A Manual of the Operations of Surgery Part 25

GASTROSTOMY has within the last few years been practised very frequently. Gross has collected 79 cases, 57 of which were for carcinoma of oesophagus, all of which died within a few weeks, except eight who survived for periods varying from three to seven months. The results in cases of cicatricial and syphilitic strictures are more favourable.--Howse's method seems the best, consisting of two stages.

1. A curved incision is made through the parietes parallel with, and a finger-breadth below, the lower margin of chest wall on left side, the peritoneum should be opened at the linea semilunaris, the stomach sought for, and then attached to the abdominal wall by an outer ring of sutures and to the edge of the wound by an inner ring. It should then be dressed with carbolised lint and supported by a bandage.

2. A small opening should be made four or five days after the first stage and the patient should be fed through this opening.

For full details, see Mr. Durham's paper in vol. i. of Holmes's Surgery, edition of 1883, pp. 801-4.

GASTRECTOMY.--Excision of whole or part of the stomach is one of the latest developments of operative daring, first done as a regular operation by Pean in 1879, it has now been repeated sixteen times; four cases have survived the operation for more than ten days. The chief points to be attended to are prevention of death from shock and haemorrhage, and very careful st.i.tching up of the wound. Considering the difficulty of the diagnosis, the danger of the operation, and the almost certain recurrence of the disease, the propriety of such operation seems very doubtful.

OVARIOTOMY.--For the pathology of ovarian disease we must refer to Sir Spencer Wells's work on the subject, and to the smaller Monograph on Ovarian Pathology, by the late lamented Dr. Charles Ritchie, junior.

Even the modifications in the method of operating which have been devised are so various and numerous, that if collected from the medical journals of the last ten years they would fill a large volume. Besides this, the operation of ovariotomy is one attended by so many complications, that individual cases vary from each other as much as do individual cases of hernia and tracheotomy; and as the specialities of each case require to be met by specialities of treatment, there is hardly any operation in surgery which requires greater readiness of invention, or more individual sagacity in the operator.

To lay open the abdominal cavity from the sternum to the p.u.b.es, and rapidly dissect out of this cavity an enormous tumour with a narrow neck, the operator's only embarra.s.sment being the peristaltic movements of the bowels, and his only care being to tie the neck of the tumour firmly with strong string, sew up the wound, and trust to nature, was an operation very easy to perform, and requiring free cutting rather than dexterity, and rashness more than true surgical insight.

Such were the ovariotomies prior to 1857.

An ovariotomy in 1883 is a very different business, varying in certain important particulars.

(1.) Instead of the incision extending from sternum to p.u.b.es, it is now made as short as possible.

(2.) Instead of being removed entire, the cyst is now emptied with the greatest possible care (prior to its removal), and none of the contents allowed to enter the peritoneal cavity.

(3.) The pedicle is brought to the surface, and in every case where it is possible is secured outside the wound.

Besides these three important and cardinal points, there are other minor matters almost equally essential; these are--(1.) The proper management of the adhesions and the thorough prevention of all haemorrhage from them; (2.) the st.i.tching up of the external wound, including the peritoneum; (3.) the treatment of the patient during the first few days of convalescence.

_Operation_ in a typical case, after the method of Sir Spencer Wells and Dr. Thomas Keith.--The patient having had her bowels gently opened on the previous day, and being as far as possible in her usual state of health, should be warmly clad in flannel, both in body and limb, and laid on an operating table of convenient height, in or near the room she is to occupy. No carrying from ward to operating theatre and back again is admissible. It will be found both cleanly and convenient to have a large india-rubber cloth over the whole abdomen, cut out in the centre so as to expose so much of the tumour as is necessary, but gummed on or otherwise secured to the sides of the abdomen, and thus protecting the clothes, and hanging down over the edge of the table; this will prevent all wetting of the clothes and unnecessary exposure of the patient's person, and can be easily removed after the operation. Chloroform being administered, the bladder is evacuated by means of a catheter, and the patient's head and shoulders are elevated on pillows. An incision is then made in the linea alba, between the umbilicus and p.u.b.es, for about four inches in length at first, so as to be large enough to admit the hand, through all the tissues down to and through the peritoneum. Care is necessary in dividing the peritoneum, on the one hand, not to divide too much, in which case the cyst-wall will be penetrated, and the contents effused into the peritoneal cavity; or, on the other hand, too little, in which case the peritoneum may be mistaken for the cyst, and separated from the transversalis fascia under the idea that adhesions exist. Once the peritoneal cavity is opened, the incision through the peritoneum must be extended to the full length of the external wound by a probe-pointed bistoury.

The operator's hand must now be pa.s.sed into the abdomen, and the tumour isolated from its connections as far as possible. When no adhesions exist it is extremely easy to pa.s.s the hand quite round the tumour, ascertain its relations to the uterus and Fallopian tubes, and the length and thickness of its pedicle. The presence of adhesions adds very seriously to the danger and duration of the operation. We will suppose at present that none exist in this typical case, and that the pedicle is found of a satisfactory size and shape. The surgeon now protrudes the anterior portion of the cyst-wall through the wound, and pierces it with a large trocar,[141] to which is attached an india-rubber tube, by means of which the effused fluid can be easily got rid of in any direction.

During the escape of the fluid from the cyst a special a.s.sistant keeps up the tension by careful pressure on the abdomen. In cases where the cyst is multilocular, and thus only a portion of the contents of the tumour is at first evaluated, the operator should, by partially withdrawing the trocar, without removing it entirely from the cyst, endeavour to pierce and evacuate the other cysts, still through the original opening in the first one.

While doing this, great care must be taken lest he pierce the external wall of the tumour, and let any of the contents escape into the abdominal cavity; to guard against this, the punctures should be made by the right hand, while the left, re-inserted into the abdomen, supports the cyst-wall.

The tumour having been as far as possible emptied of its fluid contents, must now be dragged out of the wound, care being still taken lest any of its fluid contents escape into the peritoneal cavity. In favourable cases the pedicle is now brought easily into view. This may vary very much in length and thickness. It is sometimes entirely absent, the tumour being sessile on the broad ligament of the uterus; sometimes it is thick and strong, sometimes long and slender. The manner in which it is to be managed depends on its length and thickness. Varieties in treatment will be noticed immediately. We will suppose that it is four inches in length and one or two fingers in breadth. This is quite a suitable case for the use of the clamp, the principle involved in the use of which is, that the pedicle should be brought quite out of the abdomen through the wound and secured on the surface. The best form seems to be one made like a carpenter's callipers, with long but removable handles, and a very powerful fixing-screw.

The blades of this clamp being protected by pads of lint should be made to embrace the pedicle close to the cyst, in a direction at right angles to the abdominal wound, and lying across it, the handles should then be removed, and pads of lint placed below the clamp to protect the skin.

The cyst may now be cut away at some little distance above the clamp, enough being left to prevent all danger of its slipping. Further to avoid this danger, the pedicle may be transfixed by one or two needles above the clamp.

The wound is now to be sewed up by several points of interrupted suture, some inserted very deeply through all the tissues, including even the peritoneum, others in the intervals of the first, including little more than the skin. They may be either of iron, silver, platinum, telegraph-wire (Mr. Clover's copper, coated with gutta-percha), or silk.

It seems of very little consequence which is used. Sir Spencer Wells, after many trials, uses silk, as being removed with least pain to the patient, and really causing no more suppuration than the metallic ones do, if only removed early enough, viz., about the second or third day, by which time the union of the wound should be firm.

The after-treatment should be very simple. Except under special circ.u.mstances, stimulants are rarely necessary, and indeed, to avoid vomiting, as little as possible should be given by the mouth during the first twenty-four hours. The patient should be allowed to suck a little ice to allay thirst, and opiate and nutritive enemata will be found quite sufficient to keep up the strength in ordinary cases. The urine should be drawn off by the catheter every six hours. The room should be kept quiet, and the temperature equable, so long as there is no interference with a plentiful supply of fresh air.

Some of the specialities and abnormalities involving special risks may now be briefly noticed:--

1. _Adhesions._--These vary much in amount, in position, in organisation, and danger.

_a._ _In amount._--In certain cases no adhesions exist, while in others, omentum, intestines, tumour, uterus, and abdominal wall may be all matted together in one common ma.s.s.

_b._ _In organisation._--Occasionally they are so soft and friable as to break down under the finger with ease, and so slightly organised as not to bleed at all in the process, while again they may be so firm and close as to require a careful and prolonged dissection, and so vascular as to require many points of ligature to be applied to large active vessels.

_c._ There are special _dangers_ connected with the presence of these adhesions, and varying much in different cases. Thus adhesions to the intestines can generally be separated with comparative ease, and seem, as a rule, to require the application of fewer ligatures than those which unite the tumour to the abdominal wall. Adhesions to the wall are sometimes so firm as to be quite inseparable, and thus to necessitate some of the cyst-wall being left adherent. In Sir Spencer Wells's cases, adhesions to the liver and gall-bladder occasionally occurred, requiring careful dissection to separate them, and yet the patients all survived, while pelvic adhesions, especially to the bladder and uterus, on more than one occasion prevented the completion of the operation.

Vascular adhesions to the wall which require many ligatures certainly add to the dangers of the case, while adhesions to the anterior wall of the abdomen render the operation, especially its first stages, much more difficult, preventing the cyst from being recognised.

2. _The condition of the pedicle_ is of great importance. If it is too short, it prevents the use of the clamp, as if applied it is apt either to pull the uterus up, or, pulling the clamp down, to make undue traction on the wound, and rupture any adhesions. This is especially the case where much flatus is generated, or where the patient is naturally stout.

_Treatment._--Where the pedicle is just long enough to allow the clamp to be applied, and yet too short to leave room for any distension of the abdomen without undue tension, the best plan is to transfix it with a stout double thread just below the clamp, tie it in two halves, and bring the threads out past the clamp, so that, if tension does occur, the clamp may be removed, the part beyond it cut off, and the rest allowed to slip back into the pelvis, the ligatures being kept out at the mouth of the wound.

Or again, it is sometimes possible, after applying one clamp firmly as near the tumour as possible, to apply another above it when the greater part of the tumour has been cut away; when the second is firmly fixed it may then be safe to remove the first, and thus an artificially elongated pedicle is obtained.

When still shorter, two plans remain for selection--(1.) to transfix the pedicle in one or more points, then, securing it in two, three, or more portions, cut it off above the ligatures and return it, leaving the ligatures at the lower end of the wound. This gives a free drain for pus, but theoretically the sloughing pedicle might be expected to set up peritonitis; (2.) to transfix and tie the pedicle with one or more loops of stout string, cut the ends off short, and return the whole affair, closing the external wound at once. Theoretically there are grave objections to this plan, but it has proved very successful, especially in the hands of Dr. Tyler Smith.

Another ingenious modification, sometimes useful in a short narrow pedicle, is to tie it as close to the cyst as possible, bring the ligature out at the wound, and then with a strong harelip needle transfix the pedicle, along with both sides of the wound, just below the ligature.

When the pedicle is excessively broad and stout, it should be transfixed by strong needles and double threads in various places, and thus tied in several portions. Absence of the pedicle greatly adds to the danger in any given case. Various plans have been tried, as cutting the attachment through slowly by the ecraseur, ligature of each vessel separately, so many as twelve being sometimes required, and cauterising the stump. The latter, as used by Mr. Baker Brown, has met with a large measure of success, and is much used now.[142]

Dr. Keith for a time operated with antiseptic precautions, but has now (1883) entirely given up the use of the spray, which he believes has especial dangers in abdominal surgery.

OPERATION FOR STRANGULATED INGUINAL HERNIA.--The great rule to be remembered with regard to this, as well as all other operations for hernia, is, that the earlier it is performed the better chance the patient has. Once a fair trial has been given to the taxis, aided by proper position of the patient, the warm bath, and specially chloroform, the operation should be performed.

The patient should be placed on his back with his shoulders elevated, and the knee of the affected side slightly bent. The groin should then be shaved, and the shape and size of the tumour, with the position of the inguinal ca.n.a.l, carefully studied. The surgeon should then lift up a fold of skin and cellular tissue, in a direction at right angles to the long axis of the tumour, and holding one side of this raised fold in his own left hand, commit the other to an a.s.sistant. He then transfixes this fold with a sharp straight bistoury, with its back towards the sac, and cuts outwards, thus at once making an incision along the axis of the hernia without any risk of wounding the sac or bowel. Any vessel that bleeds may now be tied. This incision will be found sufficiently large for most cases; if not, however, it can easily be prolonged either upwards or downwards. The surgeon must now devote his attention to exposing the neck of the sac, and in so doing, defining the external inguinal ring. The safest method of doing so is carefully to pinch up, with dissecting forceps, layer after layer of connective tissue, dividing each separately by the knife held with its flat side, not its edge, on the sac, and then by means of the finger or forceps raising each layer in succession and dividing it to the full extent of the external incision. It is not always an easy matter to recognise the sac, especially as the number of layers above it, which are described in the anatomical text-books, are often not at all distinct.

The thickness of the connective tissue of the part varies immensely; sometimes six layers or even more can be separately dissected, while, again, one only may be found before the sac is exposed.

If small and recent, the sac may be recognised by its bluish colour, and by the fact that it is possible to pinch up a portion of it between the finger and thumb, and thus to rub its opposed surfaces against each other.

If large and of old standing, it is sometimes so thin as not to be recognisable, or again so enormously thickened, and so adherent, as to be defined with great difficulty.

If it is small, _i.e._ when the whole tumour is under the size of an egg, it ought to be thoroughly isolated, and its boundaries everywhere defined. If large, and specially if adherent, the neck alone should be cleared.

The sac thus being reached, the external abdominal ring should be clearly defined, and the finger pa.s.sed into it so as if possible to determine the presence or absence of any constriction in it. If it feels tight, the internal pillar of the ring should then be cautiously divided on the finger by a probe-pointed narrow bistoury, in a direction parallel to the linea alba.

At this stage the question comes to be considered as to whether the sac should or should not be opened. Much has been said and written on both sides.

Not to open the sac avoids the risk of peritonitis, and of injury to the bowel; but, on the other hand, exposes the patient to the danger of the hernia being returned unreduced; for in many cases the stricture is to be found in the sac itself, and adhesions very rapidly form between coils of intestine in the sac and the inner wall. Again, not to open the sac prevents us from discovering the condition in which the bowl is; it may possibly be gangrenous, in which case such a return _en ma.s.se_ would be almost necessarily fatal.

A general rule or two may be given here:--

1. The sac should be opened in every case where there is any reason for doubt about the condition of the bowel, where there has been long-continued vomiting, or much tenderness on pressure.

2. Even in cases in which there is every reason to believe the bowel is perfectly sound, the sac should be opened, unless the whole contents can be easily and completely reduced out of the sac into the belly, as in cases where this cannot be done there probably exist either a stricture in the neck of the sac itself, or adhesions of the bowel to the sac. We should endeavour to avoid opening the sac in cases of old scrotal hernia of large size, where the symptoms have not been urgent, especially in large unhealthy hospitals, as the risk of peritonitis is so great.

Antiseptic precautions seem considerably to diminish the risk of opening the sac.