A System of Operative Surgery Part 1

A System of Operative Surgery.

Volume IV.

by Various.

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 ent.i.tled to speak with authority.

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

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

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

The task of editing a work contributed to by so many writers might well appear to be an onerous one, but, owing to the prompt.i.tude, 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.

SECTION I

OPERATIONS UPON THE FEMALE GENITAL ORGANS.

PART I

ABDOMINAL GYNaeCOLOGICAL OPERATIONS

BY

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

Surgeon to the Middles.e.x Hospital and Senior Surgeon to the Chelsea Hospital for Women, London

CHAPTER I

CLIOTOMY

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

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

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

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

The preparation of the skin needs to be very thoroughly carried out.

After a warm bath the hair is shaved from the abdomen, p.u.b.es and v.u.l.v.a, and the skin is well washed with warm soapy water and swathed in gauze compresses wrung out of a solution of perchloride of mercury, 1 in 5,000. These compresses remain for twelve hours. The abdomen is again washed, and a second compress is applied which remains on until the operation.

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

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

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

When patients are advanced in years it is extremely necessary to protect them from being chilled by undue exposure. It is well to clothe their lower limbs in warm flannel garments or drawers made out of Gamgee tissue. No open doors or windows should be permitted; though in summer this is comfortable to the surgeon it may be disastrous to the patient.

In winter the temperature of an operating-room should not be below 65F.

In this way ether pneumonia is best avoided.

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

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

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

=Basins and dishes.= All receptacles such as basins, pots, instrument dishes and the like should be boiled. Mere rinsing or was.h.i.+ng in warm water is insufficient.

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

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

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

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

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

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

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

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

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

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

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