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, 120 93-122
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, 132 125-133
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,
140 134-141
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_, 148 142-148
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, 156--_Rapid Dilatation_, 157; _Gradual
Dilatation_, 159. Operations for Hypertrophy of the Cervix,
160. Trachelorrhaphy, 161. Vaginal Fixation, 164 149-164
CHAPTER XVI
OPERATIONS FOR NEW GROWTHS OF THE UTERUS
For Uterine Fibro-myomata, 165--_for Pedunculated Tumours_, 165;
_for Sessile Tumours_, 166; _for Interstitial Tumours_, 167.
Vaginal Hysterectomy, 167--_for Carcinoma_, 168; _for
Fibroids_, 173 165-173
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,
182--_Purification of Hands_, 182; _of Instruments_, 183;
_Direction of Incision_, 183; _Position of Incision_, 184;
_Dressings_, 186; _Bandaging_, 186 177-186
CHAPTER II
OPERATIONS UPON THE LENS
Surgical Anatomy, 187. Discission or Needling, 189--_for
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, 209 187-210
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, 227 211-227
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_, 238 228-239
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_, 246 240-246
CHAPTER VI
OPERATIONS UPON THE EXTRA-OCULAR MUSCLES
Squint Operations, 247. Tenotomy, 248. Advancement, 251 247-254
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_), 261 255-262
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, 265--_Canthoplasty_, 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, 273 263-274
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_, 288 275-289
CHAPTER X
OPERATIONS UPON THE LACHRYMAL APPARATUS
For the Relief of Lachrymal Obstruction, 290--_Dilatation 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, 301 290-301
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, 305--_Sources 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, 313 305-313
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, 331 314-334
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_, 351 335-363
CHAPTER IV
OPERATIONS UPON THE EUSTACHIAN TUBE
Catheterization, 364. Passing of the Eustachian Bougie, 369.
Washing out the Tympanic Cavity through the Eustachian Tube,
372 364-372
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_, 390 373-390
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, 415 391-416
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_, 425 417-428
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, 433 429-438
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, 454 439-458
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, 471 459-471
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, 479 475-486
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,
510 487-516
CHAPTER III
OPERATIONS UPON THE TRACHEA
Tracheotomy, 517; _in Diphtheria_, 526; _in Conditions other
than Diphtheria_, 544. Tracheo-fissure and Resection of the
Trachea, 546 517-548
CHAPTER IV
INTUBATION OF THE LARYNX
Intubation v. Tracheotomy in Diphtheria, 549. Indications, 552.
Operation, 553. Difficulties, 555. After-treatment, 556.
Complications, 557 549-558
CHAPTER V
TRACHEOSCOPY AND BRONCHOSCOPY
Indications, 559. Tracheoscopy, 560. Upper Bronchoscopy, 562.
Lower Bronchoscopy, 562. Complications, 563. Results, 566
559-566
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,
580 569-580
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, 596 581-596
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, 612
597-612
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, 625 613-625
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, 659 626-660
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, 665 661-672
LIST OF ILLUSTRATIONS
FIG. PAGE
1. Secondary Cancer of the Ovary 15
2. Secondary Cancer of the Ovary in Section 16
3. An Infected Fallopian Tube 22
4. A Tuberculous Fallopian Tube and Ovary: Entire and in Section 23
5. Primary Cancer of the Fallopian Tube 27
6. A Section of Primary Cancer of the Fallopian Tube 27
7. A Gravid Fallopian Tube 30
8. A Gravid Fallopian Tube, containing Twins 31
9. A Diagram to show the Arterial Supply of the Uterus 37
10. A Fibroid growing near the Right Uterine Cornu 38
11. The Mattress Suture 39
12. The Stump after Subtotal Hysterectomy 39
13. A Bicornate Uterus 42
14. A Bicornate Uterus shortly after Delivery 43
15. Villous Disease of the Uterus 45
16. An Adenomyomatous Uterus 54
17. An Adenomyomatous and Tuberculous Uterus 55
18. Uterus with the Decidua _in situ_ 58
19. Cancer of the Uterus 64
20. The Fundus of a Uterus 68
21. Portion of Ovary and Fallopian Tube 71
22. A Uterus distorted by Fibroids 76
23. A Gravid Uterus in Sagittal Section 79
24. Diagram representing a Gunshot Injury of the Uterus 90
25. The Pulmonary Artery and Adjacent Part of the Lung and
Trachea 103
26. A Pair of Pressure Forceps 106
27. The Relation of Parts after Ricard’s Operation of
Uretero-cysto-neostomy 114
28. A Uterus in Sagittal Section 119
29. Patient prepared for Operation 126
30. Complete Laceration of the Perineum 128
31. Long-handled Sharp-pointed Scissors curved on the flat 129
32. Complete Laceration of the Perineum 129
33. Complete Laceration of the Perineum 130
34. Laceration of the Pelvic Floor 131
35. Repair of a Lacerated Perineum, with Non-union of the
Sphincter Ani, before a Plastic Operation 132
36. Repair of a Laceration of the Perineum after a Plastic
Operation 133
37. Auvard’s Self-retaining Speculum 135
38. Knives for freshening the Edges of a Vesico-vaginal Fistula 135
39. Toothed Forceps for use in Vesico-vaginal Fistula 135
40. Emmett’s Hook 136
41. Sims’s Operation for the Repair of a Vesico-vaginal Fistula 136
42. Simon’s Operation for the Repair of a Vesico-vaginal Fistula 137
43. Repair of a Vesico-vaginal Fistula by _Dédoublement_ 138
44. Repair of a Vesico-vaginal Fistula. Sims’s Operation 139
45. Stoltz’s Operation for Cystocele 141
46. Sims’s Vaginal Rest 144
47. Pozzi’s Retractors 145
48. Anterior Colpotomy 146
49. Martin’s Trochar for Pelvic Abscess 147
50. The Passage of the Uterine Sound. _Introduction of the point
into the external os uteri_ 149
51. The Passage of the Uterine Sound. _Commencement of the tour
de maître_ 149
52. The Passage of the Uterine Sound. _Completion of the tour de
maître_ 150
53. The Passage of the Uterine Sound. _Entry of the sound into
the uterine cavity_ 150
54. Chronic Uterine Inversion 151
55. Volsella for fixing the Cervix 153
56. Hegar’s Dilators (three sizes) for dilatation of the Cervix
Uteri 153
57. Metal Bougies for dilatation of the Cervix 154
58. Bozemann’s Double-channelled Tube 155
59. Budin’s Celluloid Catheter 155
60. Murray’s Flushing Curette; Blunt Curette 155
61. Dilatation of the Cervix 157
62. Marckwald’s Operation for Congenital Hypertrophy of the
Cervix 161
63. Hegar’s Operation for Supravaginal Elongation of Cervix 161
64. Emmett’s Scissors (left) for Trachelorrhaphy 162
65. Trachelorrhaphy 163
66. Pedunculated Fibroid Polypi in various Stages of Extrusion 165
67. Wire Écraseur 166
68. Submucous Fibro-myomata, capable of Treatment by
_Morcellement_ 167
69. Galabin’s Broad-ligament Needle (right) 169
70. Jessett’s Broad-ligament Needle 169
71. Vaginal Hysterectomy 170
72. Vaginal Hysterectomy. _Final stage_ 171
73. Schauta’s Needle-holder 172
74. Window of the Operating Theatre, King’s College Hospital 178
75. Bull’s-eye Electric Hand-lamp 179
76. Lang’s Eye Speculum 181
77. Undine for washing out the Conjunctival Sac 182
78. Cataract Extraction 183
79. Sympathetic Ophthalmia 184
80. Cystoid Scar after Glaucoma Iridectomy 184
81. An Eye Bandage 185
82. A Pressure Bandage 185
83. A Lens Three Weeks after Needling 187
84. Anatomy of the Anterior Segment of the Eye 188
85. Eye Speculum 190
86. Fixation Forceps 190
87. Secondary Cataract 192
88. Capsulotomy. _The method of incising the capsule_ 193
89. Capsulotomy. _The method of dividing a dense band_ 193
90. Iris Forceps 196
91. Iris Scissors 196
92. A Vectis 196
93. Pagenstecher’s Spoon 196
94. Lens Extraction 197
95. The Knife entering the Anterior Chamber in Cataract
Extraction 198
96. Making the Counter-puncture in Cataract Extraction 198
97. Incision and Iridectomy in Cataract Extraction 199
98. Opening the Capsule with Forceps in Cataract Extraction 200
99. Cataract Extraction 201
100. McKeown’s Irrigation Apparatus for washing out the Anterior
Chamber 202
101. Subconjunctival Extraction 205
102. Iridotomy 212
103. Iridotomy 212
104. Iridotomy by Ziegler’s Method 213
105. Iridotomy by Ziegler’s Method 214
106. Iridotomy by Ziegler’s Method 214
107. Optical Iridectomy 215
108. Optical Iridectomy 216
109. Optical Iridectomy 217
110. The Normal Angle of the Anterior Chamber 218
111. The Angle of the Anterior Chamber from a Case of Recent
Glaucoma 219
112. The Angle of the Chamber in a Case of Chronic Glaucoma 220
113. Iridectomy for Glaucoma 221
114. Iridectomy for Glaucoma 222
115. Iridectomy for Glaucoma 222
116. Iridectomy for Glaucoma 223
117. Glaucoma Iridectomy 224
118. Prolapse of the Iris through a Punctured Wound of the Cornea 226
119. Cyclo-dialysis Operation 229
120. Cyclo-dialysis Operation 230
121. Lagrange Operation for the Production of a Cystoid Scar in
Chronic Glaucoma 232
122. Lagrange Operation for Chronic Glaucoma 232
123. Hollow Needle used for Paracentesis of the Anterior Chamber 234
124. Author’s Chair for the Localization of Foreign Bodies in the
Eye by the X-rays 236
125. Small Electro-magnet for extracting Pieces of Steel from the
Eye 238
126. Large Electro-magnet 239
127. Electro-cautery 241
128. Tattooing Needles 243
129. Graddy’s Forceps 245
130. Tenotomy 249
131. Tenotomy by the Open Method 250
132. Prince’s Forceps for Advancement 252
133. Advancement by the Three-stitch Method 253
134. Enucleation 256
135. Mules’s Operation. _First step_ 258
136. Mules’s Operation. 258
137. Maxwell’s Operation for Contracted Socket. _First step_ 262
138. Maxwell’s Operation. _Final step_ 262
139. Canthorrhaphy 266
140. Harman’s Operation for Ptosis 270
141. Ptosis Operation. Panas’ 271
142. Ptosis Operation. Advancement of the Levator Palpebræ 272
143. Ptosis Operation. Advancement of the Levator Palpebræ 273
144. Treacher Collins’s Entropion Forceps 276
145. Lid Clamp 277
146. Streatfield’s Entropion Operation 277
147. Arlt’s Operation for Trichiasis 278
148. Snellen’s Sutures 280
149. Fergus’s Operation for Slight Ectropion of the Lower Lid 281
150. Modified Kuhnt’s Operation for Severe Ectropion. _Second
step_ 282
151. Modified Kuhnt’s Operation. _Fourth step_ 282
152. Argyll Robertson’s Operation for Ectropion. _Second step_ 283
153. Argyll Robertson’s Operation for Ectropion. _Final step_ 283
154. VY Operation for Ectropion of the Lower Lid due to a Scar.
_First step_ 284
155. VY Operation for Ectropion. _Final step_ 284
156. Denonvillier’s Operation for Ectropion of the Lower Lid.
_First step_ 285
157. Denonvillier’s Operation for Ectropion 285
158. Fricke’s Operation 286
159. De Vincentiis’ Operation to replace the Loss of the Inner
Portion of the Lower Lid 288
160. De Vincentiis’ Operation completed 288
161. Modified Dieffenbach’s Operation to replace the Loss of the
whole Lower Lid. _First step_ 289
162. Modified Dieffenbach’s Operation. _Third step_ 289
163. Canaliculus Dilator 291
164. Canaliculus Knife 291
165. Lachrymal Syringe 292
166. Muller’s Retractor for Excision of the Lachrymal Sac 295
167. Axenfeld’s Retractor for Excision of the Lachrymal Sac 295
168. Excision of the Lachrymal Sac 296
169. Excision of the Lachrymal Sac 296
170. Excision of the Palpebral Portion of the Lachrymal Gland 298
171. Clar’s Lamp 305
172. Gruber’s Aural Speculum 306
173. Angular Spring Forceps 306
174. Examination of the Ear 307
175. Aural Forceps holding Cotton-wool 307
176. Milligan’s Intratympanic Syringe 308
177. Neumann’s Syringe for Subcutaneous Injection 311
178. Burkhardt-Merian’s Aural Instrument 315
179. Crocodile Forceps 324
180. Imray’s Scoop for extracting a Foreign Body 325
181. Aural Probe 332
182. Wilde’s Aural Snare 332
183. Wilde’s Snare being passed round an Aural Polypus 333
184. Wilde’s Snare gripping the Neck of Polypus 334
185. Polypus arising from the Attic Region 334
186. Anatomical Preparation of the Middle Ear 336
187. Paracentesis Knife held in position in the Hand 338
188. Tympanic Membrane showing Incision in Acute Suppuration of
the Middle Ear 339
189. Line of Incision in Acute Suppuration of the Attic 339
190. Lines of Incisions in Intratympanic Operations 341
191. Cutting through Intratympanic Adhesions 343
192. Free Edge of Tympanic Membrane cut through 344
193. Sexton’s Instrument 345
194. Method of using Siegle’s Speculum 345
195. Division of Intratympanic Adhesion with Excision of Handle
of Malleus 346
196. Schwartze’s Tenotomy Knife 347
197. Lucae’s Probe 350
198. To show Sites of Perforation in Attic Suppuration and Caries
of the Ossicles 351
199. Removal of the Malleus by Wilde’s Snare. _First position_ 354
200. Removal of the Malleus by Wilde’s Snare. _Second position_ 354
201. Delstanche’s Ring-knife 354
202. Removal of Malleus by Delstanche’s Ring-knife 355
203. Ludwig’s Incus Hook 356
204. Zeroni’s Incus Hook 356
205. Removal of Incus by Zeroni’s Hook 356
206. Pfau’s Attic Punch-forceps 357
207. Removal of the Outer Attic-wall with Forceps 358
208. Diagrammatic Section to show Correct and Wrong Positions of
Incus Hook 360
209. Eustachian Catheter 365
210. Passing the Eustachian Catheter 366
211. Passing the Eustachian Catheter 366
212. Passing the Eustachian Catheter 367
213. Passing the Eustachian Catheter 367
214. Author’s Graduated Eustachian Bougie 370
215. Left Temporal Bone, showing Anatomy of the Middle Ear and
Mastoid Process 374
216. Diagram showing Position of Sink Incisions in Post-aural
Operations 380
217. Schwartze’s Operation 381
218. Schwartze’s Operation 383
219. Schwartz’s Seeker 384
220. Schwartze’s Operation completed 385
221. The ‘Radical’ Mastoid Operation 393
222. Stacke’s Protector 394
223. The ‘Radical’ Mastoid Operation 395
224. Pfau’s Curette for the Eustachian Tube 396
225. The ‘Radical’ Mastoid Operation completed 397
226. Wolf’s Operation 398
227. Stacke’s Operation 399
228. Post-meatal Skin Flaps 400
229. Post-meatal Skin Flaps 401
230. Closure of Wound after ‘Radical’ Mastoid Operation 402
231. Körner’s Post-meatal Flap 403
232. Panse’s Post-meatal Flap 403
233. Stacke’s Post-meatal Flap 403
234. Skin-grafting of Mastoid Wound Cavity after Operation 407
235. Ballance’s ‘Stopper’ for pushing in the Graft 407
236. Pipette for sucking Air and Fluid from beneath the Graft 408
237. Skin-grafting of Mastoid Wound Cavity after Operation 408
238. Skin-grafting of Mastoid Wound Cavity after Operation 409
239. Posterior Portion of Skin Graft covering Outer Surface of
Wound Cavity 409
240. Diagram to show Exposure of the Semicircular Canals 423
241. Operation upon the Labyrinth 424
242. Extirpation of the Labyrinth 425
243. Method of Removal of Bone by the Forceps 435
244. Diagram to show the usual Points at which the Lateral Sinus
is primarily infected 443
245. The Lateral Sinus exposed and opened 445
246. Incision for Exposure of the Internal Jugular Vein 448
247. Exposure of the Internal Jugular Vein high up 449
248. Ligature of the Internal Jugular Vein low down in the Neck 451
249. Free Exposure of the Lateral Sinus, which has been incised,
with Ligature of the Internal Jugular Vein 452
250. Method of suturing the Open End of the Internal Jugular Vein
in the Neck 453
251. Topography of the Auditory Region of the Skull 462
252. Exploration for a Temporo-sphenoidal Abscess 463
253. Exploration for a Cerebellar Abscess 467
254. Skiagram showing a Tumour of the Larynx 476
255. Horsford’s Instrument for transfixing the Epiglottis 478
256. Multiple Papillomata of the Larynx 480
257. Tube-spatulæ used for Laryngoscopy 481
258. Removal of Multiple Papillomata by Direct Laryngoscopy 483
259. Intrinsic Tumour of the Larynx 488
260. Extrinsic Tumour of the Larynx 488
261. Thyrotomy 491
262. Total Laryngectomy 499
263. Total Laryngectomy. Gluck’s Method 501
264. Infrathyreoid Laryngotomy 510
265. Instruments for Laryngotomy 512
266. Laryngotomy Canula fitted with Inner Tube 513
267. Skiagram showing an Angular Tracheotomy Tube in the Trachea 518
268. Anatomy of the Larynx and Trachea and the Position of
Incisions for the Operations in this Region 524
269. Tubes for Tracheotomy 527
270. Trachea showing Ulceration caused by a Badly Fitting Tube 537
271. Stenosis following Tracheotomy 539
272. Tubes used in the Treatment of Stenosis of the Larynx 540
273. Trachea showing Ulceration into the Innominate Artery after
Tracheotomy 541
274. Aneurism of the Aorta perforating the Trachea 542
275. Sarcoma of the Trachea 547
276. Instruments for Intubation of the Larynx 553
277. Instruments for Bronchoscopy 561
278. Instruments for Bronchoscopy 562
279. Upper Bronchoscopy with the Patient in the Dorsal Position 564
280. Lower Bronchoscopy with the Patient in the Dorsal Position 565
281. Laryngoscope Lamp 570
282. Clar’s Electric Light 571
283. Frontal Search-light 571
284. Meyer’s hollow Vulcanite Nasal Splint 582
285. Krause’s Trochar and Canula 583
286. Nasal Punch-forceps 583
287. Post-nasal Forceps 584
288. Nasal Dressing Forceps 585
289. First Step in removing the Anterior End of the Inferior
Turbinal, which is seen to have undergone Polypoid
Degeneration 587
290. Nasal Scissors 588
291. Amputation of the Posterior End of the Inferior Turbinal 590
292. Nasal Spokeshave 591
293. First Step in the Removal of the Anterior End of the Middle
Turbinal 593
294. Second Step in the Removal of the Anterior End of the Middle
Turbinal 593
295. Cresswell Baber’s Nasal Saw 597
296. The Gleason-Watson Operation for Deformity of the Septum 599
297. Asch’s Cutting Scissors 600
298. Lake’s Rubber Splint 600
299. Bayonet Knife 604
300. Incision for Submucous Resection of the Septum 604
301. Making the Incision from the Convex Side in Submucous
Resection of the Septum 605
302. Dull-edged Detacher 605
303. Denudation of the Septum in Submucous Resection 606
304. Complete Denudation of the Deviated Septum 606
305. Ballenger’s Swivel Septum Knife 607
306. The Method of employing Ballenger’s Swivel Septum Knife 607
307. Submucous Resection of the Septum 608
308. Submucous Resection of the Septum 609
309. Submucous Resection of the Septum 609
310. Semi-diagrammatic Transverse Section of the Nose 610
311. Operation for Perforation of the Septum 611
312. Nasal Snare 613
313. Luc’s Nasal Forceps 616
314. Tongue Clip 617
315. Incisions for Lateral Rhinotomy (Moure’s Operation) 619
316. The Area of Bone removed in Lateral Rhinotomy 620
317. Lateral Rhinotomy 621
318. Rouge’s Operation. _First stage_ 623
319. Rouge’s Operation. _Second stage_ 624
320. Catheterizing the Maxillary Sinus 626
321. Lichtwitz’s and Moritz Schmidt’s Antrum Needles 627
322. Puncturing the Maxillary Sinus 627
323. Antrum Drills 628
324. Solid Rubber Obturators 628
325. Antrum Nozzle 628
326. Washing out the Maxillary Sinus from an Alveolar Opening 629
327. The Incision in the Caldwell-Luc Operation upon the
Maxillary Sinus 631
328. The Caldwell-Luc Operation upon the Maxillary Sinus 632
329. Opening the Maxillary Sinus from the Nose 633
330. Carwardine’s Punch-forceps 634
331. The Opening into the Maxillary Sinus from the Inferior
Meatus of the Nose 635
332. Denker’s Operation 636
333. Catheterizing the Frontal Sinus 639
334. Radiograph to show the Value of the Röntgen Rays 640
335. Radiograph showing Canula in the Frontal Sinus 641
336. Killian’s Operation upon the Frontal Sinus 643
337. Killian’s Operation upon the Frontal Sinus 644
338. Periosteal Elevators 645
339. Killian’s Triangular Curved Chisel 645
340. Citelli’s Bone-forceps 646
341. Hajek’s Bone-forceps 646
342. Killian’s Operation upon the Frontal Sinus 647
343. Radiograph of the Sphenoidal Sinus 654
344. Radiograph of the Sphenoidal Sinus 655
345. Catheterizing the Sphenoidal Sinus 656
346. Killian’s Long Nasal Speculum 657
347. Radiograph showing a Probe in the Sphenoidal Sinus 658
348. Sphenoidal Punch-forceps 659
349. Adenoid Curette 668
350. The Removal of Naso-pharyngeal Adenoids 668
351. Removal of Naso-pharyngeal Adenoids 669
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.
[Illustration: 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.]
=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.
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’.
[Illustration: FIG. 2. SECONDARY CANCER OF THE OVARY IN SECTION. This is
a section of the ovary represented in the preceding figure. Half size.]
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:--
Fibromata 2
Sarcomata 2
Carcinomata 1
Simple cysts 45
Adenomata 25
Dermoids 15
Papillomata 2
Parovarian 5
Tubo-ovarian 3
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 adenomata 41 with 3 deaths.
Dermoids 38 " 5 "
Sarcomata 21 " 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
-+------------+-----------+--------+----------+----------------------
| _Reporter_ | _Age_ |_Result_|_Nature of| _Reference_
| | | | Tumour_ |
-+------------+-----------+--------+----------+----------------------
1|D’Arcy Power|4 months | R. |Dermoid |_Trans. Path.
| | | | |Soc._, xlix. 186.
-+------------+-----------+--------+----------+----------------------
2|MacGillivray|11 months | R. |Cyst |_Lancet_, 1907,
| | | | |i. 1487.
-+------------+-----------+--------+----------+----------------------
3|Roemer |1-3/4 years| R. |Dermoid |_Deutsche Med. Woch._,
| | | | |1883, ix. 762.
-+------------+-----------+--------+----------+----------------------
4|Péan |2 years | R. |Dermoid |_Clin. Chir._,
| | | | |1887-8, 8th series.
-+------------+-----------+--------+----------+----------------------
5|Hooks |2-1/2 years| D. |Dermoid |_Am. 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
--+-------------+-----+--------+------------------------------------
| _Reporter_ |_Age_|_Result_| _Reference_
--+-------------+-----+--------+------------------------------------
1|Owens | 80 | R. |_Brit. Gyn. Soc. Journal_, iv. 88.
--+-------------+-----+--------+------------------------------------
2|Richardson | 80 | R. |_Brit. Med. Journ._, 1894, i. 523.
--+-------------+-----+--------+------------------------------------
3|Heywood Smith| 81 | R. |_Lancet_, 1894, i. 1618.
--+-------------+-----+--------+------------------------------------
4|Spencer | 82 | R. |_Brit. Med. Journ._, 1893, ii. 1271.
--+-------------+-----+--------+------------------------------------
5|Homans | 82 | R. |_Bost. Med. and Surg. Journ._, 1888,
| | | | 454.
--+-------------+-----+--------+------------------------------------
6|Edis | 81 | R. |_Brit. Med. Journ._, 1892, i. 860.
--+-------------+-----+--------+------------------------------------
7|Bush | 84 | R. |_Ibid._, 1894, ii. 67.
--+-------------+-----+--------+------------------------------------
8|Remfrey | 83 | R. |_Trans. Obstet. Soc._, xxxvii. 152.
--+-------------+-----+--------+------------------------------------
9|Kraft | 84 | R. |_Hospitalstidende_, Copenhagen.
--+-------------+-----+--------+------------------------------------
10|Owens[1] | 87 | R. |_Lancet_, 1895, i. 542.
--+-------------+-----+--------+------------------------------------
11|Thornton | 94 | R. |_Trans. Obstet. Soc._, xxxvii, 158.
--+-------------+-----+--------+------------------------------------
12|Bland-Sutton | 85 | R. |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.
[Illustration: 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 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.
[Illustration: 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.]
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).
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.
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:--
Salpingitis 49
Pyosalpinx 31
Hydrosalpinx 10
Tuberculous 8
Ovarian abscess 2
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.
[Illustration: 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.]
[Illustration: 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.