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A
SYSTEM
OF
OPERATIVE SURGERY
BY VARIOUS AUTHORS
EDITED BY
F. F. BURGHARD, M.S. (Lond.), F.R.C.S. (Eng.)
TEACHER OF OPERATIVE SURGERY IN KING’S COLLEGE, LONDON
SURGEON TO KING’S COLLEGE HOSPITAL
SENIOR SURGEON TO THE CHILDREN’S HOSPITAL, PADDINGTON GREEN
IN FOUR VOLUMES
VOL. IV
OPERATIONS UPON THE FEMALE GENITAL ORGANS
OPHTHALMIC OPERATIONS
OPERATIONS UPON THE EAR
OPERATIONS UPON THE LARYNX AND TRACHEA
OPERATIONS UPON THE NOSE AND ITS ACCESSORY CAVITIES
LONDON
EDITOR’S PREFACE
Great as have been the advances made in Surgery during the last fifteen years, there is no direction in which they have been more noticeable than in the elaboration of those comparatively small but important details of operative technique which do so much to ensure a low mortality and a successful result.
These improvements have been developed simultaneously throughout the whole of the vast field covered by modern Surgery, and it has become increasingly difficult for any single writer to deal with such an important subject as Operative Surgery in an authoritative and efficient manner. The scope of the subject is so wide that it is difficult to ensure that the work when published shall be thoroughly up to date, while a second and even greater difficulty is for any one, however great his ability and experience, to deal equally exhaustively and authoritatively with all of the many branches of which he would have to treat.
To avoid both of these difficulties and thus to make sure that the work shall reflect faithfully the present position of British Operative Surgery, the plan has been adopted of securing the co-operation of a number of prominent British Surgeons. Each writer deals with a branch of the subject in which he has had special experience, and upon which, therefore, he is entitled to speak with authority.
Besides the two important points just referred to, a third equally important one has been kept in view throughout. Particular care has been taken to make the work of as much practical utility to the reader as possible. Not only are the various operations described in the fullest detail and with special reference to the difficulties and dangers and the best methods of overcoming and avoiding them, but the indications for the individual operations are described at length, and the after-treatment and results receive adequate notice.
It is therefore hoped that the work will be useful alike to those who are about to operate for the first time, and to those surgeons of experience who desire to keep themselves informed as to the progress that has been made in the various branches of Operative Surgery.
The division of the work into a number of sections each written by a different author, necessarily involves some overlapping of subjects and some diversity of opinion upon points of technique. Efforts have been made to prevent overlapping of subjects as far as possible by care in their distribution and by conference between the authors concerned, but no attempt has been made to harmonize conflicting views. Each author supports his individual opinions by the weight of his authority, and any discrepancies may be taken to represent the absence of unanimity on various minor points that is well known to exist among surgeons of
The task of editing a work contributed to by so many writers might well appear to be an onerous one, but, owing to the promptitude, courtesy, and forbearance of all concerned, it has been a source of great pleasure, and the Editor’s most cordial thanks are tendered to all those who have devoted so much time and trouble to the work.
PREFACE TO VOLUME IV
Every effort has been made to keep this volume strictly within the definition of a work upon Operative Surgery—a somewhat difficult task in the case of certain of the special subjects with which it deals. In some cases methods of examination or manipulation have been described that are not strictly operative in nature, but their inclusion has been justified upon the ground that many of them are essential in operations upon the regions concerned, and all require special manipulative skill and dexterity.
The Index to this volume has been arranged in five parts, one part for each Section comprised in it. In this way it has been possible to economize space and, it is hoped, to render the task of reference easier.
In the Section on Vaginal Gynæcological Operations, instrument blocks have been kindly supplied by Messrs. Montague, Down Bros., and Griffin. The remaining illustrations are from original sketches by the author.
In the Section on Ophthalmic Operations, Messrs. Weiss have kindly supplied the instrument blocks. The remainder of the illustrations are original. Mr. Mayou desires to thank Mr. W. H. McMullen for valuable help in reading the proof sheets.
In the Section on Operations upon the Ear, all the illustrations, with the exception of the instrument blocks kindly supplied by Messrs. Mayer and Meltzer and a few illustrations from Tod’s Manual of Diseases of the Ear, are original.
In the Section on Operations upon the Nose, the instrument blocks have been supplied by Messrs. Mayer and Meltzer, who have also furnished them in the Section on Operations upon the Throat. Mr. F. A. Rose has kindly read the proof sheets of the latter Section, for which Mr. Harmer desires to thank him.
CONTRIBUTORS TO THIS VOLUME
JOHN BLAND-SUTTON, F.R.C.S. (Eng.)
Surgeon to the Middlesex Hospital, and Senior Surgeon to the Chelsea Hospital for Women, London
Abdominal Gynæcological Operations
JOHN PHILLIPS, M.A., M.D. (Cantab.), F.R.C.P.
Professor of Obstetric Medicine, King’s College, London; Obstetric Physician and Gynæcologist to King’s College Hospital
Vaginal Gynæcological Operations
M. S. MAYOU, F.R.C.S. (Eng.)
Assistant Surgeon to the Central London Ophthalmic Hospital; Ophthalmic Surgeon to the Children’s Hospital, Paddington Green
Ophthalmic Operations
HUNTER F. TOD, M.A., M.D. (Cantab.), F.R.C.S. (Eng.)
Aural Surgeon to the London Hospital
Operations upon the Ear
W. DOUGLAS HARMER, M.C. (Cantab.), F.R.C.S. (Eng.)
Surgeon to the Throat and Nose Department, St. Bartholomew’s Hospital
Operations upon the Larynx and Trachea
StCLAIR THOMSON, M.D., F.R.C.P. (Lond.), F.R.C.S. (Eng.)
Professor of Laryngology and Physician for Diseases of the Throat, King’s College Hospital, London
Operations upon the Nose and its Accessory Cavities
CONTENTS
SECTION I
OPERATIONS UPON THE FEMALE GENITAL ORGANS
PART I
ABDOMINAL GYNÆCOLOGICAL OPERATIONS
By JOHN BLAND-SUTTON, F.R.C.S. (Eng.)
Surgeon to the Middlesex Hospital and Senior Surgeon to the Chelsea Hospital for Women, London.
CHAPTER I
PAGES
CŒLIOTOMY Preparation of Patient, 3. Basins, Dishes, and Instruments, 4. Suture and Ligature Material, 5. Dabs, 5. Gloves, Operating Table, Anæsthesia, 6. The Incision, 7. Misplaced Viscera, 8. Closure of Wound, 8 3–9CHAPTER II
OVARIOTOMY The Operation, 10. Cysts of the Broad Ligaments, 14. Spurious Capsules, 15. For Carcinoma of Ovary, 15. Incomplete Ovariotomy, 16. Anomalous Ovariotomy, 16. Ovariotomy followed by Hysterectomy, 17. Repeated Ovariotomy, 17. Pregnancy after Bilateral Ovariotomy, 17. Ovariotomy at Extremes of Life,CHAPTER III
OÖPHORECTOMY Operation, 22. Abdominal Hysterectomy after Bilateral Oöphorectomy and Ovariotomy, 25. Mortality, 25. Operation for Primary Cancer of the Fallopian Tube, 26 21–28CHAPTER IV
OPERATIONS FOR EXTRA-UTERINE GESTATION Indications, 29. Operation, 29. Concurrent Intra- and Extra-uterine Pregnancy, 33. Results of Operative Treatment, 34 29–35CHAPTER V
HYSTERECTOMY AND MYOMECTOMY Indications, 36. Subtotal Hysterectomy, 36. Total Hysterectomy, 40. Mortality, 44. Risks of Abdominal Hysterectomy, 45. Abdominal Myomectomy, 46 36–49CHAPTER VI
ON THE RELATIVE VALUE OF TOTAL AND SUBTOTALHYSTERECTOMY Cancer of the Body of the Uterus and Fibroids, 52. Sarcoma, 53. Cancer of the Uterus after Bilateral Ovariotomy, 55. Adenomyoma of the Uterus, 56. Fate and Value of Belated Ovaries, 56 50–60
CHAPTER VII
HYSTERECTOMY FOR PRIMARY CARCINOMA OF THE UTERUS For Cancer of the Cervix, 61. For Cancer of the Body of the Uterus, 63 61–65CHAPTER VIII
OPERATIONS FOR DISPLACEMENT OF THE UTERUS Ventro-suspension for Retroflexion of the Uterus,CHAPTER IX
OPERATIONS UPON THE UTERUS DURING PREGNANCY,PARTURIENCY, AND PUERPERY Cæsarean Section, 69; Immediately after the Death of the Mother, 72. Ovariotomy and Hysterectomy during Pregnancy and in Labour, 73. Ovariotomy during the Puerperium, 76. Fibroids and Pregnancy, 77. Pregnancy with Cancer of the Cervix, 82. Concurrent Uterine and Tubal Pregnancy, 82. Pregnancy with Tumours growing from the Pelvic Walls, 83. Operations for Puerperal Sepsis, 83 69–85
CHAPTER X
OPERATIONS FOR INJURIES OF THE UTERUS Gynæcological, 86. Obstetric, 87; to the Pregnant Uterus, 89; to the Gravid Uterus in the course of an Abdominal Operation, 89. Bullet Wounds of the Pregnant Uterus, 90. Stab-wounds of the Pregnant Uterus, 91 86–92CHAPTER XI
THE AFTER-TREATMENT, RISKS, AND SEQUELÆ OF ABDOMINALGYNÆCOLOGICAL OPERATIONS After-treatment of Abdominal Operations, 93. Complications of Abdominal Gynæcological Operations—Metrostaxis, 95; Bed-sores, 95; Post-anæsthetic Paralysis, 95; Giving way of the Wound, 96; Hæmorrhage, 97; Intrapelvic Hæmorrhage, 98; Pneumonia, 99; Parotitis, 99; Thrombosis, 101; Pulmonary Embolism, 101; Foreign Bodies left in the Abdomen, 105; Tetanus, 107; Injury to the Intestines, 109; Intestinal Obstruction, 110; Perforating Ulcer of the Stomach and Small Intestine, 111; Injuries to
PART II
VAGINAL GYNÆCOLOGICAL OPERATIONS
By JOHN PHILLIPS, M.A., M.D. (Cantab.), F.R.C.P.
Professor of Obstetric Medicine, King’s College, London; Obstetric Physician and Gynæcologist to King’s College Hospital.
CHAPTER XII
PREPARATION OF THE PATIENT FOR PERINEAL AND VAGINAL OPERATIONS:OPERATIONS FOR INJURIES TO THE PERINEUM AND PELVIC FLOOR Preparation of the Patient, 125. Operations for Repair of a Complete Laceration of the Perineum, 127. Operation for Laceration of the Pelvic Floor, 132 125–133
CHAPTER XIII
OPERATIONS UPON THE URETHRA AND BLADDER Extirpation of a Urethral Caruncle, 134. Operations for Incontinence following Labour, 134; for Vesico-vaginal Fistula, 135; for Recto-vaginal Fistula, 139; for Cystocele, 140 134–141CHAPTER XIV
OPERATIONS UPON THE VULVA AND VAGINA Operations upon Bartholin’s Glands, 142. Operations for Atresia of the Hymen and the Vagina, 143. Dilatation of the Vulval Orifice, 143. Colpotomy, 144; Anterior, 145; Posterior, 147; Lateral, 148 142–148CHAPTER XV
OPERATIONS UPON THE UTERUS Passage of the Uterine Sound, 149. Reposition of a Chronic Uterine Inversion, 151. Curetting the Uterus, 152. Dilatation of the Cervix, 156—Rapid Dilatation, 157; Gradual Dilatation, 159. Operations for Hypertrophy of the Cervix, 160. Trachelorrhaphy, 161. VaginalCHAPTER XVI
OPERATIONS FOR NEW GROWTHS OF THE UTERUS For Uterine Fibro-myomata, 165—for Pedunculated Tumours, 165; for Sessile Tumours, 166; for Interstitial Tumours, 167. Vaginal Hysterectomy, 167—for Carcinoma, 168; for Fibroids, 173 165–173SECTION II
OPHTHALMIC OPERATIONS
By M. S. MAYOU, F.R.C.S. (Eng.)
Assistant Surgeon to the Central London Ophthalmic Hospital; Ophthalmic Surgeon to the Children’s Hospital, Paddington Green.
CHAPTER I
GENERAL CONSIDERATIONS APPLICABLE TO OPERATIONSUPON THE EYE General Preliminaries to an Operation, 177. Local Preparation of the Patient, 80. Making and Healing of Wounds in the Globe, 182—Purification of Hands, 182; of Instruments, 183; Direction of Incision, 183; Position of Incision, 184; Dressings, 186; Bandaging, 186 177–186
CHAPTER II
OPERATIONS UPON THE LENS Surgical Anatomy, 187. Discission or Needling, 189—for Cataract, 189; for High Myopia, 190. Capsulotomy, 192. Evacuation, 194. Evulsion of the Capsule, 195. Extraction of the Lens, 195. Modifications, 201; Delivery of the Lens by Irrigation, 203; Extraction of the Lens in its Capsule, 204; Subconjunctival Extraction, 204. Couching, 209 187–210CHAPTER III
CHAPTER IV
OPERATIONS UPON THE SCLEROTIC Anterior Sclerotomy, 228. Cyclo-dialysis, 229. Sclerectomy, 231. Posterior Sclerotomy, 232. Paracentesis of the Anterior Chamber, 233. For Penetrating Wounds of the Globe, 234. Electro-magnet Operations—with Small Magnet, 237; with Giant Magnet, 238 228–239CHAPTER V
OPERATIONS UPON THE CORNEA AND CONJUNCTIVA Removal of a Foreign Body from the Cornea, 240. Cauterization of the Cornea, 240. Operations for Conical Cornea, 241. Removal of Tumours involving the Cornea, 243. Tattooing the Cornea, 243. Scraping Calcareous Films, 243. Operations upon the Conjunctiva—Removal of Foreign Bodies, 244; for Pterygium, 244; Expression, 245; Conjunctivoplasty, 245; Removal of Tarsal Cysts, 246 240–246CHAPTER VI
OPERATIONS UPON THE EXTRA-OCULAR MUSCLES Squint Operations, 247. Tenotomy, 248. Advancement, 251 247–254CHAPTER VII
CHAPTER VIII
OPERATIONS UPON THE EYELIDS Surgical Anatomy, 263. Suture of Wounds of the Eyelids, 263. Operations for Ankyloblepharon, 264; for Symblepharon, 264. Upon the Palpebral Aperture, 265—Canthoplasty, 265; Canthotomy, 265; Canthorrhaphy, 265; Tarsorrhaphy, 266. Ptosis Operations, 267; Shortening the Eyelid by Excision of a portion of the Tarsal Plate, 267. Attachment of the Lid to the Occipito-frontalis Muscle, 268. Advancement of the Levator Palpebræ Muscle, 272. Grafting a portion of the Superior Rectus into the Lid, 273 263–274CHAPTER IX
OPERATIONS FOR ENTROPION, REPAIR OF THE EYELIDS,TRICHIASIS, AND ECTROPION Electrolysis, 275. Skin and Muscle Operation, 275. Rectification of a Faulty Curvature of the Tarsus—Burow’s Operation, 276; Streatfield’s Operation, 277. Transplantation of the Lash-bearing Area—Arlt’s Operation, 278. Ectropion Operations, 279—for Passive Ectropion, 280; Snellen’s Suture Method, 280; Fergus’s Operation, 281; Kuhnt’s Operation, 281; Argyll Robertson’s Operation, 282. For the Active or Cicatricial Form, 284; VY Operation, 284; Denonvillier’s Operation,
CHAPTER X
OPERATIONS UPON THE LACHRYMAL APPARATUS For the Relief of Lachrymal Obstruction, 290—Dilatation of the Canaliculus, 290; Slitting the Canaliculus, 291; Syringing the Lachrymal Duct, 292; Probing the Lachrymal Duct, 292; the Insertion of Styles, 293. For Obliteration of the Canals, 294; Obliteration of the Canaliculi, 294; Excision of the Lachrymal Sac, 294. Opening a Lachrymal Abscess, 297. Operations upon the Lachrymal Gland—Removal of the Palpebral Portion, 298; Removal of the Orbital Portion, 299. Operations upon the Orbit—Exploration of the Orbit (Krönlein’s Method), 299; Evisceration of the Orbit, 301; Opening an Orbital Abscess, 301 290–301SECTION III
OPERATIONS UPON THE EAR
By HUNTER F. TOD, M.A., M.D. (Cantab.), F.R.C.S. (Eng.)
Aural Surgeon to the London Hospital.
CHAPTER I
EXAMINATION OF THE EAR: GENERAL CONSIDERATIONSWITH REGARD TO OPERATIONS Examination of the Ear, 305—Sources of Illumination, 305; Technique of Examination, 306; Method of cleansing the Ear, 307. General Considerations with regard to Operations—Preliminary Surgical Toilet, 309; Anæsthesia, 310. Position of Patient and Surgeon, 313 305–313
CHAPTER II
OPERATIONS UPON THE EXTERNAL AUDITORY CANAL Operations for Furunculosis, 314. Removal of Exostoses from the External Meatus, 316. Removal of Foreign Bodies—by Syringing,CHAPTER III
OPERATIONS UPON THE TYMPANIC MEMBRANE ANDWITHIN THE TYMPANIC CAVITY Surgical Anatomy of the Tympanum, 335. Paracentesis, 336. Artificial Perforation of the Tympanic Membrane, 340. Division of the Anterior Ligament, 341. Division of the Posterior Fold, 341. Intratympanic Operations, 342; Division of Adhesions, 342; Tenotomy of the Tensor Tympani, 346; Tenotomy of the Stapedius, 347. Removal of Granulations from the Tympanic Cavity, 348. Operations upon the Ossicles—Direct Mobilization, 349; Removal of the Ossicles, 351 335–363