocodile forceps, or by means of a fine snare, if it has not been completely detached.

The galvano-cautery is applied cold; when it is in contact with the drum, the circuit is closed so that the point of the cautery becomes red-hot. After the membrane has been burnt through it is withdrawn rapidly so as not to scorch the surrounding tissues. In using the cautery care must be taken to push it only just through the membrane for fear of injuring the inner wall of the tympanic cavity.

After-treatment. The after-treatment consists in protecting the ear by a strip of gauze, which is changed as often as may be necessary.

DIVISION OF THE ANTERIOR LIGAMENT

Indication. It is advised by Politzer in those cases of marked retraction of the drum in which inflation causes an immediate improvement in hearing, which, however, only lasts a short time. In several cases Politzer found the cause of this to be due to tension of the anterior ligament causing retraction of the malleus.

Operation. The anterior fold is divided with the paracentesis knife just in front of the processus brevis of the malleus. The knife is then introduced 2 millimetres inwards through the incision and made to cut in an upward direction as far as Shrapnell’s membrane (Fig. 190, C). This should divide the ligament.

If the operation be successful, improvement in hearing and also diminution of the subjective noises should take place.

DIVISION OF THE POSTERIOR FOLD
Lines of Incisions in Intratympanic Operations Fig. 190. Lines of Incisions in Intratympanic Operations. A, Removal of membrane in ossiculectomy; B, Division of posterior fold; C, Division of anterior ligament.

Indication. The same as for the anterior ligament. Owing to the increased tension of the upper posterior quadrant of the tympanic membrane, it is assumed that the movements of the malleus are diminished, and with this the hearing power. Seeing, however, that the prominence of the posterior fold is due to the projection outwards of the processus brevis as a result of the handle of the malleus having become indrawn with the membrane, it is difficult to understand how its division can possibly be a means of restoring the retracted membrane to its normal condition.

On the few occasions on which I have performed this operation, no improvement has followed. Others, however, maintain that it may do good in certain cases. This, perhaps, may be possible if it is combined with other intratympanic operations, such as division of the anterior ligament or of the tensor tympani muscle.

Operation. The paracentesis knife is inserted through the most prominent part of the fold and is made to cut through it from above downwards (Fig. 190, B). If this is successful, gaping of the cut edges takes place and the membrane assumes a less retracted position, and increased hearing and diminution of the subjective symptoms should occur on inflation and rarefying of air within the external ear.

INTRATYMPANIC OPERATIONS

General considerations with regard to intratympanic operations and their results. The chief difficulty, from a clinical point of view, is to determine beforehand the exact pathological changes which already exist within the tympanic cavity. For this reason the indications given with regard to operation are of necessity somewhat empirical. For example, retraction of the tympanic membrane may be due to closure of the Eustachian tube; to adhesions between it and the promontory; to contraction of the tensor tympani, of the anterior ligament, or of the posterior fold. An operation to remove only one of these causes may, therefore, be insufficient; the difficulty is to know what to do. Even if further operations are performed, the result may be negative owing to adhesions having taken place already between the ossicles themselves, or from binding down of the incudo-stapedial joint or of the stapes to the inner wall of the tympanic cavity. And apart from this, even if temporary benefit is obtained, the final result may be worse than that which existed before operation owing to the natural tendency for adhesions to re-form.

The prognosis is better in the case of post-suppurative conditions than in the non-suppurative ones.

Improvement by operation may be hoped for if a temporary increase in the hearing power, with diminution of the subjective symptoms, is obtained as a result of inflation; especially in those cases in which the malleus is only locally adherent to the promontory.

Generally speaking, however, these operations are not recommended, owing to the impossibility of being able to give a good prognosis, and therefore they can only be considered as experimental.

These operations are contra-indicated—(1) If there be internal-ear deafness.

(2) If the stapes (as shown by tuning-fork tests and Gellé’s test) be ankylosed within the fenestra ovalis, especially in the case of otosclerosis.

(3) If the membrane be completely adherent to the inner wall at its upper posterior quadrant, especially if this is of long standing, as the stapes will almost certainly also be fixed by adhesions.

DIVISION OF INTRATYMPANIC ADHESIONS

The position and extent of the intratympanic adhesions vary exceedingly, and may be the result either of middle-ear catarrh or suppuration. The following conditions may be found:

(i) Adhesion of the handle of the malleus to the promontory, the rest of the tympanic membrane being movable.

(ii) Adhesions between other parts of the tympanic membrane and the inner wall of the tympanic cavity, either by bridles or bands of fibrous tissue, or by the membrane itself being adherent over a large area.

(iii) Adhesion of the edge of a perforation to the inner wall.

(iv) Adhesions surrounding the articulation between the incus and stapes, and the stapes itself.

Indications. Operation is justifiable in the case of adhesion of the malleus to the promontory if the rest of the membrane is freely movable; if the membrane bulges outwards and there is temporary improvement in hearing on inflation; and if examination shows that the labyrinth is intact. This operation is all the more indicated if there is marked deafness on both sides: it should then be attempted on the worse side. If, however, the intratympanic adhesions are extensive, it is very doubtful whether an attempt to separate the free part of the membrane from the part adherent to the inner wall is worthy of consideration.

It must also be remembered that adhesions in the region of the stapes cannot be seen, unless a large perforation of the membrane already exists. Operation is then only justifiable as a last resource if there is extreme deafness accompanied by distressing subjective symptoms.

Operation. Unless the patient is very sensitive or nervous, local anæsthesia is sufficient. It is more convenient for the patient to be sitting up in a chair than to be in the recumbent position. The surgeon works by reflected light. Before the operation is begun, the ear must be surgically cleansed and carefully dried.

Cutting through Intratympanic Adhesions Fig. 191. Cutting through Intratympanic Adhesions. The malleus is adherent to the promontory. A, Surface view; B, Vertical section. a, Handle of the malleus; b, Membrane adherent to the promontory; c, Line of incision to cut through the membrane.
Free Edge of Tympanic Membrane cut through Fig. 192. Free Edge of Tympanic Membrane cut through. A, Surface view; B, Vertical section. a, Malleus adherent; b, Membrane adherent; c, Free edge of membrane; d, Spatula freeing membrane.

(i) Adhesion of the handle of the malleus to the promontory. With a paracentesis knife the membrane is incised round the handle of the malleus (Fig. 191). A small sickle-shaped knife, fixed at right angles to its shaft, is then inserted through the incision (in front of or behind the malleus as may be most convenient to the operator) and is made to cut through the adhesions between the malleus and the promontory (Fig. 192). In order to make sure that this has been accomplished, a small ring-knife, such as is used in the operation of ossiculectomy, is passed round the tip of the malleus, between it and the inner wall of the promontory, and slight traction is then exerted in order to pull the handle of the malleus outwards from the inner wall.

Provided asepsis has been maintained, this small operation seldom gives rise to any inflammatory reaction. The after-treatment consists in inserting a strip of gauze into the auditory canal; if it becomes moist with secretion, it should be changed.

Sexton’s Instrument Fig. 193. Sexton’s Instrument. A, For removal of a foreign body; B and C, For removal of the malleus; D, Scissors.

Many methods have been devised to prevent recurrence of adhesions, but few are successful. Amongst these are daily inflation of the ear by means of Politzer’s method or the catheter; the injection of oil into the middle ear; and the insertion of small pieces of celluloid between the malleus and inner wall of the promontory according to the method of Gomperz. Another method is to resect the handle of the malleus (Fig. 195). After being freed from the promontory as above described, the manubrium is cut through with a pair of fine scissors (Fig. 174) just below the processus brevis, and the lower fragment is removed by means of Sexton’s forceps (Fig. 193).

(ii) Adhesion between the membrane and the inner wall of the tympanic cavity. Siegle’s speculum should be used to determine the position and extent of the adhesions (Fig. 194).

Method of using Siegle’s Speculum Fig. 194. Method of using Siegle’s Speculum.

There are two methods of operation:—

(a) In the case of bands forming a bridle between the tympanic membrane and inner wall, an attempt may be made to cut through them. This is done by incising the membrane with a paracentesis knife in front of or behind the adherent portion, and then inserting through this incision the sickle-shaped knife. By rotating it upwards or downwards, as the case may be, the bands forming the adhesions are cut through. If this has been successfully performed, and if the retraction of the membrane was solely due to these bands, the tympanic membrane will be found to be freely movable on diminishing the pressure of air within the external meatus by means of Siegle’s speculum.

(b) If the adhesions be extensive, the only method affording a chance of success is to separate the free portion of the tympanic membrane from the part adherent to the inner wall, leaving the latter in situ. To do this the membrane is incised with a paracentesis knife just beyond the margin of the adherent portion, the incision being carried right round the affected part. A tiny spatula, bent at right angles to its shaft, is then inserted through the incision and passed round beneath the movable portion of the membrane so as to free it completely (Fig. 192).

(iii) Adhesion of the edge of a perforation to the inner wall. If the middle-ear suppuration has only recently ceased, it may be sufficient to divide the adhesion with a small knife curved on the flat and afterwards force the tympanic membrane outwards by means of inflation through the Eustachian tube, and by rarefaction of the air within the external meatus. In the majority of cases, however, it is necessary to excise the adhesion, especially in the more chronic conditions. This is done by cutting through the movable part of the membrane just beyond the adherent portion (vide supra).

Division of Intratympanic Adhesion with Excision of Handle of Malleus Fig. 195. Division of Intratympanic Adhesion with Excision of Handle of Malleus. A, Surface view; B, vertical section. a, Remains of malleus (handle already excised); c, Free edge of membrane; d, Scar tissue on promontory, at which point malleus and membrane were previously adherent.

(iv) Adhesions surrounding the articulation between the incus and stapes, and the stapes itself. These adhesions can only be observed if a large perforation involves the upper posterior quadrant. Even then it may be anatomically impossible to see the stapes. The operation should only be performed if definite bands of adhesions can be seen. Sometimes, although rarely, it happens that such adhesions are present. If the incudo-stapedial joint be fixed to the inner wall of the tympanic cavity, the adhesions are separated from it by passing the knife between the joint and the inner wall. In order to cut through adhesions surrounding the base of the stapes, a small horizontal incision should be made along its upper margin, and also along the lower, if this is in view. This operation, however, is seldom of any value.

TENOTOMY OF THE TENSOR TYMPANI

Indication. The chief indication for this operation is marked retraction of the tympanic membrane, in a case of middle-ear deafness, in which there are no adhesions between the membrane and the inner wall of the middle ear, and in which it is assumed that the retraction is due to shortening of the tensor tympani muscle.

Schwartze’s Tenotomy Knife Fig. 196. Schwartze’s Tenotomy Knife.

Operation. The first step of the operation is to incise the tympanic membrane with a paracentesis knife in a vertical direction just behind the margin of the malleus. At the same time the posterior fold can be cut through, if required, by continuing the incision upwards. Through the incision thus made Schwartze’s tenotomy knife (a very fine blunt-pointed instrument curved on the flat (Fig. 196)) is inserted, its point being directed upwards. The knife is pushed upwards until its shaft is on a level with the processus brevis. The handle is then rotated in a forward direction so that the sharp edge of the knife, which is kept close to the posterior border of the neck of the malleus, makes a circular movement forwards and downwards and thus cuts through the tendon of the muscle. If the knife has been too deeply inserted, the attempt to rotate the shaft forwards will be resisted by the projecting processus cochleariformis. To overcome this difficulty the shaft of the instrument is rotated backwards so as to raise the point of the tenotomy knife and thus free it; the instrument is then withdrawn slightly and the shaft again rotated forwards. The division of the tendon can be distinctly felt, and may be accompanied by a slight crackling noise; after this has been effected, the knife is rotated backwards and withdrawn through the incision in the tympanic membrane.

After-treatment. There is usually a slight effusion of blood within the tympanic cavity, but no special treatment is required beyond keeping the ear aseptic. Absorption takes place rapidly.

The result of the operation is disappointing. There is seldom any improvement with regard to hearing; a few cases, however, have been reported in which the attacks of vertigo have diminished in intensity.

TENOTOMY OF THE STAPEDIUS

Indications. They are limited.

(i) As the result of middle-ear suppuration the malleus and incus may become exfoliated. The theory has been advanced that the unopposed action of the stapedius muscle prevents free movement of the stapes in these cases, and for this reason tenotomy of its tendon is advocated.

This operation, however, should only be performed provided that the edge of the membrane is not adherent to the inner wall of the tympanic cavity, and there is no internal-ear deafness.

(ii) The operation is also performed as a preliminary measure to removal of the stapes (see p. 361).

Operation. The operation is simple, as the head of the stapes and the tendon of the stapedius muscle are usually within view in consequence of the destruction of the tympanic membrane. The ear is cleansed and dried, and the part rendered insensitive by the previous application of a pledget of cotton-wool soaked in cocaine solution. The tiny tendon is severed with a snick of the paracentesis knife, cutting through it from above downwards under good illumination.

Results. These vary; usually there is no improvement, but sometimes marked increase of hearing occurs. As the operation can do no harm and can be done without any inconvenience to the patient, it may be attempted subject to the restrictions given above.

REMOVAL OF GRANULATIONS FROM THE TYMPANIC CAVITY

Indications. Granulations should always be removed if conservative treatment fails.

Operations. (a) Cauterizing; (b) Curetting. The former method is employed when the granulations are very small and localized; the latter when they are multiple and larger.

Cauterization. The tympanic cavity is cleansed and rendered anæsthetic (see p. 310). The auditory canal and tympanic cavity are then carefully dried. This is of importance in order to prevent scalding of the surrounding tissues during the act of cauterization. The ordinary electric cautery is used; only a weak current is necessary as the point of the cautery, of necessity, is very small. Under good illumination, the cautery is inserted cold along the auditory canal until it just touches the granulation. The circuit is then closed, and on the point of the cautery becoming white-hot, it is pressed against the granulation and then rapidly withdrawn from the ear. The current should not be shut off until the cautery is withdrawn, otherwise it will adhere, on cooling, to the tissues with which it is in contact, and on withdrawal will cause bleeding.

Instead of the electric cautery, the granulations may be touched with a bead of chromic acid fused on to a probe, or with a saturated solution of trichloracetic acid. The galvano-cautery has the greatest effect. Chromic acid has the disadvantage that unless it is very accurately applied it tends to affect a larger area than was possibly intended. Trichloracetic acid, although more localized in effect, is not so potent.

After-treatment consists in blowing in a slight amount of boric acid powder and keeping the ear dry.

Curetting. This is performed by means of small ring-knives (Fig. 178) or sharp spoons. They vary in size, and are either straight or bent in different directions to the shaft of the instrument. The instrument selected depends on the position and size of the granulation.

To minimize the hæmorrhage, adrenalin may be added to the cocaine solution. The curette is made to encircle the granulation and cuts through its attachment with a firm movement, limited to the area of the granulation. Curetting should not be done in a haphazard fashion, but deliberately under good illumination. If bleeding occurs it must be arrested before further curetting takes place.

After-treatment. The ear is syringed out to remove any fragments of granulation tissue or blood-clot. It is then dried and a strip of sterilized gauze inserted. After twenty-four hours this is removed and drops of rectified spirits, if necessary containing ten grains of boric acid or a drachm of the perchloride of mercury lotion to the ounce, may be instilled into the ear three or four times a day.

Dangers. With due care none should occur. The following mishaps, however, have occurred from too violent curetting: (1) Injury or displacement of the ossicles; (2) internal-ear suppuration from dislodging of the stapes or injury to the promontory; (3) facial paralysis; (4) meningitis from injury to the tegmen tympani; (5) acute inflammation of the mastoid process.

Results. Provided that the granulations are localized and due to inflammation of the mucous membrane, a good result may be anticipated. If, however, there be underlying bone disease of the tympanic walls, or if the mastoid process be already affected, recurrences are usual, and further operative treatment may become necessary.

OPERATIONS UPON THE OSSICLES

DIRECT MOBILIZATION OF THE OSSICLES

The object of the operation is to improve the hearing by breaking down the fibrous adhesions with the tympanic cavity, which diminish the mobility of the ossicles.

Direct massage of the malleus. Indications. (i) As a therapeutic measure. If the malleus be adherent to the promontory and there is no improvement on inflation, but perhaps slight improvement as a result of pneumatic massage.

(ii) As a means of diagnosis. If temporary improvement takes place it may be assumed that the stapes is not absolutely fixed, and that the deafness is partly due to adhesions preventing movements of the ossicles, a condition which may point to the advisability of performing ossiculectomy in suitable cases.

Operation. The ear is rendered insensitive by means of cocaine or Gray’s solution (see p. 310).

Lucae’s Probe Fig. 197. Lucae’s Probe.

The manipulation is carried out with a Lucae’s probe (Fig. 197). Within its handle is a spring to render its movements resilient; and at its tip is a cuplike depression to embrace the point of the processus brevis of the malleus. The tip of the probe may be covered by a fine layer of cotton-wool or india-rubber.

The probe is inserted, under good illumination, into the auditory meatus and is applied to the processus brevis of the malleus. The vibrations are given by the rapid movements of the hand from the wrist, the arm being kept fixed. This procedure, which may be painful, should not last longer than one minute. Frequently there is considerable reaction, shown by congestion about the processus brevis and Shrapnell’s membrane. It is therefore wiser not to repeat the procedure at shorter intervals than one week.

Results. It is difficult to foretell what the result will be, as it is chiefly dependent on the extent of the adhesions already existing within the tympanic cavity and on the mobility of the stapes within the fenestra ovalis. If the latter is already fixed, then improvement is impossible. If, however, the adhesions are limited, a better result may be obtained by this method than by pneumo-massage and inflation. The surgeon must be guided by the extent and duration of the improvement as to how long to continue the treatment. Unfortunately, relapses are not uncommon, though temporary benefit may be obtained.

Massage of the stapes. This is only done as a last resource in the hope of obtaining some improvement in hearing.

Indications. (i) In cases in which mobilization of the malleus has caused no improvement, and it is hoped, from the history of the case, that this is due to fibrous adhesions fixing the stapes within the fenestra ovalis. This condition must be carefully distinguished from otosclerosis or bony ankylosis of the stapes, in which latter conditions any such procedure is absolutely contra-indicated.

(ii) Direct mobilization may be undertaken as a preliminary step previous to removal of the stapes itself. If the stapes is movable and slight improvement occurs, then its removal may be justifiable under certain conditions. If, however, the stapes is fixed and no improvement occurs, then its removal will be attended with such difficulty as to almost negative this being attempted.

Operation. If a perforation of the upper posterior quadrant be present, a small pledget of cotton-wool soaked in a 20% solution of cocaine is brought into contact with the inner wall of the tympanic cavity. After a few minutes Lucae’s probe is placed in position against the head of the stapes and the vibratory movements are carried out. If no perforation of the drum exists, then it is first necessary to excise a flap in the upper posterior quadrant of the membrane.

Difficulties. The chief difficulty is anatomical. Projection forward of the upper posterior part of the tympanic ring or a deeply placed niche of the fenestra ovalis may prevent a view of the stapes.

If the membrane has to be incised, the slight amount of bleeding may also prevent a good view being obtained.

There is no actual danger in the operation, but if the stapes is fixed or if much force is used, it is by no means difficult to fracture the crura of the stapes.

REMOVAL OF THE OSSICLES

Except under the most rare conditions only the malleus and incus are removed; the stapes, if possible, being left undisturbed.

These operations will therefore be considered separately.

Removal of the malleus and incus. This operation was first proposed by Schwartze in 1873, and later by Kessel, Ludewig, Sexton, and Zeroni.

Indications. The indications for operation may be considered with regard to (1) chronic middle-ear suppuration and (2) non-suppurative middle-ear disease, whether the result of a previous middle-ear suppuration or of a chronic middle-ear catarrh.

In chronic middle-ear suppuration, the chief object of the operation is to ensure drainage and if possible to remove the cause of the suppuration; in non-suppurative conditions, to improve the hearing.

Sites of Perforation in Attic Suppuration and Caries of the Ossicle Fig. 198. To show Sites of Perforation in Attic Suppuration and Caries of the Ossicles. 1. Perforation in front of malleus. 2. Perforation behind malleus. 3. Perforation involving posterior attic region and upper posterior part of membrane. (From the Author’s Diseases of the Ear.)

It may here be mentioned that the position of the perforation in the attic region is frequently of importance when considering the question of treatment. If situated in front of the malleus, the disease is probably limited to the outer attic region and malleus; if just behind the malleus, then probably both the malleus and incus are affected; but if the perforation extends farther back, involving the upper posterior quadrant of the drum, especially its bony margin, it suggests disease not only of the ossicles together with the walls of the aditus and antrum, but perhaps also of the mastoid process (Fig. 198).

(i) In chronic middle-ear suppuration. Before operation is considered, it is presumed that conservative measures, such as syringing, instillation of astringent and antiseptic drops, and washing out of the attic by means of Hartmann’s canula with various solutions, have been given a thorough trial and failed.

(a) If the suppuration be limited to the attic region (although the main portion of the tympanic membrane is intact), provided there is marked deafness and there are symptoms of lack of free drainage indicated by recurrent attacks of headache, a feeling of heaviness or giddiness, or pain radiating up the head on the affected side.

(b) If there be caries of the malleus and incus, and the outer attic wall, with recurrence of granulations after repeated removal, especially if accompanied by cholesteatomatous formation, provided there is no evidence of disease of the mastoid process itself.

(c) Although the general symptoms and the condition found on examination justify the complete mastoid operation, yet if the patient refuses to have this operation performed, the simpler operation of ossiculectomy may be undertaken if desired. This will permit of free drainage and diminish the risk of future intracranial complications. It should, however, be clearly explained to the patient that no guarantee can be given with regard to effecting a permanent cure as a result of this operation.

(ii) In non-suppurative conditions.

(a) If there be marked middle-ear deafness, the result of adhesions, and the malleus is fixed to the promontory. Operation is justifiable if it is found that after each inflation of the middle ear, improvement of hearing is obtained which, however, is not permanent but only temporary.

(b) If, as the result of artificial perforation, made under the conditions already laid down, improvement takes place temporarily, but a relapse occurs from closure of the perforation (see p. 340).

(c) If tinnitus and attacks of vertigo, due to marked retraction of the membrane, are temporarily relieved by inflation. In this case operation should only be carried out as a last resource after all other measures have failed to cure and if the symptoms are very severe and distressing.

(d) If there be marked middle-ear deafness with extensive adhesions on both sides and evidence points to the stapes being freely movable. The operation is justifiable, as an experiment, on the worse side.

Operation. The only operation to be considered is the intrameatal one. Stacke originally suggested a post-auricular incision, and reflecting the auricle forward, and, after removing the ossicle, to remove also the outer attic-wall by means of the chisel. This method, however, has now been given up as being too radical, but will be mentioned later on in connexion with the mastoid operation (see p. 397).

Unless contra-indicated, a general anæsthetic should be given, as it is not always possible to foretell whether the operation will be difficult or easy. In addition it may be necessary to curette out granulations and also to remove the outer wall of the attic. Unless the patient is very insensitive, this is almost impossible under local anæsthesia (see p. 311).

Before the anæsthetic is given, the ear should be filled with a 5% solution of cocaine containing a 1 in 2,000 solution of adrenalin chloride in order to diminish the bleeding during the operation.

The field of operation is isolated from the surrounding parts by covering the head with a sterilized towel having an opening cut in it just sufficient to expose the auricle and meatus.

The following are the steps of the operation: (1) freeing the malleus from its attachments to the tympanic membrane, and from the inner wall of the middle ear, if adherent to it; (2) cutting through the tendon of the tensor tympani muscle; (3) removal of the malleus; (4) removal of the incus; (5) removal of the outer wall of the attic; (6) curetting out of granulations, if present. The method of operation varies slightly according to the condition found.

Removal of the malleus. In post-suppurative and non-suppurative conditions the chief cause of failure is the recurrence of adhesions, so for this reason it is wisest to remove the membrane as completely as possible.

With a paracentesis knife, the membrane is incised below and behind the malleus. The incision is then carried upwards along its posterior border to the posterior fold, then round the complete margin of the tympanic membrane and along the anterior fold and border of the malleus, so as to meet the original point of the incision. The knife is then reinserted just in front of the processus brevis and cuts through the anterior ligament in an upward direction; in a similar fashion the posterior fold is also cut through (Fig. 190).

The next step is tenotomy of the tensor tympani muscle (see p. 345).

The malleus thus freed can easily be removed by seizing its handle with a pair of Sexton’s (Fig. 193) or crocodile forceps (Fig. 179). In removing the malleus it is necessary to remember that its head is situated within the attic and therefore cannot be pulled out directly, but must first be drawn downwards until it is seen within the tympanic cavity. If this precaution be not taken, the neck of the malleus may be broken, leaving the head behind. If this takes place its extraction may be a matter of difficulty.

Removal of the Malleus by Wilde’s Snare Fig. 199. Removal of the Malleus by Wilde’s Snare. First position. After cutting through the tensor tympani muscle by Schwartze’s method.
    
Removal of the Malleus by Wilde’s Snare Fig. 200. Removal of the Malleus by Wilde’s Snare. Second position. Malleus pulled down from attic—about to be withdrawn from auditory canal.

Instead of using Sexton’s forceps, the malleus may be removed by means of Wilde’s snare. This is the method advocated by Schwartze. After cutting through the tensor tympani muscle, the loop of the snare is threaded over the head of the malleus and guided upwards until it embraces its neck. The loop is then drawn tight so as to hold the malleus firmly in its grasp. The ossicle is extracted by first pulling it downwards (Fig. 199), so as to dislodge it from the attic, and then outwards (Fig. 200).

Delstanche’s Ring-knife. Fig. 201. Delstanche’s Ring-knife.
Removal of Malleus by Delstanche’s Ring-knife Fig. 202. Removal of Malleus by Delstanche’s Ring-knife. A, Curette inserted round handle of malleus; B, Curette pushed upwards, in act of cutting through tendon of tensor tympani muscle.

Another method of extracting the malleus, and in my opinion the one to be preferred, is by Delstanche’s ring-knife (Fig. 201). This instrument differs from the ordinary ring-knife in that the upper border of its anterior part is especially sharpened so as to form a fine cutting surface. After the malleus has been freed from the membrane by means of the paracentesis knife, Delstanche’s ring-knife is made to encircle its handle. It is then pushed gradually upwards, keeping as close to the posterior border of the malleus as possible, until it cuts through the attachment of the tensor tympani. In doing this the instrument will embrace the neck of the malleus (Fig. 202). This permits of sufficient leverage to extract the malleus by gentle traction in a downward and outward direction without danger of fracturing its shaft. If much resistance be felt, probably the tensor tympani muscle has not been cut through, and another attempt should be made to do this before trying further extraction. The advantage of this instrument is, that once the knife has encircled the malleus it should be possible not only to cut through the tensor tympani, but to extract the bone itself without the use of any other instrument. If Schwartze’s tenotomy knife be used, two tenotomy knives are required, one for the right and one for the left ear. Delstanche’s ring-knife is equally good for either ear.

Extraction of the incus. Although it is frequently stated that extraction of the incus is more difficult than that of the malleus, in reality it is the easier part of the operation as, unlike the malleus, it has no firm attachments.

After removal of the malleus all hæmorrhage must be arrested and a view obtained of the inner wall of the tympanic cavity. If it be possible to see the long process of the incus and its articulation with the head of the stapes, the articulation should be cut through with a small sickle-shaped knife. The knife is inserted just in front of the long process of the incus and, keeping close to it posteriorly, is made to cut downwards and backwards, thus separating its connexion with the stapes. Frequently the long process cannot be seen, or it may indeed have already disappeared as a result of caries. Theoretically this delicate manœuvre is performed in order to prevent injury or dislodgment of the stapes during the act of removal of the incus. From a practical point of view, however, it does not appear to make any difference whether the incudo-stapedial articulation is cut through or not.

Ludewig’s Incus Hook Fig. 203. Ludewig’s Incus Hook.
    
Zeroni’s Incus Hook Fig. 204. Zeroni’s Incus Hook.

A variety of instruments have been described for the purpose of removal of the incus. Ludewig’s incus hook (named after Ludewig, who was one of the first to draw attention to this operation) is still recommended by many as being the best. It consists of a solid curved hook, having a length of 5 millimetres and a width of 2 millimetres, bent at right angles to its shaft (Fig. 203). A pair of these are necessary, one for each ear; also several sets of different sizes may be required owing to the variation in depth, height, and roof of the attic region. I, however, prefer Zeroni’s (Fig. 204). This hook, instead of being solid, consists of a steel eyelet having a backward curve similar to that of Ludewig’s.

Removal of Incus by Zeroni’s Hook
Fig. 205. Removal of Incus by Zeroni’s Hook. A, Diagrammatic section showing opening in tegmen tympani: b, processus cochleariformis; c, external semicircular canal; d, aditus and antrum. B, Diagrammatic section, through the auditory canal, just beyond the tympanic membrane: e, long process of incus; f, incudo-stapedial joint; g, tympanic ring; h, remains of the tympanic membrane; i, fenestra rotunda; above it is the promontory.

The technique is the same whichever pattern is employed. The instrument is inserted in such a fashion that the hook is directed upwards, having its concavity backwards. It is passed into the attic at the point previously occupied by the head of the malleus. The shaft of the instrument is then rotated backwards so that the hook passes over the body of the incus (Fig. 205). As the rotatory action is continued downwards and finally forwards, the incus is dislodged from its position and forced into the tympanic cavity. It can now be seized by a pair of Sexton’s or crocodile forceps and removed. If it falls into the floor of the tympanum, it can usually be dislodged by syringing, or else by means of a small hook passed in circular fashion along the floor of the cavity.

Removal of the outer wall of the attic. In the majority of cases of chronic middle-ear suppuration, it is advisable to remove the outer wall of the attic in addition to performing the simple operation of ossiculectomy. If granulations be present they should first be removed, in order to give a clear view of the inner wall of the tympanic cavity, which can usually be obtained, owing to the fact that a large perforation of the membrane is probably present. The malleus and incus are then removed.

Pfau’s Attic Punch Forceps Fig. 206. Pfau’s Attic Punch Forceps.
    
Removal of Outer Attic-wall with Forceps Fig. 207. Removal of Outer Attic-wall with Forceps. A, Outer attic-wall.

To remove the outer wall of the attic a small but strong pair of punch-forceps is required (Fig. 206). The instrument is directed along the roof of the auditory canal, its cutting edge held upwards and the blades kept slightly open, until the outer blade is felt to pass over the outer wall of the attic. The handle is then depressed so that the end of the forceps is forced upwards and embraces the outer wall between its points (Fig. 207). This is confirmed by attempting to withdraw the forceps, which the outer bony wall of the attic will now prevent. The position of the forceps being assured, its blades are brought together by pressure on the handle, and in this manner a small portion of the bone is punched out. In this way the outer wall of the attic is gradually cut away in small fragments. Sometimes this is extremely easy, owing to the auditory canal being large and the outer wall of the attic being thin and easily cut through. In other cases, owing to the thickness of the bony walls or to the narrowness of the canal, it is extremely difficult. If the outer wall of the attic has been completely removed, a fine probe, whose point is bent upwards, can be inserted into the attic and then withdrawn without encountering any obstruction, owing to the roof of the attic and outer wall of the auditory canal being now continuous. In some cases this part of the operation may not be necessary, as the outer wall of the attic may have already disappeared as a result of the caries.

Into the larger opening thus made, small curettes are passed upwards and backwards and any granulations in the region of the aditus and entrance to the antrum are curetted away. Finally the cavity is thoroughly swabbed out with the pledgets of cotton-wool soaked in a 1 in 2,000 alcoholic solution of biniodide of mercury. The cavity is then dried and a small drain of sterilized gauze inserted within the auditory canal, the ear being afterwards covered with a pad of gauze kept in position by a bandage.

After-treatment. In cases of non-suppuration there is rarely any pain, and if asepsis has been maintained, there is seldom much discharge beyond slight sanious oozing. Unless there is considerable discomfort the dressing need not be changed for two or three days. If possible the ear should not be syringed, but merely mopped out with pledgets of cotton-wool moistened with boric lotion and then dried, the gauze drain being afterwards inserted. This process may be repeated daily until healing is complete.

In middle-ear suppuration there may be considerable pain, owing to the forcible bruising of the tissues of the inner part of the auditory canal during the act of removal of the outer wall of the attic. Sometimes, indeed, there is much swelling of the lining membrane of the canal, with the occurrence of furuncles as the result of septic infection.

If there be no pain, the after-treatment is the same as above described, excepting that it may be necessary to syringe out the ear at each dressing owing to the discharge. If there be much pain, with swelling of the canal, the gauze drain should be removed and a 10% solution of carbolic acid in glycerine frequently instilled into the meatus. Subsequently drops of rectified spirit may be substituted.

Difficulties. 1. If the auditory canal be very small there may not be sufficient room to insert the instruments through the speculum. In such cases, if there be no middle-ear suppuration, it is wiser to leave the condition alone. If, however, suppuration exists, either the conservative treatment must be continued or the complete mastoid operation recommended.

2. Hæmorrhage, especially on curetting away the granulations, may be sufficient to prevent a view of the deeper parts. It can, however, usually be arrested quickly by plugging the auditory canal with gauze soaked in adrenalin and cocaine solution. Even if the surgeon has to wait a few moments, this must be done, as it is very necessary to obtain a clear view of the field of operation.

3. Extensive adhesions between the membrane and inner wall may render it difficult to separate the shaft of the malleus without fracturing its neck.

4. In old-standing cases in which there is a large perforation of the membrane, the malleus may be so retracted as not only to be difficult to see but difficult to seize. In this particular case, division of the tensor tympani with Schwartze’s tenotome and then extraction of the malleus by means of Sexton’s forceps is a better procedure than trying to encircle its shaft with Delstanche’s ring-knife.

5. Removal of the incus by the ordinary instruments may be rendered impossible owing to the narrowness of the attic posteriorly from chronic thickening of its walls. In these cases a seeker, such as Schwartze uses in the mastoid operation (Fig. 219), may be employed with advantage. It is passed over the incus in the same manner as an incus hook.

Accidents. 1. Fracture of the handle of the malleus. This is the result of too forcible extraction. If a Delstanche’s ring-knife has been used, this may be due to the tensor tympani not having been cut through; this should now be done. The head of the malleus is then removed either by means of a small hook or some form of curette bent at right angles to its shaft, depending on what is most suitable for the case in question.

2. Failure to extract the incus. In the course of a chronic middle-ear suppuration, the incus may become exfoliated or gradually disappear as the result of caries. It does not therefore always follow that inability to extract the incus means that the surgeon has failed in his manipulations, although frequently this is the case, the instruments failing to extract the incus, or perhaps dislodging it into the mastoid antrum, a fact which is difficult to determine and may only be discovered if the subsequent performance of the complete mastoid operation becomes necessary.

3. Facial paralysis. This accident is usually due to the incus hook not being inserted high enough up, so that, instead of entering the attic, it presses on the inner upper border of the tympanic cavity, and on being rotated in a backward and downward direction, it follows the line of the facial canal (Fig. 208). If much force be employed the frail wall of the facial canal will be fractured or pressed in on the underlying facial nerve. It is very rarely, however, that the nerve is completely crushed or torn through, and therefore recovery almost invariably takes place.

The facial nerve may also be injured whilst curetting away granulations in the upper posterior part of the tympanic cavity.

Diagrammatic Section to show Correct and Wrong Positions of Incus Hook