This is probably due to injury to the pelvic floor and the anterior
fibres of the levator ani, producing a backward displacement of the
urethra.
=Operation.= The operation recommended by Dudley consists of first
denuding the vaginal mucous membrane over a horseshoe-shaped space
between the clitoris and the urethral orifice and then drawing the
urethra forward with sutures passed through the anterior portion of the
orifice and inserted near the clitoris. It will then be seen that the
urethra is carried forward nearly an inch. The raw edges are brought
together in the usual manner by catgut or silk sutures.
The author’s experience of this operation has been unsatisfactory on the
whole, and he has obtained better results by the wearing of a ring
pessary.
OPERATIONS FOR VESICO-VAGINAL FISTULA
=For simple vesico-vaginal fistula.= This condition is fortunately very
rare at the present time. Many operations have been devised for this
condition, but the original one recommended by Sims, with subsequent
modifications, appears to the author to be most efficient and applicable
to the large majority of varieties of this condition.
[Illustration: FIG. 37. AUVARD’S SELF-RETAINING SPECULUM.]
[Illustration: FIG. 38. KNIVES FOR FRESHENING THE EDGES OF A
VESICO-VAGINAL FISTULA.]
[Illustration: FIG. 39. TOOTHED FORCEPS FOR USE IN VESICO-VAGINAL
FISTULA.]
=Preparatory treatment.= The chief object is to obtain a healthy
condition of the fistulous edges, which are nearly always inflamed,
thickened, and covered by urinary deposits, usually of a phosphatic
character. These are best removed by means of a soft sponge or
cotton-wool, and the raw edges treated with a weak solution of nitrate
of silver (gr. ij to the ounce). Hot vaginal douches of lysol solution
(ʒj to a quart) should be given night and morning, and the parts freely
smeared with vaseline to protect them from the action of the irritating
urine. Any cicatricial tissue which may be present around the fistula
should be treated by submucous division.
[Illustration: FIG. 40. EMMETT’S HOOK.]
=Operation.= The instruments necessary are: a Sims’s or Auvard’s (Fig.
37) speculum; two flat spatulæ; three long-handled knives (Fig. 38), one
with a long haft and a short straight narrow blade, and the others with
angular blades (right and left); two long-handled, sharp-pointed, curved
scissors (right and left); an Emmett’s hook for making counter-pressure
(Fig. 40); toothed forceps (Fig. 39) and tenaculum; six Spencer Wells’s
forceps; Schauta’s needle-holder (Fig. 73) with short curved needles.
[Illustration: FIG. 41. SIMS’S OPERATION FOR THE REPAIR OF A
VESICO-VAGINAL FISTULA.
_a._ Bladder mucous membrane.
_b._ Vaginal wall.
_c._ Suture passed but not tied.
_d._ Section of denuded surface.
_e, e_{1}._ Liberating incisions.
_f._ The fistula.
]
The patient is placed in the lithotomy position. A strip of mucous
membrane is then removed from the whole of the vaginal edge of the
fistula by means of an angular knife. In the original operation Sims
(Fig. 41) made the surface oblique, but Simon (Fig. 42) considered the
raw surface should be at right angles to the mucous membrane. The blade
of the knife should not wound the vesical mucous membrane.
After the bleeding has ceased, the sutures, which may be of silk or
catgut, are passed by means of the needle through the pared edge of the
fistula on one side, passing across the fistula, and piercing the raw
surface on the opposite side. The entry of the needle should be made
about 1/4-1/3 of an inch from the raw edge (Fig. 44). Emmett’s hook,
shaped like a button-hook, is useful to produce counter-pressure against
the needle point. The sutures are tied, and milk is injected into the
bladder to test the accuracy of the union.
As a rule, fistulæ are bounded by rather scanty and inelastic walls,
owing to the presence of cicatricial tissue; it is therefore more
advantageous not to remove any tissue in order to produce a raw surface,
or as little as possible. To fulfil this condition, the method of
_dédoublement_ or flap-splitting, as practised by Walcher, may be
carried out (Fig. 43, A, B, and C).
[Illustration: FIG. 42. SIMON’S OPERATION FOR THE REPAIR OF A
VESICO-VAGINAL FISTULA. Letters as in the preceding figure.]
The patient is placed, as before, in the lithotomy position, and the
cervix is pulled down, while the edges of the fistula are kept steady by
a volsella on either side. The margin of the orifice is then split all
round to a depth of from a quarter to half an inch. Vesical and vaginal
mucous membrane flaps are thus produced, giving a large raw surface
without any loss of substance. The sutures are passed as shown in Fig.
43, C.
=After-treatment.= This is very simple: if the patient is able, she
should pass water, either in the dorsal or genu-pectoral position,
otherwise a catheter should be passed every six hours.
_Modifications of this operation_ have been devised, more especially for
the larger fistulæ: they will be briefly mentioned.
1. Repair by turning up vaginal flaps to form the base of the bladder is
recommended by A. Martin of Berlin. He first frees the adherent edges of
the fistula and then raises the flaps from the vaginal wall and brings
them over the opening, suturing them carefully together. By this method
the mucous membrane of the vagina forms the new lining to the bladder,
and the exposed raw surface a new anterior vaginal wall. The edges of
this latter denuded surface are united by sutures, as in the operation
of colporrhaphy.
2. Closure of the fistula by detaching the bladder from the vagina and
suturing it independently is described and practised by Mackenrodt.
[Illustration: FIG. 43. REPAIR OF A VESICO-VAGINAL FISTULA BY
DÉDOUBLEMENT.
A. The flap-splitting stage.
B. The flaps separated and the suture passed.
C. Suture tied, approximating the flaps.
_a._ Bladder mucous membrane.
_b._ Vaginal wall.
_c._ Suture.
_e, e_{1}._ Liberating incisions.
_k, k_{1}._ Flap-splitting incisions.
In A the flap-splitting is seen in section (_k, k_{1}_); in B the flaps
have been everted towards the bladder and vagina respectively and the
suture passed. In C this suture has been tied; liberating incisions, _e,
e_{1}_, have been made on the vaginal surface to prevent tension in the
wound.
]
The patient is placed in the lithotomy position, and the fistula is
exposed: the cervix is drawn downwards and backwards by means of a wire
loop or tenaculum, and the urethral prominence held with a pair of
hooked forceps. An incision is then made in the median line extending
across the fistula and through the vaginal walls down to the bladder, in
this way exposing the entire base of the bladder. The edges of the
fistula are then split so that the bladder and the vaginal walls are
separated. The two vesical flaps are now carefully and separately
sutured by catgut and the edges of the vaginal wound are brought
together as much as possible: if necessary, the fundus of the uterus
may be used to assist in closing the opening.
=For vesico-utero-vaginal or juxta-cervical fistula.= In this affection
the cervix is involved, and it must therefore be carefully
differentiated from the vesico-vaginal variety, in which the cervix is
intact.
[Illustration: FIG. 44. REPAIR OF A VESICO-VAGINAL FISTULA. _Sims’s
Operation._ The edge of the fistula has been denuded and the sutures
have been passed.
_a.v.w._ Anterior vaginal wall.
_cl._ Clitoris.
_s_{1}, s_{11}._ Retractors.
_sp._ Posterior speculum.
_t._ Tenaculum.
_u._ Orifice of urethra.
_v.v.f._ Vesico-vaginal fistula.
]
In operating upon such cases the chief difficulty will be found in
denuding the surfaces necessary for the introduction of the sutures,
owing to the density of the cicatricial tissues, which are always
present. This is best overcome by drawing the cervix forcibly downwards
and backwards and incising the anterior cul-de-sac; the bladder wall
with its fistulous opening is then dissected off the anterior surface of
the cervix and carefully sutured independently of the cervical
laceration; the latter is treated by suture in the usual way (see p.
128). In the deeper forms of juxta-cervical fistula, the above technique
is impossible, and suprapubic incision and suture of the bladder must be
substituted.
RECTO-VAGINAL FISTULA
This condition may be defined as an opening between the rectum and
vagina through which flatus, or fæces, or both, may pass from the former
into the latter; it is chiefly the result of an imperfect union
subsequent to an operation for complete perineum laceration. It may also
be caused by the rupture of a pelvic abscess or by the spread of primary
malignant disease of the rectal wall.
=Operation.= If the sphincter ani is incompletely united, it will be
found much the most satisfactory proceeding to divide the healed
portions of the perineum and make a complete perineal laceration; this
may then be treated as described above (see p. 128).
If, however, the sphincter is intact and serviceable the fistula should
be pared and the edges brought together by silk sutures. It is not
infrequently necessary to perform a temporary colostomy (see Vol. II) in
order to divert the fæcal contents of the bowel during the process of
healing.
OPERATIONS FOR CYSTOCELE
In cystocele there is prolapse of the anterior vaginal wall and the
corresponding area of the posterior bladder wall. Cystocele often
complicates rectocele and prolapsus uteri, and operation upon it is
often carried out in combination with colpo-perineorrhaphy.
=Operation.= The operation for the cure of this affection is very
simple, and may be performed:--
(1) By denuding an oval space over the swelling and bringing the raw
edges together.
(2) By Stoltz’s operation, which is really purse-string suture.
The instruments necessary are a bladder sound, two tenacula,
sharp-pointed angular scissors, a needle-holder and fine silk.
(1) The parts are exposed with a Sims’s or Auvard’s speculum and a
volsella, or silver wire is passed through the cervix, by means of which
traction downwards and backwards may be exerted. The cystocele itself is
fixed by tenacula, and, with the sound in the bladder, an oval incision
is carried completely round the base of the cystocele. The whole area
contained in this incision is denuded by knife or scissors, care being
taken to avoid wounding the bladder mucous membrane.
Any bleeding having been controlled, a spiral buried suture, as in the
operation for perineorrhaphy (see p. 128), is passed antero-posteriorly,
thus reducing the size of the raw area and making a solid support in the
median line. The raw edges are then brought together by sutures. The
catheter should be passed every eight hours for three days, and then the
patient should be allowed to micturate on her hands and knees.
(2) _Stoltz’s operation._ The instruments necessary are: a No. 8 male
bladder sound; two tenacula; hooked forceps; sharp-pointed angular
scissors, and a needle-holder (Schauta’s for preference).
The patient is placed in the lithotomy position and the parts are
exposed by means of an Auvard’s speculum. A silver wire or tenaculum is
passed through the posterior lip of the cervix, by means of which
downward and backward traction may be exerted. Four points must be
selected: two lateral (Fig. 45, 1, 1'), fixing the external boundaries
of the surface to be denuded; one immediately behind the orifice of the
urethra (2); and a fourth in front of the cervix (3). These four points
should be capable of close approximation. They are carefully joined by
curved incisions so that the area to be denuded is almost oval in shape.
The bladder sound is now passed, and the mucous membrane of the vagina
kept on the stretch by pressure on its point. The process of denudation
should be carried out with a scalpel or pointed curved scissors. It will
be found that bleeding rarely gives any trouble. The point of the needle
threaded with silk is inserted on the operator’s right side of the
urethral orifice and a little below it; it pierces the mucous membrane
on the left side of the median line, and again appears upon the surface.
By an in-and-out stitch all the way round the circle which has been
pared, the point finally issues on the operator’s left side of the
urethra and below it: by traction on these two ends the edges of the
denuded surface are drawn together and the prolapsed bladder is sutured
in its normal situation. A puckered cicatrix results. This method is
valuable for prolapsus uteri when combined with the operation of
posterior colporrhaphy.
[Illustration: FIG. 45. STOLTZ’S OPERATION FOR CYSTOCELE. The oval
surface has been denuded and the circumferential suture passed but not
tied.
1,1',2,3. The four points first selected as boundaries for denudation.
_s._ Suture, the arrows denoting the direction in which it is passed.
_sp._ Retractor.
_t._ Tenaculum.
_u._ Urethral orifice.
]
CHAPTER XIV
OPERATIONS UPON THE VULVA AND VAGINA
OPERATIONS UPON BARTHOLIN’S GLANDS
The glands of Bartholin, or the vulvo-vaginal glands, are two racemose
structures about the size of a pea, lodged between the layers of the
triangular ligament, one on each side of the orifice of the vagina.
Their ducts open a little in front of the fossa navicularis, on each
side of the vaginal orifice, in the groove between the attached border
of the hymen and the labium minus.
=Removal of a cyst of Bartholin’s gland.= These cysts really arise in
the ducts rather than in the gland itself. The orifice of the main duct
is very liable to become blocked from inflammation of the vulva, and
leads to the formation of a single cyst varying in size from a cherry to
an orange. Less common is the blocking of the secondary ducts, wherefrom
a collection of small cysts results. The cyst forms a characteristic
tense ovoid or pyriform swelling in the posterior third of the labium
majus. The chief symptoms the patient complains of are discomfort in
walking and pain on coitus.
=Operation.= The best procedure is complete excision of the cyst. A
longitudinal incision is made over its cutaneous surface, and the cyst
carefully dissected out, together with the gland itself: care must be
taken not to perforate the vaginal mucous membrane stretched over the
inner surface of the cyst. Brisk bleeding from vessels at the base of
the cyst, usually follows from the cavity which contained the cyst and
this must be carefully arrested, otherwise a large hæmatoma may result.
The cavity is closed by five or six interrupted catgut sutures, passing
deeply through its sides and floor, so as to ensure complete closure. A
gauze drain may be inserted and retained for twenty-four hours.
The method of incising the cyst, swabbing its interior with undiluted
carbolic acid, and packing it with gauze is not to be recommended, for
cure is neither so rapid nor so certain as in excision.
=Incision of an abscess of Bartholin’s gland.= Abscesses arise by
infection passing into the gland along the ducts, and are a very
frequent accompaniment of gonorrhœa. The orifice of the duct can usually
be seen red and prominent, and may exude pus if pressure be made over
the abscess-sac. Sometimes the abscess bursts and spontaneous recovery
may follow, but it is very liable to recur, for infection lurks among
the smaller ducts and is carried to a fresh part of the gland, and the
process may continue until the whole gland has been thus destroyed.
=Operation.= The abscess must be freely incised and all pockets and
septa broken down. It is stuffed with iodoform gauze, which is changed
daily, and the cavity is allowed to granulate up from the bottom. If the
abscess recurs, or if it consists only of a small collection of pus
surrounded by brawny œdema, the whole gland should be excised.
OPERATIONS FOR ATRESIA OF THE HYMEN AND THE VAGINA
Occlusion of the hymen is the commonest form observed. The vagina
becomes slowly distended with blood, forming an elastic pelvic swelling
(hæmato-colpos) upon which the uterus is, so to speak, perched. Later in
the course of the disease, this organ itself (hæmato-metra) and the
Fallopian tubes (hæmato-salpinx) may become affected similarly.
=Indications.= In atresia of the hymen symptoms only commence after
puberty; there is then congenital amenorrhœa with periodic pelvic pain
and gradual formation of a pelvic swelling. On inspection the hymen is
distended and the blood-tumour above it gives a bluish tint to its
surface.
=Operation.= After administration of an anæsthetic, careful palpation of
the tubes should be made _per rectum_: if they are distended it is
better to open the abdomen, ligature and remove them; if not, the hymen
should be incised by means of a crucial opening and the characteristic
tarry fluid allowed to escape: no hypogastric pressure should be used.
Irrigation and packing with gauze may be resorted to as after-treatment,
but are considered unnecessary by a large number of operators.
Atresia of the vagina may be congenital or acquired. In the latter case
the condition results from contraction of adhesions developed from
damage done during labour; or it may follow acute septic vaginitis, the
introduction of acids or irritating materials to produce abortion, or as
a sequel to typhoid fever.
Treatment is by slow dilatation with Hegar’s bougies over an extended
period of time; relapse is common.
DILATATION OF THE VULVAL ORIFICE
=Indications.= This is done for vaginismus due to a pathological spasm
of the levator ani and resulting in more or less complete obstruction to
coitus.
=Operation.= Under an anæsthetic the vulval orifice should be thoroughly
dilated by means of the thumbs, and for some days subsequently
graduated Sims’s ‘vaginal rests’ (Fig. 46) should be inserted twice
daily and worn for twenty minutes at a time. This treatment may be
necessary for a fortnight or longer. In many cases of dyspareunia the
cause will be found to be due to a thick, fleshy, and unruptured hymen
or to tenderness about the remnants of that organ. Under these
circumstances, exsection is the better plan to pursue. The hymen is
seized with a pair of toothed forceps and removed with curved scissors
along its entire base of attachment. Free bleeding often occurs from the
raw surface, which must be controlled by ligatures. The two almost
parallel cut edges must then be carefully brought together either by
continuous or interrupted suture.
[Illustration: FIG. 46. SIMS’S VAGINAL REST.]
COLPOTOMY OR VAGINAL CŒLIOTOMY
By colpotomy is meant making an opening into the peritoneal cavity
through the vagina; the operation is known as anterior or posterior
colpotomy, according to whether the opening is made through the anterior
or posterior fornix.
Colpotomy has certain _advantages_ over abdominal section. There is less
interference with the peritoneum and intestines, and therefore less
shock; if pus is present, there is less risk of infecting the general
peritoneal cavity, and better drainage; there is no abdominal scar, and
therefore no risk of hernia; lastly, there are certain pathological
products which can be more easily reached by this route. The operation
is difficult in a nullipara, where the vagina is narrow, and easier in a
multipara, where the vagina is more capacious, and it is still easier if
the cervix can be drawn down as far as the vaginal orifice.
A serious _disadvantage_ is that, during the course of the operation, it
may be found impossible to deal adequately with the conditions for which
the operation is being performed; in the case of a tumour, for instance,
its size, position, or the presence of adhesions may render it necessary
to complete the operation by the abdominal route. Further, in more than
one instance, the abdomen has had to be opened after the completion of
the operation on account of bleeding, the source of which could not be
dealt with by the vagina.
Therefore, before deciding upon the removal of a tumour by colpotomy,
all the above points must be taken into consideration.
=Indications.= When the above conditions are fulfilled, colpotomy is
suitable for:--
(i) The evacuation of collections of pus or blood in Douglas’s pouch.
(ii) The removal of fibro-myomata, ovarian tumours of small size, and
early tubal pregnancies.
(iii) The drainage of collections of pus or the removal of the
appendages in cases of acute inflammation where immediate operation is
necessary.
(iv) Conservative operations upon the Fallopian tubes or ovaries.
(v) A preliminary to the performance of vaginal hysteropexy.
(vi) Those cases in which the patient’s general condition is
unfavourable to the performance of exploration by the abdominal route.
Anterior colpotomy is more suitable for removing small tumours growing
from the anterior wall of the uterus, or for conservative operations on
the ovaries. Posterior colpotomy is more suitable for removing inflamed
appendages, and for evacuating collections of pus or blood from
Douglas’s pouch.
[Illustration: FIG. 47. POZZI’S RETRACTORS.]
Posterior colpotomy has been used for many years for the opening of
abscesses and hæmatoceles in Douglas’s pouch. The anterior operation is
of more recent date, and its relative advantages and disadvantages and
the indications for its use have not yet been definitely agreed upon by
the majority of gynæcologists. Taking all things into consideration, the
disadvantages of colpotomy seem to outweigh its advantages, and, except
for the evacuation or drainage of collections of blood or pus behind the
uterus, the operation may be said to have few indications.
=Anterior colpotomy.= A posterior Pozzi’s (Fig. 47) or Péan’s retractor
is passed into the vagina, and the cervix is seized with a volsella and
drawn downwards and backwards. A sound passed into the bladder defines
its lower limit. A T-shaped incision is now made through the vaginal
mucous membrane, the transverse portion just below the point to which
the bladder has been found to extend (Fig. 48, _b_). This incision
should pass completely through the vaginal mucous membrane, but no
further, and should extend across the whole width of the anterior
surface of the cervix. Some operators use a simple longitudinal or a
transverse incision. The vaginal mucous membrane is now carefully pushed
upwards with the pulp of the finger until the lower limit of the bladder
is defined. Great help is gained at this stage by the use of the bladder
sound. On pushing up the vaginal mucous membrane still further the
peritoneum is reached, and is recognized by its white glistening
appearance, and by the fact that its two opposed surfaces glide freely
over one another under the finger. The next step is to open the
peritoneum: it is picked up with catch-forceps, and a small transverse
incision is made into it with a pair of scissors; the finger is passed
through, and the incision is extended on either side, care being taken
not to pass too far outwards for fear of injuring the ureters or uterine
vessels.
[Illustration: FIG. 48. ANTERIOR COLPOTOMY.
The patient is in the lithotomy position, the speculum is passed and the
cervix pulled down by a tenaculum. The T-shaped incision has been made.
_b._ Outline of bladder.
_c._ Cervix.
_cl._ Clitoris.
_l.m._ Labium minus.
_sp._ Speculum.
_u._ Urethral orifice.
_v,v',v''._ Volsella.
]
After the peritoneum has been opened, the pelvic organs can be carefully
examined with the fingers, and the purposes for which the operation has
been undertaken can be proceeded with. The next step usually consists in
drawing out the fundus of the uterus, by which much more room and much
better access to the pelvic organs is gained. To accomplish this, the
uterus is caught with a volsella in the middle line, as high up as
possible, and drawn downwards and forwards. If necessary, a second
volsella is applied above the first, and so on, until the uterus is
delivered. A very complete examination of the appendages can now be
made, for the tubes and ovaries can be drawn out of the wound and
examined directly.
When the object of the operation has been attained, and all the blood
has been carefully removed by swabs, the next and final step consists in
closing the peritoneal and vaginal wounds. The uterus is replaced, and
the peritoneal incision is closed by a single layer of catgut sutures;
the vaginal incision is similarly dealt with. The vagina is cleared from
blood-clot and gently irrigated with an antiseptic solution. A gauze
plug is inserted lightly, and the patient is put back to bed. The
catheter should be used every six or eight hours for the first
twenty-four hours.
=Posterior colpotomy.= A posterior speculum is passed and the cervix
drawn downwards and slightly forwards with a volsella. A transverse
incision is then made through the vaginal mucous membrane at the
junction of the posterior fornix with the cervix. This exposes the
peritoneum more or less easily, and this structure is picked up with
catch-forceps, and a transverse incision made into it with scissors; a
finger is passed through this, and the incision is extended on either
side. The pelvic organs can now be explored and the tubes and ovaries
drawn down and examined. The peritoneal and vaginal incisions are then
closed by separate layers of catgut sutures.
[Illustration: FIG. 49. MARTIN’S TROCHAR FOR PELVIC ABSCESS.]
_To open a collection of pus in Douglas’s pouch_, the best method is to
pass a pair of sinus-forceps, with the blades closed, into the most
prominent part of the swelling. The blades are then opened and the
forceps withdrawn. The finger passed into the abscess cavity gently
breaks down any adhesions. The cavity is then irrigated with hot salt
solution and a drainage tube inserted, which projects just outside the
vulva: the lower end of the tube should be carefully packed around with
cyanide gauze. The tube should be changed every day and the vagina
douched with an antiseptic. Another method is to plunge a Martin’s
trochar (Fig. 49) into any softened spot in the swelling and then
withdraw the needle, leaving a blunt dilating forceps to extend the
opening.
In opening an abscess, the most stringent precautions against sepsis
should be observed. The vagina must be most carefully prepared
beforehand, by rubbing over with swabs and ethereal soap, and by a
subsequent copious douche of 1 in 1,000 perchloride of mercury:
otherwise continual reinfection of the abscess cavity occurs, and
healing is much delayed.
=Lateral colpotomy--Paravaginal section.=
=Indications.= The object of the operation is to increase the amount of
room in the vagina in certain cases of vaginal hysterectomy in elderly
virgins, or in women who have a small vagina.
=Operation.= The same preliminaries are carried out as before. The
incision is carried completely round the cervix at its junction with the
vagina. The lateral margin of the vulva is then held tense, and an
incision is made, beginning at the circumcervical incision running down
the lateral vaginal wall, through the margin of the vulva and on to the
skin externally, ending at a point midway between the perineum and the
ischial tuberosity, _i.e._ about 1-1/2 inches to the side, and in front
of the perineum; the incision may be lateral only or bilateral. In
sewing up, it is important to reunite the cut edges of the levator ani,
or pelvic weakness will result.
CHAPTER XV
OPERATIONS UPON THE UTERUS
PASSAGE OF THE UTERINE SOUND
This is an operation which is much less frequently resorted to than
formerly, owing partly to the risks of sepsis attending its performance
and partly to the greater perfection of the bimanual examination.
Passing the uterine sound should always be looked upon as a surgical
operation. The facts learnt by the use of the sound are: (1) the length
and direction of the uterine cavity; (2) the condition of the
endometrium: bleeding as a rule follows withdrawal in fibro-myomata and
endometrial disease; (3) whether a fibroid growth is projecting into the
uterine cavity, and if so, how much.
[Illustration: FIG. 50. THE PASSAGE OF THE UTERINE SOUND. _Introduction
of the point into the external os uteri._]
[Illustration: FIG. 51. THE PASSAGE OF THE UTERINE SOUND. _Commencement
of the tour de maître._]
The sound may be passed in the dorsal position (Fig. 61), the cervix
being held by a volsella and exposed by means of a posterior speculum,
or in the left lateral position, the method usually adopted in the
consulting room. In the latter the right index-finger is passed up to
the anterior lip of the cervix, the sterilized sound is taken in the
left hand with its concavity backwards and its bulbous end is slid
gently along the palmar surface of the finger in the vagina until the os
uteri externum is reached; through this it should be passed for about a
quarter of an inch (Fig. 50). The instrument should now be steadied by
the thumb and the two distal joints of the second finger of the right
hand, and its subsequent movements controlled by the left (Fig. 51).
[Illustration: FIG. 52. THE PASSAGE OF THE UTERINE SOUND. _Completion of
the tour de maître._]
[Illustration: FIG. 53. THE PASSAGE OF THE UTERINE SOUND. _Entry of the
sound into the uterine cavity._]
If the uterus is in a state of retroversion, the bulbous end will
gradually enter the uterine cavity by pressing the handle of the sound
forward and at the same time giving an upward and slightly backward
impulse to its tip; the rough surface of the handle will be found to be
looking towards the sacrum. Should the uterus be anteverted, the handle
is held in the left hand as before and passed through an arc of a circle
by raising the handle and turning it forward until it lies beneath the
symphysis pubis, in the median line (_tour de maître_) (Fig. 52). The
rough surface of the handle now looks anteriorly and the bulbous end is
pressing against the internal os uteri; now bring back the handle
directly to the perineum and it will glide into the uterine cavity (Fig.
53).
_Difficulties_ to be met with will be: (1) An acutely anteflexed uterus;
if traction is made on the cervix with a volsella the canal is
straightened and the difficulty overcome. (2) Spasmodic contraction of
the internal os uteri; this soon passes off with a little steady
pressure. (3) A fibroid may project into the lumen of the canal. (4)
Congenital or acquired stenosis of the external os uteri.
When there is a septic discharge from the vagina, the sound should be
passed in the dorsal position and through a speculum.
REPOSITION OF A CHRONIC UTERINE INVERSION
=Indications.= Chronic inversion of the uterus, with severe hæmorrhage
and bearing-down pain. The uterine fundus presents in the vagina and
simulates a fibroid polypus in process of extrusion.
=Operation.= This is most likely to be successful if continuous pressure
be brought to bear against the inverted fundus while an attempt is made
simultaneously to dilate the contracted cervix.
The patient is placed under an anæsthetic in the dorsal position and the
whole hand is passed gradually into the vagina. The tips of the fingers
and thumb should be pressed into the circular space at which the flexion
of the walls of the body on the cervix has occurred. With the palm of
the hand upward pressure is made, counter-pressure being exerted by the
other hand over the lower hypogastrium. Reduction usually begins by a
slight dimpling of the inverted fundus.
[Illustration: FIG. 54. CHRONIC UTERINE INVERSION. Aveling’s repositor
in place with elastic cords A, B, and C, in action.]
A more scientific method of exerting continuous pressure is by the
application of Aveling’s sigmoid repositor and elastic cords (Fig. 54).
This instrument consists of a vulcanite cup into which is secured a
steel S-shaped rod terminating below in a loop. The cup is made of
various sizes and should always be smaller than the inverted fundus over
which it fits.
After it has been applied, the instrument is carefully packed round with
gauze to keep it in place. Two elastic bands in front and two behind are
fastened by one end to the steel loop and by the other end to an
abdominal belt. By this means constant and direct pressure is obtained
on the fundus uteri in the direction of the pelvic axis.
Pain is usual and must be relieved by morphine. The cup usually elevates
the fundus and corrects the inversion in about twenty-four hours, but as
much as three days has been occupied in the process.
CURETTING THE UTERUS--CURETTAGE
The term ‘curetting’ is applied to the operation of scraping away the
lining membrane of the uterus, either for the relief of some
pathological condition or for diagnostic purposes.
The endometrium is not removed in its entirety by curetting, for the
uterine glands dip down to a slight extent between the muscle fibres of
the uterine wall. The endometrium is removed as far down as the muscular
coat, and, consequently, those parts of the glands lying amongst the
muscular fibres are left intact.
=Indications.= These may be divided into the cases in which the
operation is (1) Remedial and (2) Diagnostic in nature.
The diseased states of the endometrium are many and their exact
pathology is still under discussion. It is, therefore, more practical to
consider _the remedial indications for curetting_ from the point of view
of symptoms.
(i) _Uterine hæmorrhage_ is the chief symptom which calls for curetting.
The causes of the hæmorrhage may be _certain forms of endometritis_.
Thus hæmorrhage is a prominent symptom of the so-called ‘hypertrophic
glandular endometritis’, a diffuse overgrowth or adenomatous condition
of the endometrium, probably the after-result of a previous
inflammation. There is one form which gives rise to specially profuse
hæmorrhage--the ‘polypoid’ or ‘villous’ form, which arises usually in
women over forty years of age.
The hæmorrhage from _fibro-myoma of the uterus_ may require removal of
the endometrium in order to relieve the bleeding temporarily at any
rate. When milder measures fail, curetting is of great service in
arresting the profuse menorrhagia which so often accompanies
_subinvolution of the uterus_.
Certain cases in which the actual cause of the hæmorrhage is not evident
are relieved by curetting; amongst these are such conditions as
arterio-sclerosis of the uterine vessels.
(ii) _A leucorrhœal discharge_ is another symptom for which curetting is
sometimes indicated.
It may be called for when the endometrium is congested and œdematous
from such conditions as displacements of the uterus and chronic
subinvolution.
It is better not to curette for a purulent uterine discharge; extension
of the infection may be caused and give rise to pyosalpinx.
(iii) _Sterility._ Curetting should follow dilatation, in the hope that
the new endometrium formed may afford a better nidus for the ovum.
(iv) _Frequent abortion in the early months._ Curetting often cures this
by removing the diseased endometrium.
(v) _Inoperable carcinoma of the cervix._ Removal of the redundant
portions of the growth by the curette, followed by cauterization or
other measures, relieves the hæmorrhage and foul discharge. Great
caution must be exercised, lest the peritoneum or bladder be opened into
by the curette and the sufferings of the patient thereby increased.
Cells of the disease may also be pushed into the pelvic lymphatics;
considerable febrile disturbance may also follow the operation. In this
condition a blunt curette (Fig. 60, B) may be gently used; the same
instrument is safest in abortion up to the eighth week of pregnancy;
after this date it is better to use the fingers only.
[Illustration: FIG. 55. VOLSELLA FOR FIXING THE CERVIX.]
[Illustration: FIG. 56. HEGAR’S DILATORS (THREE SIZES) FOR DILATATION OF
THE CERVIX UTERI.]
Fragments removed by the curette are subjected to microscopical
examination _for diagnostic purposes_. The various conditions which may
have to be diagnosed are:--
1. Carcinoma of the body of the uterus.
2. Retained products of conception.
3. Tuberculosis of the endometrium.
4. Chorio-epithelioma malignum.
=Operation.= The following instruments are required: a volsella (Fig.
55); a self-retaining weighted speculum (Fig. 37); uterine dilators
(Figs. 56, 57); a uterine sound; a Bozemann’s tube (Fig. 58); Budin’s
celluloid catheter (Fig. 59); and one or other flushing curettes.
There are many varieties of curettes, and each has its own adherents.
The most generally useful is Murray’s sharp flushing curette, which has
a groove for the recurrent flow (Fig. 60, A). There are many varieties
of blunt curettes. The model depicted in Fig. 60, B, enables the
operator to clear out the uterine cornua and is of the best shape.
The patient is placed in the lithotomy position and the various
antiseptic precautions already described are carried out. A speculum is
passed and the cervix is steadied by a volsella applied to the anterior
lip.
The cervix is first dilated up to a suitable degree for the passage of
the curette; up to No. 12 Hegar is usually sufficient. The curette is
now taken and passed into the uterus. In performing the operation a
definite plan should always be followed so as to ensure that no part of
the uterine cavity is missed. The curette is passed up to the top of the
fundus uteri with its cutting edge directed to the posterior wall. It is
then drawn downwards with steady pressure to just below the internal os.
It is then again passed upwards and the manœuvre repeated with just
sufficient change of direction to ensure the curette passing over fresh
tissue. This is repeated until the whole of the posterior wall has been
thoroughly dealt with from side to side. The anterior wall and sides of
the uterus are then treated in turn in the same way. Finally the fundus
is curetted by a lateral movement of the instrument, especial attention
being paid to the Fallopian tube angles, which are very apt to escape
the curette.
[Illustration: FIG. 57. METAL BOUGIES FOR DILATATION OF THE CERVIX.
_a._ As used by the author.
_b._ Ends of bougies considered unsuitable.
]
A rasping or grating sound indicates that the endometrium over a given
part has been removed and that the muscular walls have been reached. In
spite of the most careful attention it is very difficult to remove the
endometrium completely. If a uterus be scraped, as it is thought,
thoroughly, and be examined _post mortem_, strips of mucous membrane
will often be found untouched, showing the difficulties of complete
removal.
[Illustration: FIG. 58. BOZEMANN’S DOUBLE-CHANNELLED TUBE.]
[Illustration: FIG. 59. BUDIN’S CELLULOID CATHETER.]
[Illustration: FIG. 60. A, MURRAY’S FLUSHING CURETTE; B, BLUNT CURETTE.]
After the operation an intra-uterine douche of 1 in 2,000 perchloride of
mercury or some other suitable antiseptic is given with a Bozemann’s
tube or Budin’s catheter. If a flushing curette has been used, this of
course has already been done. After the douche, some application may be
made to the interior of the uterus: the best is iodized phenol (liquid
carbolic acid, 2 parts; tincture of iodine, 1 part). To do this the
interior of the uterus is first dried with a Playfair’s probe armed with
cotton-wool; another similar probe is then taken, dipped into the
solution, and passed into the uterus. The vagina is protected by
inserting a plug of cotton-wool into the posterior fornix. The uterus is
then lightly packed with ribbon gauze. If there is hæmorrhage, the
packing should be firmer, and a vaginal tampon should be placed in below
the cervix. The packing should be removed in twenty-four hours. The
patient may get up at the end of a week and resume her ordinary duties
in a fortnight.
DILATATION OF THE CERVIX
=Indications.= Dilatation may be performed:--
(i) As a means of diagnosis.
(ii) As a preliminary to the use of the curette or to
removal of intra-uterine growths.
(iii) As a method of cure for spasmodic dysmenorrhœa.
_Contra-indications_ to the rapid method of dilatation of the cervix are
very few: a recent attack of peri- or parametritis would certainly be
one, but when the effects of a salpingitis have quieted down there seems
very little reason against its use. Where carcinoma of the body of the
uterus is known to exist, and in old age, it should only be resorted to
with the greatest caution, if at all.
=Methods=:--
(_a_) Rapid dilatation by means of graduated metal bougies.
(_b_) Gradual dilatation by means of tents.
(_c_) Combined gradual and rapid dilatation.
In a large majority of cases rapid dilatation is the operation selected.
Its one disadvantage is that when a great degree of dilatation is
necessary, or when the operation is performed too rapidly, the cervix is
liable to be torn, an event which is especially liable to occur when the
tissues of the cervix are rigid. These lacerations are longitudinal in
direction and in the neighbourhood of the internal os uteri. They
sometimes result in hæmorrhage, which can easily be controlled by
plugging the cervical canal. Unless strict asepsis be maintained, these
lacerations of course form a channel for infection of the pelvic
cellular tissue.
It is obvious that dilatation will be easier to perform, and laceration
less liable to occur, if the cervix is in a softened condition--a
physiological state which is always present during pregnancy and labour.
Efforts should therefore be directed, when possible, to ensure a soft
state of the cervix before performing rapid dilatation.
Immediately after the cessation of a period, the cervix is soft and
somewhat patent, and advantage may be taken of this fact. The
introduction of a glycerine tampon two hours beforehand produces a
certain amount of softening. But nothing ensures so much softening as
the introduction of a tent into the cervix about twelve hours previous
to the rapid dilatation.
It is therefore recommended in all cases, where possible, to perform
dilatation by this latter means, viz. a combination of the gradual and
rapid methods.
=Rapid dilatation= by means of graduated metal bougies. Hegar’s original
dilators (Fig. 56) were solid vulcanite bougies, graduated from 1 to 26,
the numbers corresponding to the diameter of the bougie in millimetres.
Each was 5-1/4 inches in length, the handle measuring 1-1/2 inches and
the bougie the remainder. The bougie formed a slight curve and tapered
off to a blunt point.
These bougies were rather short and too sharply pointed, and they could
not be sterilized by boiling. To overcome these disadvantages, uterine
dilators are now made about the same length as a male catheter, with a
sharper curve than Hegar’s original one, and a blunter point; the larger
sizes are of hollow metal for the sake of lightness. There are many
varieties of dilator, each with minor differences as to length, curve,
handle, and shape of the point.
[Illustration: FIG. 61. DILATATION OF THE CERVIX. The patient is in the
lithotomy position. Auvard’s speculum has been inserted, a volsella
attached to the anterior cervical lip and a bougie passed. (_From a
photograph._)
_d._ Right hand inserting bougie.
_s._ Speculum.
_v._ Volsella.
]
The author uses metal bougies. These have somewhat the shape of the
ordinary uterine sound, are thirty-five in number, and graduated in
size. Like the sound, the upper portion is bent at an angle of about
160° with the solid handle, a circular shallow depression indicating the
2-1/2 inch mark in the smaller numbers; in the larger this is not
considered necessary.
=Operation.= Instruments: an Auvard’s self-retaining weighted flushing
speculum; a volsella; a Bozemann’s tube or Budin’s catheter; a uterine
sound; and a set of dilators.
The patient is anæsthetized and placed in the lithotomy position with
the legs supported by a crutch. Strict asepsis must be observed; the
labia must be shorn of long hairs; this is followed by cleansing of the
vagina and a vaginal douche, and finally the vulva is washed with
antiseptic lotion. The speculum is passed and held by an assistant, but
if self-retaining, as in Fig. 61, the assistant is not necessary: a
sound is then inserted to ascertain the length and direction of the
uterine cavity. If anteflexion be present, the anterior lip of the
cervix should be seized with the volsella and fixed by slight traction.
If retroversion or retroflexion be present, then the posterior lip
should be fixed. Traction by the volsella tends to straighten out the
uterine canal, and thus makes the passage of the bougies easier. The
bougies are now passed in order, commencing with the size which will
pass easily. The bougie is passed by means of the right hand into the
cervical canal until the internal os uteri is reached; resistance will
now be felt. Firm and continuous pressure in the proper direction must
be made, and in a short time the resistance gives way, and the bougie
will pass into the uterine cavity. An interstitial fibroid produces a
tortuous channel and much difficulty will often be experienced in
passing a bougie in such a case. It will be found on attempting to
withdraw the instrument that it is grasped by the internal os uteri; in
the course of one to five minutes this spasm will relax, and only then
should the bougie be withdrawn. The next in size should be ready and
introduced in the same manner, and the succeeding ones are inserted
until the required dilatation is produced. Sterilized vaseline or
glycerine of perchloride of mercury may be smeared over the point of the
dilator to facilitate its passage. Each succeeding bougie should
increase in size by not more than 1 mm.: occasionally a case is met with
where this seems too large a difference, and it is really better to have
them made with a 1/2 mm. difference. As a preliminary to the use of the
curette, dilatation up to No. 12 Hegar is necessary. The index-finger
can be introduced into the uterine cavity after the passage of No. 19 or
20 Hegar, while full dilatation up to No. 26 is required for any
operation with scissors or the écraseur on intra-uterine growths.
It is evident that the degree of dilatation for exploratory purposes
will be governed by the diameter of the operator’s finger, or rather of
its second joint, and this varies very much in different people. By
means of the finger a uterus can be explored in which the cavity is much
longer than the operator’s finger, if the viscus be forced down on to
the finger by the pressure of the other hand above the symphysis pubis.
The operator must not be satisfied until he has felt the whole extent of
the uterine wall, especially the two cornua, which are favourite seats
of disease. After completion of the operation it is well to give an
antiseptic intra-uterine douche by means of a Bozemann’s tube. The
uterus and cervix should be lightly packed with sterile ribbon gauze, 1
inch wide; the free end is left projecting through the os uteri. The
packing should be removed in twenty-four hours, and an antiseptic douche
given.
=Difficulties and dangers.= The difficulty due to non-dilatability is
overcome by means of the preliminary use of a tent. The complication
produced by a fibroid, altering the direction of the uterine canal, has
been mentioned. Extreme anteflexion or retroflexion gives trouble during
the passage of the earlier numbers, but as dilatation is effected this
disappears.
The dangers are:--
1. Laceration of the cervix.
2. Rupture of the uterus.
3. Sepsis and its sequelæ.
4. Hæmatoma between the layers of the broad ligament.
_Laceration of the cervix_ has been referred to: it begins as a rule at
the internal and extends towards the external os uteri; it may be deep
or superficial, and is recognized as a sulcus into which the finger can
be passed from above downwards: rarely, laceration into the peritoneum
may take place.
_Rupture of the uterus_ is liable to occur when the uterine wall has
been weakened by the changes which accompany the completion of the
menopause, or has been infiltrated by carcinoma, or, more rarely, by
vesicular mole.
_Sepsis_ may occur from absorption through a laceration if asepsis has
not been maintained: it may lead to an attack of pelvic cellulitis or
even septicæmia.
If the uterus is fixed or not freely mobile, and the condition is
complicated by any tubal or ovarian disease, great care must be
exercised in manipulation.
=Gradual dilatation= by tents. There are three varieties of
tents--sponge, laminaria, and tupelo.
Sponge tents should never be used, for they are extremely difficult to
render sterile.
The commonest and the safest to use, because they can be most easily
sterilized, are laminaria tents, made from sea-tangle (_Laminaria
digitata_). These are cylindrical rods, which expand evenly, from
imbibition of moisture. Tupelo tents are larger than laminaria and
expand more rapidly.
To use tents that are not absolutely sterile is to court disaster, and
in former times they were responsible for many fatalities from sepsis.
The best way to keep laminaria and tupelo tents is in a solution of 1 in
1,000 corrosive sublimate in absolute alcohol. They may be kept in this
for an indefinite period, and so are always ready for use.
=Contra-indications.= All septic states of the uterus and cervix, for
the retention of pent-up discharges is very likely to lead to local or
general infection. Tents should never be used then in such conditions as
carcinoma of the body of the uterus, sloughing polypus, acute
endometritis and cervicitis.
=Method of introduction of a tent.= The patient is placed in the lateral
or lithotomy position and a vaginal douche given. A Sims’s speculum is
passed and the cervix seized and drawn down with a volsella so as to
straighten the cervical canal. The direction and length of the uterine
cavity is ascertained by passing the sound. The most suitable size of
tent is now selected, and, being held in a special form of tent
introducer or suitable pair of forceps, is passed into the cervical
canal, well past the internal os uteri. The end should project slightly
into the vagina. The vagina should then be douched again and lightly
packed with sterilized gauze. The patient must remain in bed.
The tent should be left in position for twelve to fifteen hours, when it
will have exerted its full action. The action of tents is twofold: it
causes (1) dilatation, and (2) softening of the cervix, the softening
being accompanied by an abundant secretion of mucus from the cervical
glands.
=Method of removal.= Tents are removed by traction on the silk thread
attached to the vaginal end. The part of the cervical canal which exerts
the greatest resistance to the dilating action is the internal os uteri,
and after the tent has been removed a well-marked constriction is always
to be seen at this point. If there is much resistance to removal by
reason of the tent being gripped at the internal os, it should be taken
in a pair of forceps and gently pulled and levered out.
OPERATIONS FOR HYPERTROPHY OF THE CERVIX
This is a congenital condition and there is no thickening of the mucous
membrane and underlying tissues; hence the diameter of the cervix is not
increased. The operation best adapted for the treatment of this
condition is the wedge-shaped incision, recommended by Marckwald (Fig.
62).
=Operation.= The cervix is split bilaterally into an anterior and
posterior portion by means of scissors, and out of each portion is
excised a wedge-shaped piece of tissue, leaving a deep groove. The
sutures are passed as in Fig. 62, and the raw surfaces are brought
together.
_Circular amputation_, as carried out by Hegar, is more suitable for
supravaginal elongation of the cervix, the result of prolapsus uteri.
The patient is anæsthetized and placed in the lithotomy position and the
cervix is pulled down by a volsella and amputated transversely by a
knife or scissors. A certain amount of retraction of the stump takes
place, producing an inversion of the vaginal wall. The raw surface
remaining must be covered by uniting the vaginal and cervical mucous
membranes. Sutures are passed in the following manner: a short stout,
straight needle, threaded with a loop of silk, is passed from the
vaginal mucous membrane, across and beneath the raw surface of the
stump, and emerges on the mucous membrane of the cervix (Fig. 63). From
eight to ten of these sutures are passed at regular intervals and tied.
The sutures are removed on the tenth day and the patient should be kept
in bed for fourteen days.
[Illustration: FIG. 62. MARCKWALD’S OPERATION FOR CONGENITAL HYPERTROPHY
OF THE CERVIX. The wedge-shaped portions have been excised and the
sutures passed but not tied.
_a,p._ Anterior and posterior lip of cervix before exsection.
_e.o.u._ External os uteri.
_i.o.u._ Internal os uteri.
_s,s'._ Sutures.
]
[Illustration: FIG. 63. HEGAR’S OPERATION FOR SUPRAVAGINAL ELONGATION OF
CERVIX. The cervix has been removed and four sutures passed but not
tied.
_c.m.m._ Cervical mucous membrane.
_s._ One of the sutures.
_sp._ Speculum.
_v.m.m._ Vaginal mucous membrane.
]
TRACHELORRHAPHY.
=Indications.= This operation is performed for the repair of certain
forms of laceration of the cervix. It was formerly practised in every
case in which a laceration occurred: it is now only permissible in cases
in which there is extroversion of the mucous membrane with certain
symptoms, such as hæmorrhage or free leucorrhœal discharge accompanied
by backache on exertion and general ill health. It was formerly
considered that there was a direct relation between cervical laceration
and cancer, but further inquiry has failed to corroborate this view.
The instruments required are: a Sims’s or Auvard’s speculum;
long-handled, angular-bladed knives (right and left); Emmett’s scissors
(right and left) (Fig. 64); toothed dissecting forceps; short stout
needles with sharp triangular points, straight or very slightly curved.
=Operation.= As it is usually found that subinvolution is present and
kept up by the laceration, it is best to perform a preliminary curettage
(see p. 154) before proceeding to the operation proper.
[Illustration: FIG. 64. EMMETT’S SCISSORS (LEFT) FOR TRACHELORRHAPHY.]
The patient is placed in the lithotomy position and an Auvard’s speculum
is inserted. A piece of stout silver wire or a tenaculum is passed
deeply through the anterior and posterior lips of the cervix; steady
traction can be made through these and the uterus kept fixed while
denudation and suturing are carried out. Should marked extroversion be
present, with hypertrophy of the cervical glands, the curette should be
freely applied to the diseased surface.
The uterine sound is passed to mark the situation of the internal os
uteri, and an antero-posterior linear piece of lining membrane, about a
quarter of an inch in breadth, must be allowed to remain untouched. This
is necessary to prevent total occlusion of the cervical canal when the
denuded flaps are sutured (Fig. 65).
_Denudation._ The right half of the anterior and posterior lips of the
cervix (upper and lower from the operator’s point of view) are first
pared by means of the angular knives and scissors, great care being
taken to see that the deep angle of the reflexion is not overlooked. The
other side is then treated in a similar manner. The tissues will be
found extremely hard and resistant, especially if there be much
cicatrization about the angle of the laceration.
_The passage of the sutures_ (Fig. 65). The short stout,
triangular-pointed needle is first doubly threaded with silk or stout
chromicized catgut so that a loop of three to four inches in length is
produced. The needle and the silk suture are passed as in Fig. 65, two
on either side.
[Illustration: FIG. 65. TRACHELORRHAPHY. The patient is in the lithotomy
position. The left half of the cervix has been denuded and two sutures,
_a_, _a'_ and _b_, _b'_, passed. The right half is intact, but the
method of passing the needle _n_ is indicated.
_ant._ Anterior lip of cervix.
_post._ Posterior lip of cervix.
_t,t._ Tenacula.
_o.u.i._ Os uteri internum.
_sp._ Speculum.
_w._ Wire.
]
The triangular-pointed needle must be held in Schauta’s specially strong
holder (Fig. 73), and should be made to pierce the cervix near the raw
surface on one lip, and pushed through the tissues immediately below
this to emerge on the strip of unpared cervix already mentioned. It is
then carried across the sulcus and is made to emerge through the
opposite lip of the cervix. A stout wire is now hooked into the loop and
pulled through the needle track. When the two wire sutures are inserted
on either side, the flaps are brought together and the wires twisted
together.
=Results.= Primary union is the rule, and the wire sutures may be
removed at the end of the tenth or twelfth day. The cervix has the
appearance observed in the nullipara, and may lead to complications in
any ensuing labour from difficulty of dilatation.
Dührssen modifies Emmett’s operation by a flap-splitting procedure
which, however, does not appear to possess sufficient advantages to
warrant its general introduction.
VAGINAL FIXATION (Hysteropexy)
This operation consists in the fixation of the retroverted fundus uteri
in an anteverted position, by suturing it to the anterior vaginal
cul-de-sac.
=Indications.= These are somewhat uncertain, and the field of utility of
the operation is rapidly becoming more limited. Advocates of this
procedure recommend it for backward displacement of the uterus with or
without adhesions. It is considered specially applicable to cases in
which slight retroversion is complicated by moderate prolapsus. The
results which have so far obtained do not appear to be so good as those
resulting from the use of a well-fitting pessary.
=Operation.= The technique recommended by Dührssen appears to be the
most satisfactory, and is as follows: The patient is anæsthetized and
placed in the dorsal position with the knees supported by a Clover’s
crutch. After purification of the parts (see p. 126) the cervix is
pulled down as far as possible by means of a volsella: a curettage is
then carried out as a preliminary measure (see p. 154). If cervical
hypertrophy is present, amputation by Marckwald’s method (see p. 160)
should be performed, as an elongated cervix acts as a preventive to
satisfactory anteversion of the uterus. A transverse or T-shaped
incision is now made as in vaginal hysterectomy (see p. 169), and the
cellular tissue pushed up by the index-finger until the peritoneum is
reached. The peritoneum is now seized with a volsella and cut through,
and the edges sutured to the lips of the vaginal wound. The uterine
fundus is then anteverted by means of a sound: by pressing the handle of
the instrument towards the perineum the fundus is brought into the
wound. By means of a rectangular curved needle a stout silk suture is
passed through the anterior wall of the fundus as high up as possible:
the vaginal flaps are not included, as the suture is to be used for
traction only. The uterus is now forcibly pulled down and two other
sutures are introduced in the same manner higher up. Three sutures of
catgut are passed through the uterine wall, including the vaginal and
peritoneal flaps. The silk traction sutures are now withdrawn and the
permanent ones tied. The vaginal wound is carefully sutured by means of
fine silk.
=Difficulties and dangers.= The risks of the operation are peritonitis
and wounding of one or both ureters or the bladder wall. Absolute rest
for fourteen days is necessary and no local after-treatment is called
for.
CHAPTER XVI
OPERATIONS FOR NEW GROWTHS OF THE UTERUS
Uterine growths include primary malignant disease and fibro-myomata; the
former should be treated by exploration and subsequent vaginal
hysterectomy (see p. 168), while the latter should be dealt with
according to their relations and attachments to the uterine wall.
[Illustration: FIG. 66. PEDUNCULATED FIBROID POLYPI IN VARIOUS STAGES OF
EXTRUSION. (_From drawings made at time of operation._)]
OPERATIONS FOR UTERINE FIBRO-MYOMATA
Fibro-myomata may present themselves to the operator in one of the
following forms:--
1. As a fibroid polypus still intra-uterine or presenting through a
naturally dilated and thinned-out cervix (submucous pedunculated).
2. As sessile growths presenting by their lower segments at the os
uteri, which may be closed, or may be in varying degrees of dilatation
(submucous sessile).
3. As tumours incorporated in the uterine wall (interstitial).
=Operations for pedunculated tumours.= _If a fibroid polypus be still
intra-uterine_ (Fig. 66) the proper treatment is to dilate the cervix
(see p. 156), and, if the pedicle be sufficiently thin, to seize the
growth with a pair of stout polypus forceps and twist it off by a slow
rotary movement of the handles. Should the pedicle be thicker than the
finger, the use of the wire écraseur is advisable. This is a scientific
snare, with a loop of pianoforte wire and a handle or wheel by which it
can gradually be tightened, causing the wire to slowly cut through the
stalk of the growth (Fig. 67).
[Illustration: FIG. 67. WIRE ÉCRASEUR.]
The cervix is steadied with a volsella and the loop of the écraseur is
shaped and bent to the size and position of the fibroid. The instrument
is then passed into the uterine cavity and the noose pushed over the
tumour up along the pedicle. The wire loop is then tightened up by means
of the handle or wheel, and the wire cuts its way through and separates
the growth from the uterine wall. It is somewhat dangerous to put any
traction on the tumour before its separation, as is recommended by some
writers, as the uterine wall itself may become somewhat inverted and the
wire loop may cut through into the peritoneal cavity.
_If the fibroid polypus has passed through the external os uteri_,
treatment is more simple. Slight traction may be made upon it by means
of forceps, and the pedicle severed with scissors; no hæmorrhage takes
place, owing to the retraction of the stump.
=Operations for sessile tumours.= In submucous sessile fibroids (Fig.
68) in which the lower segment of the uterus is somewhat thinned out and
dilated, operative interference may be as follows: Preliminary
dilatation of the cervix by bougies may be necessary. The capsule of the
tumour is then incised with a sickle-shaped knife and the growth is
enucleated by means of the finger or a blunt spoon. In some cases mere
incision of the capsule is sufficient, and the uterus expels the growth
later on.
Another method of treating these cases is by the operation of
_morcellement_, which consists in removing the tumour piecemeal by means
of specially made forceps.
The instrument used by the author consists of a strong pair of forceps
somewhat like those used in lithotomy, with the two distal ends notched
with sharp teeth like a volsella. A portion of the tumour is seized
between these two blades, and partly cut and partly twisted off. With
patience and care the whole tumour may be thus removed. In one case the
author was enabled to remove two large growths, each filling a pint
measure. This operation is specially suitable in women in whom an
abdominal operation is to be avoided.
=Operations for interstitial tumours.= Interstitial fibroid tumours, if
not above the size of a small fœtal head, should be treated by vaginal
hysterectomy (_vide infra_); if large, by hysterectomy by the abdominal
route (see p. 36).
[Illustration: FIG. 68. SUBMUCOUS FIBRO-MYOMATA, CAPABLE OF TREATMENT BY
MORCELLEMENT. (_From drawings made at time of operation._)]
=Vaginal hysterectomy.= By vaginal hysterectomy is meant removal of the
whole uterus by the vagina, with or without the appendages. The
advantages that the vaginal operation possesses over abdominal
hysterectomy are, there is less disturbance of peritoneum and
intestines, less shock, and no abdominal scar or risk of subsequent
hernia. The operation is limited to uteri not exceeding in size the head
of a full-time fœtus.
=Indications.= (i) Malignant disease of the uterus (fundus or cervix) in
an early stage: chorio-epithelioma malignum.
(ii) Certain cases of fibro-myoma of the uterus.
(iii) Certain cases of inflammatory disease of the uterine appendages
complicated by recurrent attacks of local perimetritis.
(iv) Other conditions, such as intractable uterine hæmorrhage, usually
due to uterine myo-fibrosis, and, as a last resort, severe
dysmenorrhœa.
It has also been advised for irreducible chronic inversion of the
uterus, and for severe procidentia uteri. No case of the former has
occurred in the author’s experience in which the operation was found
necessary. In the latter condition the operation is not to be
recommended, the almost certain result of the procedure being prolapse
of the vaginal walls and the intestines (enterocele).
=Vaginal hysterectomy for carcinoma.= The only cases suitable for
operation are early ones, in which the disease is still confined to the
uterus itself, which should be freely mobile in all directions. No signs
of infection of the surrounding cellular tissue and vaginal walls should
be present. It cannot be too strongly insisted that all cases should be
thoroughly examined under anæsthesia to settle this point before
operation is decided upon. Rectal examination is most important to
estimate the condition of the sacro-uterine ligaments, the cervix being
pulled down so as to place them on the stretch.
Occasionally, cases of carcinoma of the cervix are seen, in which the
cellular tissue immediately surrounding the cervix is apparently free
from disease, but if search be made further outwards, a hard, fixed mass
is found plastered, as it were, on to the side of the pelvis, indicating
advanced disease of the lymphatic glands, or cellular tissue at the
outer part of the broad ligaments. Such cases are hopeless for
operation.
If the disease is in the sloughing stage, and there is foul discharge,
Paquelin’s cautery should be applied to the diseased surface, followed
by vaginal douches of formalin (ʒj to the pint), or some other efficient
antiseptic, given three times a day for three days prior to operation.
The operation consists of three main stages:--
(_a_) Separation of the cervix from the vagina, pushing up of the
bladder and ureters, and opening the anterior and posterior
peritoneal pouches.
(_b_) Removal of the uterus by ligaturing and dividing the broad
ligaments.
(_c_) Treatment of the peritoneal and vaginal flaps thus left.
First of all, the growth, if of the cervix, should receive careful
preliminary attention, for it constitutes a continuous source of
infection, not only by means of septic organisms, but also of cancer
cells, which may become implanted in the wound and cause early
recurrence. The cervix is drawn down with a volsella and all visible
growth is burnt away with the Paquelin cautery, until apparently healthy
tissue only is left. The cervix is then completely closed by the
application of a volsella or three or four stout silk sutures, passing
through both anterior and posterior lips. The ends of the sutures may be
left long if preferred and serve as tractors.
After these preliminary measures against infection have been completed,
the removal of the uterus is proceeded with. A posterior speculum,
Auvard’s or Pozzi’s, is passed, and the cervix is drawn downwards and
somewhat backwards by traction on the volsellum or the long ends of the
silk sutures. A sound is passed into the bladder to define its lower
limit. A transverse or T-shaped incision (Fig. 48) is now made through
the vagina at the level of the cervico-vaginal junction in front. This
constitutes the anterior incision, and the transverse portion should
extend completely across the anterior aspect of the cervix, passing
through the whole thickness of the vagina, but no further.
[Illustration: FIG. 69. GALABIN’S BROAD-LIGAMENT NEEDLE (RIGHT).]
[Illustration: FIG. 70. JESSETT’S BROAD-LIGAMENT NEEDLE.]
The knife is now laid aside, and the operator proceeds to push up the
vagina and bladder from the anterior aspect of the cervix with the
index-finger or a winged director, until the anterior peritoneal pouch
is reached. This is at once recognized by its glistening white
appearance and by the manner in which its opposing surfaces glide over
one another.
This part of the operation must be conducted very cautiously for fear of
injury to the bladder: the pulp of the finger only must be used in the
separation. The frequent use of the bladder sound is very useful at this
stage, as it is quite easy to wound this viscus laterally. Bleeding from
the divided twigs of the vaginal vessels often obscures the field of
operation and renders the separation of the bladder troublesome: it well
repays the operator to stop all bleeding after making the vaginal
incision.
The peritoneum is next picked up and opened with scissors. The anterior
fold of peritoneum may sometimes be more easily reached after the bases
of the broad ligaments have been ligatured and divided, thus allowing
the uterus to be drawn down more readily, and making the peritoneum more
accessible. An anterior retractor is then passed to keep the bladder out
of the way.
[Illustration: FIG. 71. VAGINAL HYSTERECTOMY. The patient is in the
lithotomy position, the vaginal incisions have been made and the
peritoneal cavity opened. The left broad ligament is exposed, and a
Galabin’s needle threaded with silk is being passed from before
backwards on to the index-finger of the operator’s left hand inserted
into the peritoneal cavity. (_Semi-diagrammatic, from a photograph._)
_a, a_{1}, a_{11}_. Retractors.
_c._ Cervix.
_p._ Supravaginal cervix denuded of its coverings.
_ut._ Uterine artery.
_b.lig._ Broad ligament.
_n._ Galabin’s needle.
_v._ Volsella.
]
A second incision similar to the first is now made across the posterior
aspect of the cervix at the level of the cervico-vaginal junction, more
or less cellular tissue is traversed, and the posterior peritoneal pouch
is opened. By joining the ends of these two incisions the cervix is
completely separated from the vagina.
The uterus is now suspended in the pelvis by the attachments of the
broad ligaments only; the next step consists in ligaturing and dividing
these. The cervix is drawn over towards the patient’s right side by an
assistant, so as to expose the base of the left broad ligament.
Additional space is gained by drawing aside the left wall of the vagina
by means of a retractor. By passing the left index-finger behind the
broad ligament the tube and ovary can be easily felt, and if necessary
the bent finger can pull them down for inspection; the finger is then
placed beside the cervix below and behind the base of the broad
ligament. A Galabin’s or Jessett’s (Fig. 70) needle, carrying a stout
silk suture, is passed through the ligament from before backwards, on to
the tip of the finger (Fig. 71).
[Illustration: FIG. 72. VAGINAL HYSTERECTOMY. _Final stage._ The uterus
has been removed, and the peritoneal flaps are in process of suture.
_a, a_{1}, a_{11}, a_{111}._ Retractors.
_f, f'._ Spencer Wells forceps attached to the anterior
and posterior vaginal flaps.
_p._ Circular orifice left open in the peritoneal flaps
for insertion of gauze drain.
_sp._ Stump of left broad ligament with bundle of
ligatures (_l_).
_cl._ Clitoris.
_l.m._ Labium majus.
_u._ Urethra.
]
The ligature should be passed about one-third of an inch up the broad
ligament. It is then tied tightly and the ends left long and drawn
aside. The segment of broad ligament included in the ligature is divided
as near the uterus as is justifiable; in carcinoma of the cervix at
least half an inch from the disease should be allowed. Care must be
taken at this stage to avoid injury to the ureters; these lie about one
inch distant from the cervix; consequently all ligatures must be passed
as near the cervix as possible compatible with being clear of the
disease.
A second ligature is now passed through the broad ligament above the
first and then a third, and more if necessary. The second generally
includes the uterine artery, which can always be recognized by its
strong pulsation under the finger; the third ligature will control the
Fallopian and ovarian arteries. After the arteries on the left side have
been secured and divided, attention is directed to the right broad
ligament. The cervix is drawn over to the left side, the fundus
delivered, and the upper portion of the right broad ligament is dealt
with in a similar manner, but from above downwards. If the ovaries and
tubes are diseased, they can now be removed by piercing the pedicle and
tying the stump in the usual way.
[Illustration: FIG. 73. SCHAUTA’S NEEDLE-HOLDER.]
The uterus having been extirpated, the next step consists in dealing
with the wound. First, all bleeding is stopped, and the wound is swabbed
clean and dry. The ligatures on either side are tied in two bunches and
the ends cut off just within the vagina (Fig. 72). The anterior and
posterior flaps of peritoneum are united with a few catgut sutures
passed by means of Schauta’s needle-holder (Fig. 73); the walls of the
vaginal vault are treated in a similar fashion, leaving a circular
orifice in the median line into which gauze can be inserted for the
purpose of drainage.
Some operators prefer to control the vessels in the broad ligaments by
means of hæmostatic forceps instead of ligatures. Each broad ligament is
clamped in three or more portions and the tissue between them and the
uterus cut through. They must be allowed to remain in position for at
least forty-eight hours, as recurrent hæmorrhage is possible if they are
removed earlier. The only advantages of the forceps appear to be the
rapidity with which the operation can be carried out, and the good
drainage. The disadvantages are, that it is a somewhat unsurgical
proceeding; there is often much pain from the nipping of the broad
ligaments, and inconvenience from the presence of the handles between
the labia; the intestines may be damaged; sloughing and risk of sepsis
must be reckoned with.
=After-treatment.= The catheter should be used at first four times
daily; the author recommends that the gauze should be removed at the end
of twenty-four hours, but some operators retain it longer. The ligatures
should be pulled upon a little daily after the seventh day, and they
gradually cut their way through the tissues in their grasp. No vaginal
douching should be administered until after the expiration of a week.
=Vaginal hysterectomy for fibroids.= This is not often called for. The
operation is necessarily limited to fibroid uteri not exceeding in size
a fœtal head. Uterine fibroids of such a size can usually be treated in
other ways, either temporarily by curetting, or, if submucous,
permanently by enucleation through the vagina. The operation is most
suitable for uteri containing many small fibroids causing severe
hæmorrhage which cannot be controlled by more palliative measures.
The vagina must be large enough to admit of delivery of the uterus
through its lumen. Therefore, in virgins and nulliparæ, the abdominal
operation is always to be preferred. In any case, if the vagina be too
narrow, additional room may be gained by lateral vaginal section (see p.
148) or episiotomy.
The operation does not differ in technique from the removal of the
uterus for carcinoma, already described. In some cases it may be
preferable to bisect the uterus in the sagittal plane before removing
it, after the cervico-vaginal attachments have been separated and the
peritoneal pouches opened.
SECTION II
OPHTHALMIC OPERATIONS
BY
M. S. MAYOU, F.R.C.S. (Eng.)
Assistant Surgeon, Central London Ophthalmic Hospital;
Surgeon, The Children’s Hospital, Paddington Green
CHAPTER I
GENERAL CONSIDERATIONS APPLICABLE TO OPERATIONS UPON THE EYE
Operations upon the eye differ so widely from general surgical
operations that it is necessary to say something of the preparations for
them before passing on to their actual performance. Although not
formidable in themselves, they require great accuracy and presence of
mind; slight mistakes, such as too small an incision, may cost the
patient his sight, which sometimes may be almost more important than
life itself.
Most intra-ocular operations are performed without general anæsthesia;
it is therefore important that the patient should be given confidence by
talking to him during the operation, so that he may follow the
instructions of the surgeon during its performance; loss of self-control
on the part of the patient, movement of the head, screwing up of the
eyes, &c., may lead to disastrous results, however well performed the
operation itself may be.
GENERAL PRELIMINARIES TO AN OPERATION
_The urine_ should always be examined, especially in cases of cataract,
as not infrequently this disease is associated with diabetes, and it is
often advisable to treat the general condition before operation.
_The bowels_ should be opened by an aperient the night before the
operation, as it is desirable to keep them confined for the first two
days afterwards, so as to avoid straining. During the first week after a
major operation, when the patient is confined to bed, they should be
evacuated in the supine position.
_The best time_ for operating, if possible, is the morning, as the
patient has had a night’s rest and is less likely to lose self-control.
Usually there is some pain after the cocaine has gone off, and the
patient is better able to stand it during the daytime.
_Anæsthetics._ _General_ anæsthesia should be induced in all patients
with congested eyes, in small children, patients who are deaf, and those
who show a want of self-control. Chloroform should be used for all
intra-ocular operations, and should be given to the full surgical
degree. It should be given on a towel or an inverted mask specially made
for the purpose, a Junker’s inhaler being used during the time the
actual operation is being performed. As the surgeon usually stands at
the head of the patient, the anæsthetist should stand on the side away
from the eye being operated on. The local use of cocaine in addition to
general anæsthesia is indicated when operating on patients to whom it is
advisable to give as little anæsthetic as possible.
[Illustration: FIG. 74. WINDOW OF THE OPERATING THEATRE, KING’S COLLEGE
HOSPITAL. The windows are fitted with outside blinds so that either can
be used separately, or the surgeon may stand in the angle and operate
with his back to the light. A recess beneath the window allows the
patient’s face to be brought close to the light on dark days.]
_Local_ anæsthesia is obtained by the use of a 4% solution of cocaine
instilled four or five times before the operation at intervals of three
minutes; a drop of the solution should also be instilled into the eye
which is not being operated on, to prevent an accidental reflex
stimulation of the conjunctiva and screwing up of the eyes. Adrenalin
(1-1,000) may be used in conjunction with the cocaine; it is especially
useful in squint operations, as it lessens the hæmorrhage. Eucaine and
stovaine have been used, but are not nearly so satisfactory. Under
ordinary circumstances the only pain felt during an intra-ocular
operation is during removal of the iris; this is obviated to a great
extent by instilling the cocaine at least 15 minutes before the
operation is performed, so as to allow time for its diffusion into the
anterior chamber. The patient should be warned when to expect the pain,
so that he may not move; his self-control may be tested beforehand by
pricking the nose with a pin.
_The theatre._ The theatre should possess, as far as possible, all the
modern improvements found in an up-to-date general surgical
operating-room. The light should proceed from a single large window,
which, if possible, should face the north. _The window_ should consist
of a single pane of glass or of two panes forming the angle of the
theatre; it should begin about 5 feet from the floor and should extend
to the ceiling (Fig. 74). The advantage of an angular window is that it
allows the operator to stand with his back to the light in the angle,
and so enables onlookers to see. No top light should be allowed, as it
produces a corneal reflection which may prevent the operator from seeing
the position of his knife in the anterior chamber. Beneath the window
there should be a recess for the end of the operating table, so that the
patient’s face can be brought close to the window if necessary (Fig.
74). This recess is formed by building the main wall of the theatre
further out than the window, which has to be supported by a transverse
girder.
[Illustration: FIG. 75. BULL’S-EYE ELECTRIC HAND-LAMP. For use when
artificial illumination is required.]
The window should be fitted with outside blinds so that the theatre can
be easily darkened for the operations, such as capsulotomy, which
require the use of artificial light. The best artificial light is a
small enclosed electric hand-lamp fitted with a bull’s-eye, by means of
which the operation field can be brilliantly illuminated while the
surrounding area is left in comparative darkness (Fig. 75). Failing
this, a single powerful lamp with a ground-glass globe, placed in front
of the patient, will serve, the rays of light being brought to a focus
on the eye by means of a large convex lens of about + 10 D.
For _squint operations_ it is desirable to have a light fixed to the
ceiling, directly over the head of the operating table, for testing the
position of the eyes either by the reflection of the light from the
surface of the cornea or by the Maddox rod test.
_The operating table_ should be provided with a means of adjusting its
height and the position of the head-piece, so that the patient’s head
can be brought to about the level of the operator’s elbows when the
latter is standing upright with his arms at his side.
_After operation_ the patient should be warned to lie still and not to
strain in any way; he should be carried to bed and should lie on his
back if possible. If a patient cannot sleep on his back it is better
that he should lie on the sound side than be without rest. A length of
bandage should be fastened round the wrist of the hand on the same side
as the eye which has been operated upon, and should be attached to the
bed so as to prevent the hand being put up to the eye during sleep.
After major operations, such as those for cataract and glaucoma, the
patient is confined to bed for ten days, during the first four of which
the head should not be raised from the pillow, the bowels being
evacuated while the patient is in the supine position; but old patients
with a tendency to bronchitis or hypostatic pneumonia must be propped up
in bed and allowed to get up earlier: in these patients it is better to
perform the operation in the summer if possible. In old people and
patients with a tendency to melancholia the mental condition must be
carefully watched, as frequently they cannot stand the confinement to
bed and darkness.
LOCAL PREPARATION OF THE PATIENT
When operating upon the eye, a surgeon has to face the great difficulty
that he is operating in an area which is not always aseptic, since it is
practically impossible to render the conjunctival sac sterile. At the
same time, the conjunctiva has been shown to be sterile in health in 25%
of cases, pyogenic organisms (principally the staphylococcus albus)
being found only in 15%; but, although these are usually not of a very
virulent character, they are by far the most frequent cause of sepsis;
ten cases of suppuration after operation which the author has examined
were all due to this organism. After the methods of purification given
below, this percentage is considerably reduced, so that, if due
precautions are taken, the risk of sepsis is comparatively small. On
the other hand, if conjunctivitis or lachrymal obstruction be present,
the risks are enormously increased, especially in the latter condition
owing to the frequent presence of the pneumococcus in the discharge,
unless special precautions are taken. It is, therefore, of the utmost
importance that every case should be examined for lachrymal obstruction
before operation. Care should be taken also to see that there is no
purulent discharge from the nose or any septic sores about the face.
Sepsis after intra-ocular operations manifests itself in one of two
forms: either by suppuration, which usually ends in a rapid and complete
destruction of the eye (panophthalmitis), or more rarely in less
virulent cases by recurrent attacks of hypopyon associated with acute
irido-cyclitis; or by a plastic irido-cyclitis, which may lead to slow
disorganization of the eye, with always the possibility of destruction
of the other eye by sympathetic cyclitis (sympathetic ophthalmia).
Although these conditions are comparatively rare, owing to the
improvement in modern aseptic and antiseptic methods, every surgeon of
experience will meet with these disastrous complications; indeed it has
been suggested that immunization with staphylococcus vaccine should be
carried out before major intra-ocular operations, since infection is
generally due to this organism.
[Illustration: FIG. 76. LANG’S EYE SPECULUM. Designed to hold the lashes
away from the field of operation.]
_The methods of purifying the eye before operation._ On the second night
previous to the operation the eye should be bandaged and examined the
following morning for conjunctival discharge. If any be present, an
examination for organisms should be made, and the operation postponed
until the conjunctival condition has improved. In the event of the case
being extremely urgent, the conjunctiva should be swabbed over with
nitrate of silver (10 gr. to the oz.) immediately before the operation;
some surgeons prefer 1-2,000 perchloride of mercury. If lachrymal
obstruction be present, the sac should be thoroughly washed out with
boric lotion and protargol (10%) injected. The canaliculi may be
temporarily occluded subsequently (see p. 294). If the lashes be very
long they should be cut short. Epilation is performed by some
Continental surgeons, but is not practised in this country. Various
forms of specula are made to keep the lashes out of the field of
operation; of these, a modification of Lang’s is perhaps the best (Fig.
76).
On the morning of the operation the lids should be thoroughly cleansed
with soap and water, followed by 1-2,000 solution of perchloride of
mercury, special attention being paid to the lid margins and lashes. The
conjunctival sac should be washed out with boric lotion and a pad of
cyanide gauze applied over the closed lid.
GENERAL CONSIDERATIONS AS TO MAKING AND HEALING OF WOUNDS IN THE GLOBE
It has already been pointed out that the great danger in intra-ocular
operations is sepsis. It is the aim and object of every ophthalmic
surgeon to make such wounds into the globe as will become rapidly shut
off from the conjunctival sac. Delay in the healing tends to the
formation of a fistulous opening into the globe. This aperture in the
continuity of the globe may lead either directly on to the surface or
beneath the conjunctiva, subsequent inflammation in which may spread to
the interior of the eye.
[Illustration: FIG. 77. UNDINE FOR WASHING OUT THE CONJUNCTIVAL SAC.]
_Cocaine_ and other solutions used at the time and subsequently to
operation should be sterilized. To ensure this the solutions should
either be boiled immediately before use, or put up in drop bottles made
in one piece with a long tapering neck, which is sealed off, and can be
broken immediately before use. These bottles can be kept in an aseptic
solution so as not to soil the hands of the surgeon.
_The hands_ of the surgeon are purified. After the dressings have been
removed, the patient’s head and the area surrounding the operation are
covered with sterilized towels. In operations such as advancement, where
sutures are used, it is desirable that the face should be covered with
sterile muslin, with a hole cut in it for the eye, so as to prevent the
sutures being contaminated from the skin of the face. The eyelids are
again washed in 1-2,000 perchloride of mercury lotion, and the
conjunctival sac is washed out with a strong stream of boric lotion or
normal saline by means of a sterilized irrigator or an undine (Fig. 77)
which has been kept in a bowl of lotion.
_Instruments._ Non-cutting instruments are boiled for 15 minutes in
distilled water and placed in a tray of 1-80 carbolic lotion. Some
surgeons prefer to place the instruments in the tray without lotion on
sterile wet lint, as this excludes infection from the surgeon’s hands
due to the lotion running off them on to the instrument. Failing
distilled water, a small quantity of soda may be added to the water used
for boiling, but this has the disadvantage that a deposit is liable to
form on the instruments. This may be obviated to a certain extent by not
placing them in the solution until it is boiling. Cutting instruments
should be sterilized by dipping them in liquefied carbolic acid
(crystals dissolved by heating with 10% of water) for half a minute
immediately prior to use and then into absolute alcohol to remove the
acid; they are then placed in the tray. The greatest care should be
taken to see that cutting instruments and needles do not touch the side
of the dish. The edges and points should always be carefully tested
immediately before sterilization on a drum covered with fine kid
specially made for the purpose. The points should pass through the drum
by the weight of the instrument held flat on the open palm; the cutting
edge should also be tested. Scissors are best tested by cutting wet
cigarette paper, special care being taken to see that the edges are good
near the points. Immediately after operation the instruments should be
boiled, and dried whilst hot in order to prevent rust.
[Illustration: FIG. 78. CATARACT EXTRACTION. The drawing shows the line
of incision. Note the conjunctival flap.]
_The direction of an incision_ into the globe should be as oblique as is
consistent with the object of the operation, so as to allow larger
healing surfaces to come into apposition. With this object in view it is
desirable that a conjunctival flap should be formed to all wounds
wherever possible (Fig. 78). Further, owing to the extreme vascularity
of the conjunctiva, as has been shown elsewhere,[3] wounds in it become
firmly united after 48 hours. As a rule sutures are best avoided and are
seldom required.
[3] Mayou, _Hunterian Lectures_, 1905.
_Position of the incisions._ Corneal incisions are to be avoided, if
possible, for the following reasons: firstly, the cornea being free from
blood-vessels heals comparatively slowly; secondly, the wound is liable
to become fistulous owing to the rapidity with which the epithelium
grows down the side of the wound. On the other hand, incisions situated
from 3 to 6 millimetres behind the limbus are liable to injure the
ciliary body, and, in addition to irido-cyclitis being set up by the
trauma, the iris or ciliary body will prolapse into the wound and
prevent the union of its edges, with the result that sepsis may spread
into the globe along the prolapsed portion of the uveal tract and set up
an irido-cyclitis which may not only ruin the eye affected but may also
cause a sympathetic irido-cyclitis in the other eye (Fig. 79).
[Illustration: FIG. 79. SYMPATHETIC OPHTHALMIA. The exciting eye of a
case following cataract extraction. The section shows the incarceration
of the iris in the wound.]
[Illustration: FIG. 80. CYSTOID SCAR AFTER GLAUCOMA IRIDECT]
_The site of election of an incision_ into the anterior part of the
globe is therefore about 1 millimetre behind the limbus; that is to say,
as near the cornea as is consistent with obtaining a good conjunctival
flap to cover the wound in the globe (Fig. 78). When possible it is
advisable to make all incisions in an upward direction for the following
reasons: They are more easily performed; any deformities, such as an
iridectomy, are hidden by the upper lid; more perfect rest is obtained,
as the wound is not exposed in the palpebral aperture, the eye being
turned upwards when the lids are closed.
[Illustration: FIG. 81. AN EYE BANDAGE. The first turn, A, encircles the
head and is fixed with a pin. This portion of the bandage can be put on
before the operation and obviates movement of the head. The turn B is
then brought up below the ear and fixed with pins.]
[Illustration: FIG. 82. A PRESSURE BANDAGE. The first turn of a
1-1/2-inch bandage encircles the head. It is then carried beneath the
ear and over the head in a figure-of-eight. The final turn goes round
the head and is fixed by a pin at the point of crossing of the previous
turns.]
The immediate danger of the passage of a knife into the anterior chamber
of the eye is the wounding of the lens. To avoid this the point of the
knife should be always kept superficial to the iris if a clear lens be
present in the eye. After operation the chief danger is prolapse of the
iris into the wound. This is best avoided at the time of operation by
carefully replacing the iris with the spatula at the end of the
operation, but unfortunately prolapse not infrequently occurs during the
first few days owing to the reaccumulation of the aqueous in the
anterior chamber and its sudden escape through the imperfectly healed
wound as the result of straining or of some movement on the part of the
patient; the iris may be carried into the wound with the escaping
aqueous, and a fistulous opening or a scar may form subsequently (Fig.
80).
The less manipulation used consistent with the object of the operation
the less likelihood is there of cyclitis following it. All instruments
should be held lightly in the fingers, which should be as far as
possible responsible for the fine manipulation required. The part of the
hand not actually holding the instrument should be steadied on the face
before the instrument is brought in contact with the eye.
When more than one operation has to be performed on the same eye it is
desirable that all ciliary injection after the first operation should
have disappeared before the second is undertaken.
_Dressings._ A pad of sterilized wool, with a few layers of cyanide
gauze moistened with 1-6,000 perchloride of mercury lotion next the
closed eyelid, held in position by a bandage, is all that is necessary.
_Bandaging._ The bandage is started on the forehead over the affected
eye and is carried in a direction away from the eye to be covered. A
complete turn is made to encircle the head and is fixed with a pin. The
bandage is then brought up beneath the ear and over the eye and fixed
with pins on the forehead (Fig. 81). When absolute rest is desired, it
is necessary to bandage both eyes. After intra-ocular operations this is
desirable for the first three days. When pressure is desired, a
figure-of-eight bandage should be used (Fig. 82). A useful bandage
(Moorfield’s bandage) for occlusion of both eyes is made from
stockinette, which fits closely over the eyes and nose and is fastened
with tapes.
The dressings should not be disturbed for at least 24 hours. The lids
are then cleansed with 1-6,000 perchloride of mercury lotion, and the
lower one is pulled down so as to allow the escape of tears and to see
if any discharge be present. The upper lid should not be touched. If no
discharge be present the eye is re-dressed. If discharge be present the
conjunctival sac should be washed out carefully with boric lotion. Most
wounds with conjunctival flaps are shut off in 48 hours, after which
time it is advisable to wash out the conjunctival sac twice a day with
boric lotion. Great care should be taken to see that no undue pressure
is made on the globe. The patient should be warned not to screw up the
eyes or strain whilst the dressing is being performed.
CHAPTER II
OPERATIONS UPON THE LENS
=Surgical anatomy.= The lens consists of fibres which are developed from
cells originating in an inclusion of the fœtal epiblast. A normal lens
is surrounded by a capsule, the anterior half of which is lined with a
single layer of epithelial cells on its inner surface. In fœtal life the
cells which line the posterior half of the capsule go to form the lens
fibres, so that after birth the lens capsule is lined by cells only on
its anterior surface. The lens capsule, which is deposited from the
epithelial cells lining it, consists of a highly elastic membrane; small
wounds in its continuity, therefore, gape widely. Throughout life the
cells lining the capsule continue to become new lens fibres, but at the
same time the bulk of the lens does not increase markedly. This is due
to the fact that the lens fibres become more closely packed together and
lose some of their watery constituents (sclerosis). The older central
part of the lens is the first to undergo this process, with the result
that a definite hard nucleus is found in the lenses of people about the
age of thirty to thirty-five and upwards.
[Illustration: FIG. 83. A LENS THREE WEEKS AFTER NEEDLING. The section
shows the swelling and breaking up of the lens in the anterior chamber.
The iris has become adherent to the needle puncture.]
Chemically the lens fibres are composed of crystallin, which is closely
allied to a serum globulin and is therefore soluble in salt solution.
When the lens capsule has been opened, by operation or accident, the
saline aqueous is admitted to the lens, which becomes opaque, swells up,
and is gradually absorbed (Fig. 83). In those under the age of thirty,
therefore, a simple incision into the capsule is all that is required to
cause it to be absorbed. But, as has already been pointed out, the lens
develops a hard nucleus after that age and will not then be absorbed
satisfactorily by simply opening its capsule; to remove it, as is done
in senile cataract, the hard nucleus must be extracted from the eye.
[Illustration: FIG. 84. ANATOMY OF THE ANTERIOR SEGMENT OF THE EYE.
Cil. P. Ciliary process.
S. Ch. Canal of Schlemm.
L. P. Lig. pectinatum, between the fibres of which are the spaces
of Fontana.
Sup. C. Ly. S. Suprachoroidal lymph-space which extends
backwards between the choroid and sclerotic.
M. Longitudinal portion} of the ciliary muscle.
C. M. Circular portion }
O. Circulus arteriosus.
S. Lig. Suspensory ligament of the lens.
E. Epithelium covering the ciliary process.
Pars Cil. Pars ciliariis retinæ. Pars plana of the ciliary body.
R. The retina. } The junction of these with the pars plana is known as
C. The choroid.} the ora serrata.
J. Iris.
S.M. Sphincter muscle.
Cry. Crypt.
M. M. Pigment epithelium.
S. Cornea. Substantia propria.
B. M. Bowman’s membrane.
D. M. Descemet’s membrane.
A. Cap. Anterior capsule of the lens.
C. P. Canal of Petit.
]
The lens is held in position by the suspensory ligament, which consists
of interlacing fibres attached on the one hand to the ciliary process
and on the other to the capsule at the lenticular margins (Fig. 84).
Prolapse of the vitreous after cataract extraction is prevented by the
integrity of this ligament and the posterior capsule of the lens,
together with the hyaloid membrane of the vitreous. The tension on the
fibres of the suspensory ligament, in addition to keeping the lens in
its place, also exercises traction on the lens capsule. In dislocated
lenses there is a gap in the suspensory ligament either as the result of
injury or of congenital malformation; when such cases require operation
there is some difficulty in producing a sufficient gap in the capsule to
promote their absorption, owing to the mobility of the lens and the want
of traction on the incision in the capsule.
DISCISSION OR NEEDLING
Discission of the lens has for its object the tearing open of the
anterior capsule, so that the lens substance may be broken up and
absorbed.
=Indications.= This operation will be required:
(i) =For cataract in patients under the age of about thirty.= The forms
of cataract for which these operations are usually performed are: (i)
_complete congenital cataract_, in which the whole lens is opaque and
consists of little more than a shrunken capsule which may have to be
extracted if discission is unsuccessful; (ii) _lamellar cataract_, of
sufficient density to interfere seriously with vision; (iii) _posterior
polar cataract_ in rare instances; (iv) _traumatic cataract_, to
complete the absorption of the lens by breaking up its fibres.
Before operating on any form of cataract the following facts must be
ascertained as far as possible:--
(_a_) _Vision._ It must be remembered that in children a defective eye
retaining the power of accommodation is often more useful than an eye
which sees better but has to wear different glasses for different
distances. Vision must be reduced to less than 6/18 in both eyes after
correction with glasses before the operation should be undertaken. In
rare cases, in children, and in traumatic cataract where the cataract is
very dense and confined to one eye, it may be removed partly to improve
the personal appearance and partly to enable the patient to see large
objects.
An eye without a lens (aphakia) will not work with an eye with a lens
even if the former be corrected with glasses.
If the patient be unable to see letters, he should have a ready and
quick perception of light, no cataract, however dense, being sufficient
to prevent this.
(_b_) A patient should have a good _projection of light_; that is to
say, he should be able to locate the light when thrown into the eye with
a mirror whatever direction it comes from. Children generally turn the
head towards the light, provided that they can see it and that the eye
is not defective from other causes.
(_c_) Note whether _the pupils_ are equal and active. In children most
useful information can often be obtained as to the condition of the
fundus by means of the pupil, which often will not react when the
patient is unable to appreciate light.
(_d_) _The condition of the fundus of the other eye_, if observable,
should be taken into account, as many diseases of the fundus, such as
choroiditis and myopia, are bilateral, and would influence the prognosis
considerably.
(_e_) _The lachrymal sac_ and conjunctiva should be free from all signs
of inflammation (see p. 181).
[Illustration: FIG. 85. EYE SPECULUM.]
[Illustration: FIG. 86. FIXATION FORCEPS.]
(ii) =For the removal of a lens for high myopia.= In selected cases
operation gives very satisfactory results with great improvement of
vision; indeed full normal distance vision has been obtained without
glasses. The operation, however, is only justifiable under certain
circumstances, the chief of which are:--
(_a_) The amount of myopia should exceed 18 D.
(_b_) Distance vision should be defective--less than 6/18
with glasses.
(_c_) Ophthalmoscopically the macular region should be sound.
(_d_) Binocular vision should be absent.
(_e_) The patients should be children or young adults.
(_f_) If there is some serious reason why the patient is
unable to wear glasses.
In emmetropia, if the lens be removed, a glass of + 11 D. has to be
placed before the eye for distance vision and + 14 D. for near vision.
It is impossible to predict the exact amount of correction of myopia
which will be produced by the removal of the lens, owing to the
surgeon’s inability to estimate the refractive power of the lens
associated with the distortion of the posterior pole of the globe.
Usually a patient with about 22 D. of myopia is rendered emmetropic by
the operation.
There are two main objections which have been raised to the operation:
first, that there is a slight risk of septic infection, sympathetic
ophthalmia even having been known to occur; secondly, that retinal
detachment seems rather more common after operation than in ordinary
myopia of the same degree. As a rule it is only advisable to perform the
operation on one eye, the patient using the other for reading purposes,
but under certain circumstances, as when the operation has been
successful for a considerable period of time, it would be justifiable to
perform it on the other eye. The operation should never be performed on
patients having only one eye.
=Instruments.= Speculum (Fig. 85), fixation forceps (Fig. 86),
discission needle.
=Operation.= _First step._ The operation is best performed by artificial
light. The pupil having been dilated with atropine and the eye
anæsthetized with cocaine (a general anæsthetic being necessary,
however, for young children), the speculum is inserted by first drawing
up the upper lid, making the patient look down, and inserting the top
blade, and then drawing down the lower lid, making the patient look up,
and inserting the lower blade. The speculum is opened to its full width
without undue strain on the canthus and is kept in position by
tightening the screw. The eye is steadied by fixation forceps held in
the left hand, which grasp the conjunctiva as close to the cornea as
possible directly opposite to the spot at which the puncture is to be
made; the puncture is made directly behind the limbus and the needle is
passed into the anterior chamber.
_Second step._ Using the shaft of the needle lying in the cornea as a
fulcrum on which to rotate the needle, an incision is made in the
anterior capsule of the lens, and the lens fibres are broken up by a
stirring movement. The needle is then rapidly withdrawn in the same
plane in which it was inserted so as to avoid making a crucial incision
in the cornea with the spear-like end and thereby losing the aqueous.
The best way to make sure of this is to mark one side of the handle so
that it may be inserted and withdrawn in the same position. A pad and
bandage are then applied.
=After-treatment.= The pupil should be kept dilated subsequently by the
use of atropine twice a day until the lens has become absorbed. The
bandage may be removed about the fourth day and dark glasses worn.
The effect of the operation on the lens varies considerably. It may
swell up so rapidly that the tension of the eye becomes increased, in
which case an evacuation may have to be performed; in other cases,
especially in the cases of a patient with high myopia, several needlings
may be required before absorption is complete.
CAPSULOTOMY
Capsulotomy is the division of the opaque capsular membrane left after a
cataract has been removed.
=Indications.= After a cataract has been removed, either by discission
or extraction, an opaque membrane is usually left. This is due to the
proliferation of the cells in the anterior capsule of the lens while
attempting to lay down new lens fibres. Although the posterior capsule
is clear and free from cells, those from the anterior capsule may spread
to it and so render it opaque. A fibrinous exudate may also organize and
help to thicken the membrane (Fig. 87). For these reasons and also
because the soft matter may not have absorbed entirely, it is not
advisable to operate too soon after a cataract has been removed. There
should be at least six weeks’ interval after an extraction has been
performed. A few surgeons operate earlier than this, the idea being that
the membrane is then softer and more easily divided.
[Illustration: FIG. 87. SECONDARY CATARACT. Opaque capsule after
cataract extraction.]
Although the operation of discission for after-cataract (capsulotomy) is
simple it is not to be undertaken lightly. The patient’s vision should
be less than 6/18. In former days the operation was looked upon as
attended with as much risk as the extraction, owing to the frequency
with which it was followed by inflammation. The reasons for this seem to
have been want of proper antiseptic precautions, the passage of the
needle through the non-vascular corneal tissue instead of through the
conjunctiva, and also the use of a badly made needle, often resulting in
prolapse of the vitreous into the wound. A proper discission needle
should have sufficient width in its spear-like point to cut a hole large
enough to admit the shaft freely; hence needles which have been
sharpened several times should be discarded. It need hardly be said
that there should be no signs of cyclitis (keratitis punctata) present
when the operation is undertaken.
=Instruments.= These are the same as for discission, with the addition
of a needle with a long cutting edge.
[Illustration: FIG. 88. CAPSULOTOMY. _The method of incising the
capsule._ The fulcrum of movement of the needle is where the shaft lies
in the sclerotic.]
[Illustration: FIG. 89. CAPSULOTOMY. _The method of dividing a dense
band._ This is done with two needles.]
=Operation.= Capsulotomy is best performed by artificial light under
cocaine. The cutting needle is inserted into the anterior chamber as in
the previous operation. The point is then thrust through the membrane
below (but it should not penetrate deeply, otherwise the vitreous will
be torn) and an incision is made in an upward direction. This incision
usually gapes sufficiently to give a clear pupil (Fig. 88). Those
surgeons who operate early try to cut out a triangular portion of the
membrane. When a dense band is present which gives before the needle
and cannot be divided, a second or ordinary discission needle should be
passed into the anterior chamber from the limbus opposite to the cutting
needle. The discission needle is made to pass behind the band whilst the
cutting needle lies in front of it. By a rotary movement of the
discission needle around the cutting needle the band is carried against
the edge of the latter and so divided. The needles are then withdrawn
(Fig. 89).
=Results.= These are good as a rule, but the operation may have to be
performed again owing to an insufficient or non-central opening being
obtained in the membrane, or to a fresh membrane forming; this is liable
to take place if any irido-cyclitis follow the operation.
=After-treatment.= This should be carried out as described for needling.
EVACUATION
=Indications.= (i) In cases of increased tension associated with soft
lens substance in the anterior chamber.
(ii) To accelerate the absorption of soft lens matter from the anterior
chamber. As a rule it is only undertaken for the former condition.
=Instruments.= Speculum, fixation forceps, bent broad needle, curette.
=Operation.= Under cocaine.
_First step._ An incision is made behind the limbus, usually in an upper
segment of the cornea, by means of a bent broad needle. The point of the
instrument is passed into the anterior chamber immediately behind the
limbus with the handle at right angles to the cornea; directly the
anterior chamber has been entered the handle is depressed so that the
point of the instrument shall turn forwards and avoid injuring the iris.
The blade is passed on into the anterior chamber until the point reaches
about the centre of the pupil. It is then either withdrawn directly, or,
if a larger incision be desired, lateral pressure is made so that in
withdrawing the blade the wound is enlarged.
_Second step. Evacuation._ With the rush of aqueous which follows the
incision some soft matter is usually evacuated; then a curette may be
introduced, if necessary, and the lens fragments removed by gentle
manipulation. Occasionally the iris may prolapse into the wound; if this
happens it should be replaced, but if it occur more than once the
prolapsed portion should be removed. Suction apparatus has been used for
removing the soft lens matter, but it is not to be recommended in most
cases, owing to the difficulty of sterilization and the trauma which it
may cause. After-treatment as for needling should be carried out.
EVULSION OF THE CAPSULE
=Indications.= (i) In congenital cataract when the lens consists of
little more than a dense capsular mass.
(ii) In dense capsular membranes following removal of a lens by
discission in which a cutting needle cannot make a hole.
=Instruments.= Speculum, fixation forceps, keratome, capsule forceps,
discission needle.
=Operation.= A general anæsthetic is usually desirable.
_First step._ The pupil is previously dilated with atropine. In the case
of congenital cataract a discission needle is first passed into the mass
to estimate its consistency. If it consist of little more than capsule
an incision is made at the limbus with the keratome as described for
evacuation.
_Second step._ The blades of the capsule forceps are then inserted
closed, opened, and the opaque capsule grasped and withdrawn from the
eye. The speculum is then removed and a pad and bandage applied. The
pupil should be kept dilated with atropine subsequently, as a certain
amount of irido-cyclitis following the operation is not infrequent.
Occasionally the iris may become entangled in the wound, and it should
then be removed.
EXTRACTION OF THE LENS
=Indications.= (i) For all forms of cataract in patients over thirty
years of age.
(ii) For cases of high myopia over the same age.
(iii) For lenses containing foreign bodies.
(iv) For displacement of the lens causing irritation.
Probably no operation in surgery has so many modifications, many of
which possess advantages and disadvantages which counterbalance each
other so nearly that the individual surgeon must decide for himself
which is the most satisfactory to carry out. The opinion of many
surgeons, including the author, is that the ideal operation is one which
can obtain sight for the patient at one sitting. The operation described
below is carried out with this object in view, the various modifications
and the indications for their use being subsequently discussed.
_Instruments._ Speculum, two pairs of fixation forceps, a Graefe’s
knife, iris forceps (Fig. 90), iris scissors (Fig. 91), capsule forceps,
cystotome, curette or spoon, iris spatula, vectis (Fig. 92), or lens
spoon (Fig. 93).
=Operation.= The operation is performed under cocaine and is divided
into five steps:--
1. Incision.
2. Iridectomy.
3. Opening the lens capsule.
4. Delivery of the lens.
5. Toilet of the wound.
[Illustration: FIG. 90. IRIS FORCEPS. Care should be taken to see that
the teeth dovetail properly.]
[Illustration: FIG. 91. IRIS SCISSORS. Their cutting power should be
tested on wet cigarette paper before use.]
[Illustration: FIG. 92. A VECTIS. It should be made of stiff steel.]
[Illustration: FIG. 93. PAGENSTECHER’S SPOON. It is an advantage to bend
the shaft near the spoon to a right angle.]
=First step.= _The incision._ The surgeon, standing behind the patient’s
head and holding the knife with the edge directed upwards, in the right
hand for the right eye and in the left hand for the left, fixes the eye
with a pair of forceps held in the other hand, by grasping the
conjunctiva below and to the inner side as close to the limbus as
possible (Fig. 94). Most continental surgeons stand in front of the
patient and cut upwards. The point of the knife is then passed on the
flat into the anterior chamber from the outer side, 1.5 millimetres
behind the corneo-sclerotic junction.
[Illustration: FIG. 94. LENS EXTRACTION. Showing the position of the
hands when making a section upwards with a Graefe’s knife.]
It is first directed downwards and inwards until the chamber is
penetrated (Fig. 95). The knife-point is then directed horizontally and
passed across the anterior chamber in a line parallel with an imaginary
tangential line across the top of the cornea. The counter-puncture is
then made, the knife emerging 1 millimetre behind the corneo-sclerotic
junction (Fig. 96). In making the counter-puncture the beginner is apt
to go too far back in the sclerotic owing to the angle of the chamber
being placed behind the limbus; he should therefore aim for a point
about 1 millimetre inwards from the limbus. The knife is next made to
cut upwards by a sawing movement so that a flap is formed of corneal
tissue about 3 millimetres in breadth (a breadth and a half of a new
Graefe’s knife), the upper margin being at the corneo-sclerotic
junction. When the corneal flap has been made, the knife should lie
beneath the conjunctiva, from which a flap about 3 or 4 millimetres in
length should be formed. The knife-edge is then turned forward and made
to cut its way out. In making the section, care must be taken not to
prick the patient’s nose or eyelid with the point of the knife, as it
may cause him to move his head with disastrous results. This is more
likely to happen with patients who have sunken eyes.
[Illustration: FIG. 95. THE KNIFE ENTERING THE ANTERIOR CHAMBER IN
CATARACT EXTRACTION. The point of the knife is directed downwards and
inwards.]
[Illustration: FIG. 96. MAKING THE COUNTER-PUNCTURE IN CATARACT
EXTRACTION. The counter-puncture is shown completed.]
=Second step.= _Iridectomy._ The patient is made to look downwards. A
pair of iris forceps are inserted, closed, into the anterior chamber,
opened, and the iris grasped near its root, and withdrawn. The piece of
iris is then removed with the iris scissors, dividing it parallel with
the incision as close to the eye as possible (Fig. 97). If the
conjunctival flap hinders the insertion of the iris forceps into the
anterior chamber, it may be turned forward over the cornea with the
point of the closed forceps.