OPERATIONS ON ABDOMEN.
PARACENTESIS ABDOMINIS.--To withdraw fluid from the abdominal cavity is
an exceedingly simple operation in itself, though certain precautions
are necessary to render it safe.
_Trocar._--The usual instrument used to be a simple round canula with a
trocar, the point of which should be very sharp, and in the shape of a
three-sided pyramid. It should be about three inches in length, and a
quarter of an inch in diameter. It may for convenience have an
india-rubber tube fixed to its side or end, for the purpose of conveying
the fluid to the pail or basin, but any other additions or alterations
have not been improvements. Lately surgeons have been diminishing the
size of the tube so as to withdraw the fluid more slowly, and taking
many precautions to insure the wound being kept aseptic.
_Where to tap._--In the linea alba, midway between the umbilicus and
pubes, or rather nearer the umbilicus. Here, there are no muscles nor
vessels, the opening is a dependent one, and the bladder is quite out of
the way of injury.
_N.B._--It is a wise precaution, in every case where there is a
possibility of doubt as to the state of the bladder, to pass a catheter.
I have myself known at least one case in which a surgeon was asked to
tap an over-distended bladder, as a case of ascites.
_The Operation._--As there is great risk of syncope coming on during the
operation, from the sudden relief to the pressure on the organs, a broad
flannel bandage should be applied to the belly, the ends of which are
split into three at each side, and crossed and interlaced behind. An
assistant should stand at each side to make gradual pressure by pulling
on the ends of the bandage, thus assisting the flow, and maintaining the
pressure. A hole should be cut in the bandage at the spot where the
puncture is to be made, and the trocar inserted by one firm push,
without any preliminary incision, unless the patient is inordinately
fat. As the trocar is withdrawn, the canula should be pushed still
further in. The surgeon should be ready at once to close the canula with
his thumb, if the flow begins to cease, lest air should be admitted. If
the flow ceases from any cause before all the fluid seems to be
evacuated, the trocar should _not_ be re-introduced, lest the intestines
be wounded, but a blunt-headed perforated instrument fitting the canula
should be inserted.
When all the fluid that can be easily obtained is evacuated, the canula
may be withdrawn, and a pad of lint secured over the wound by strapping.
GASTROTOMY.--Cutting into the stomach for the extraction of a foreign
body has now been performed at least ten times, and all but one
recovered. A typical example is that by Dr. Bell of Davenport, who
removed a bar of lead one pound in weight and ten inches in length, by
an incision four inches in length from the umbilicus to the false ribs.
The opening into the stomach was as small as possible, and required no
sutures.
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
hæmorrhage, and very careful stitching 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 pubes, and
rapidly dissect out of this cavity an enormous tumour with a narrow
neck, the operator's only embarrassment 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 pubes, 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 hæmorrhage from
them; (2.) the stitching 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 pubes, 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 passed into the abdomen, and the tumour
isolated from its connections as far as possible. When no adhesions
exist it is extremely easy to pass 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 assistant 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
circumstances, 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 mass.
_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 écraseur, 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 canal, 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 assistant. 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 passed 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 masse_ 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.
If the sac then is not to be opened, the rest of the operation is very
simple. Endeavour to reduce the bowel out of the sac, and then return
the sac itself, unless the hernia is of old standing, and adhesions
prevent its reduction. A few silver stitches to close the wound and a
carefully adjusted pad are now all that is requisite.
If the sac is to be opened, how can it be done with least danger to the
bowel?
If the hernia is small, and it is possible to define it all, the sac
should be opened at its lower end, as _there_ a small quantity of serous
fluid which intervenes between the sac and the bowel will be found.
Where this is present, there is no danger of wounding the bowel, as the
sac can be easily pinched up; but this is by no means invariably the
case, so great care should always be taken. A small portion of the wall
being thus pinched up should be divided in the same manner as the
layers of cellular tissue were divided in exposing the sac. A few drops
of serum will then escape, and the glistening surface of the bowel be
exposed; the finger should then be introduced at the opening, and the
incision enlarged by a probe-pointed bistoury. If the hernia is small
the sac should be slit up to its full extent; if large, only a
sufficient portion of the neck should be opened. As soon as the opening
in the sac is large enough to admit the point of the operator's
forefinger, it should be inserted so as to protect the intestines, and
the remainder of the sac slit up on it as a guide.
The sac thus opened, the next step is to divide the constriction,
wherever it be. It is most likely to be found at the neck of the sac,
just where it protrudes through the internal ring in an oblique hernia,
or through the tendons of the transversalis and internal oblique, where
the hernia is direct. Now, this constriction might be divided in any
direction were it not for the risk of wounding the epigastric artery,
and also of injuring the spermatic cord, which is in close relation to
the neck of the sac of an oblique hernia.
Wound of the epigastric artery is the chief danger, for in _all_ cases
it is close to the neck of the sac. Were its position in relation to the
neck of the sac constant, it might be easily avoided by an incision in
the opposite direction; but as this relation varies according to the
nature of the hernia, an element of danger is introduced. Thus, in
oblique inguinal ruptures, where the sac passes out through the internal
ring (Fig. XXXII. IR), the artery will always be found to the inside of
the neck of the sac; while in direct herniæ, where the bowel has made
its escape through the triangle of Hesselbach (Fig. XXXII. +), and
passed through the conjoint tendon straight to the external ring, the
epigastric artery will be found on the outside of the neck of the sac.
In recent herniæ the differential diagnosis is comparatively easy, but
in those of old standing and large size, in which the obliquity of the
canal has been much diminished, it is almost impossible to tell of what
kind the hernia originally was, and consequently to determine in which
direction it is safe to incise the neck of the sac.
Such being the case, the best rule is to incise the neck of the sac
directly upwards, _i.e._ in a line parallel with the linea alba, and
also to cut it very cautiously bit by bit, in every case, if possible,
with the finger inserted as a guide to the position of a vessel and a
protection to the gut.
The spermatic vessels lie sometimes behind, sometimes on either side of
the sac, and in very old herniæ may be separated from each other so as
really to surround the sac. The cut directly upwards is also the safest
for them.
All constrictions being overcome, it is not sufficient merely to push
back the gut into the belly. Its condition must be carefully examined,
and it must be decided whether the constriction has caused gangrene or
not. To examine this properly, it is generally best to pull down an inch
or two more of the gut, so as thoroughly to bring into view the
constricted portion, as _it_ is most likely to be fatally nipped.
It is not always easy to decide as to the condition of the bowel.
Certain points must be observed:--
(1.) _Colour._--There may be very great alteration in the colour of the
bowel from congestion, and yet no gangrene. It may be dark red, claret,
purple, or even have a brownish tint, and yet recover; where it is
black, or a deep brown, the prognosis is unfavourable.
(2.) _Glistening._--So long as the proper glistening appearance of the
bowel remains, there is hope for it, even when the colour is bad; if it
has lost it, and especially if, instead of being tense and shining, it
is dull and flaccid and in wrinkles, the bowel is almost certainly
gangrenous.
(3.) _Thickness._--If much thickened, and especially if rough on the
surface, the bowel has probably been forming adhesions to the sac, or to
contiguous coils, and the prognosis is less favourable.
(4.) _Smell._--The peculiar gangrenous odour on opening the sac is very
characteristic. In cases where ulceration and perforation have occurred,
the odour is fæcal.
1. If, then, the bowel is tolerably healthy-looking, though discoloured,
it should be returned gradually, not _en masse_, into the abdomen, the
wound sewed up, and a pad of lint put on, with a bandage.
2. If there are adhesions of bowel to sac or to a neighbouring coil, or
of omentum to sac, the stricture should be freely divided, the
protruding coils of intestine should be emptied of their contents, but
no rash attempt made to force their return. Especially is this rule to
be observed with protruded, swollen, or adherent omentum, for
considerable risks attend any attempt at excision of the protruded
portion--risks of hæmorrhage, peritonitis, and ulceration of the
contiguous bowel.
If the bowel be returned, or even the continuity of the canal restored
by the cutting of the stricture, though the bowel be not returned, no
great risks accrue from the retention of a piece of omentum in the sac,
in a position which it may possibly have already occupied for years.
3. If the bowel is absolutely gangrenous, even in a very small portion
of its length, no reduction should be attempted, but the gangrenous
portion should be kept outside, with the hope that adhesive inflammation
may be set up, so as to glue the bowel to the abdominal wall, prevent
fæcal extravasation, and form a temporary artificial anus. If the
gangrenous portion be very full of fæces or flatus, incisions may be
made into it. This should be avoided in cases where the patient is
already much prostrated, as I have seen cases in which the opening of
the bowel seemed to inflict a fatal shock.
Enterectomy or excision of the gangrenous portion has recently been
recommended and performed by some surgeons. The very high authority of
the late Professor Spence is against such procedure.[143]
Cases of gangrene of even large portions of bowel are by no means
necessarily fatal. They may recover with an artificial anus, the remedy
of which by surgical means we must notice in its proper place.
OPERATION FOR STRANGULATED FEMORAL HERNIA.--While the general principles
guiding treatment and ruling the conduct of the operation are the same
as in inguinal, there are some differences in points of detail which
render a brief separate description necessary.
A single word on the anatomy. Tracing a femoral rupture from within
outwards, we find that its first stage is to push its way through
the weak point of the arch formed by Poupart's ligament, that is,
the spot called the crural arch, bounded on its outer side by the
sheath of fascia which surrounds the femoral vein; above by
Poupart's ligament; on its inner side by the curved fibres of
Poupart's ligament, which, curving backwards, are inserted into the
ilio-pectineal line, have a sharp falciform edge, and have been
dignified by the special name of Gimbernat's ligament (Fig. XXXII.
G); and below by the os pubis itself. This arch or ring thus
bounded is, in the normal state of parts, filled by a layer of
fibrous texture, a little fat, and occasionally a small gland.
These parts are pushed forwards in the descent of the hernia, and
in a small recent one may be said to form a sort of inner covering;
in a larger and older one they are split by the hernia, and, while
forming a constriction round its neck, leave the fundus of the sac,
so far as they are concerned, quite uncovered.
A femoral hernia may stop there, satisfied with merely coming
through the ring, and, if sudden and recent in a healthy, well-knit
subject, such a rupture is exceedingly dangerous, the constriction
being very severe, and the consequent gangrene of the bowel very
rapid if unrelieved. In most cases, however, it makes its way still
further out, and the next covering it gains is from the cribriform
fascia. This is the layer of fibres, pierced (as its name implies)
with orifices for the passage of veins and lymphatics, which
stretches between the two curved edges of the saphenous opening. It
varies much in strength; when the rupture has been slow and
gradual, it will certainly add a covering of greater or less
thickness, but where the hernia is large and old we must not expect
to find many traces of the cribriform fascia, at least over the
fundus of the tumour.
The ordinary superficial fascia of the part, with its fat, nerves,
veins, and lymphatics, and the thin skin of the groin, are the only
remaining coverings. It is very remarkable how exceedingly thin all
the so-called coats become in large femoral herniæ of long
standing, especially in thin old people.
_Operation._--Various incisions are recommended. The one which gives
freest access and exposes the sac best, is shaped like a T, the
horizontal limb of which is oblique, the direction of the obliquity
varying on the two sides. The horizontal incision should be made just
over Poupart's ligament, and parallel to it, the centre of the incision
corresponding to the neck of the sac, and its length varying according
to the size of the tumour and the depth of the parts; the other should
extend downwards from the centre of the former, as far as is necessary
to display the whole sac. The first should be made by pinching up and
transfixing the skin, the second by ordinary incision, to the same depth
as the first. The small flaps thus made must now be thrown back; any
vessels that have been divided are to be tied. Now, with great care and
caution the surgeon is to pinch up and divide any layers of condensed
cellular tissue which may still cover the sac, till it is thoroughly
exposed to its full extent, and remove any glands which may intervene.
The neck of the sac being exposed, it may be possible in some very
exceptional cases to give the patient the benefit of the minor
operation, which consists in leaving the sac unopened. In such a case
(to be described immediately), the surgeon passes his finger along the
neck of the sac as far as possible into the ring, and then with a
probe-pointed bistoury very cautiously nicks the upper edge of
Gimbernat's ligament, in one or more places, being careful to feel for
any pulsation before dividing a single fibre. He may then be able to
empty the sac of its contents, and return the bowel and omentum, still
retaining the sac outside.
On the other hand, where it is determined to open the sac, the pinching
up of the sac must be managed with great care, to avoid injury of the
bowel. There is generally a little fluid to be found at the fundus,
which will protect the bowel. In one case in which Liston operated, he
tells us, "there was no possibility of pinching up the sac, either with
the fingers or forceps; it contained no fluid, and was impacted most
firmly with bowel; very luckily the membrane was thin; and, observing a
pelleton of fat underneath, I scratched very cautiously with the point
of the knife in the unsupported hand, until a trifling puncture was
made, sufficient to admit the blunt point of a narrow bistoury."[144] If
the sac contains bowel and omentum, it is safer to open it over the
omentum than over the bowel. When a small opening is made, an escape of
the contained fluid takes place, and then the sac should be slit up as
far as its neck by a probe-pointed bistoury, guided by the finger,
introduced to protect the bowel, whenever the opening is sufficiently
large. The forefinger must now be cautiously insinuated into the neck of
the sac, the nail being directed to the bowel, the pulp to the
crescentic margin of Gimbernat's ligament, and any constriction very
cautiously divided. The bowel should then be drawn down a little, the
constricted point carefully examined, and then returned or not,
according to its condition.
Two points require a brief separate notice:--
1. In what direction is the crural arch to be divided? Not outwards
certainly, on account of the vein, nor downwards, as the bone prevents
that direction. Is it to be upwards or inwards? Not upwards, for such
an incision would endanger the spermatic cord or round ligament, besides
greatly weakening the abdominal wall by the division, partial or
complete, of Poupart's ligament. Inwards then it must be; and little
more need be said about it, were it not for the occasional existence of
an abnormal course and distribution of the obturator artery.
[Illustration: FIG. XXXII.[145]]
The usual origin of this vessel is from the internal iliac, in which
case (Fig. XXXII. N O) it never comes near the sac at all. In certain
cases (1 in 3-1/2) it rises from the epigastric, and in a very few (1 in
72) from the external iliac. If rising from either of the two last, it
most commonly passes downwards at the outer side of the hernia, in which
case (Fig. XXXII. S O) no harm can possibly result; but in a few rare
cases, perhaps 1 in every 60 of those operated on, the vessel winds
round the hernia (Fig. XXXII. O), crossing at its inner side, and thus
may be (and has actually been) divided by a rash incision. With due
care, however, and by cutting a very little at a time, even this danger
may be avoided.
2. Under what circumstances is it possible or justifiable to reduce a
femoral hernia, without previously opening the sac? Only in certain very
select cases, where the hernia is recent, the constricting parts lax,
the general symptoms very mild, and where there is reason to believe the
bowel has completely escaped injury by compression or the taxis. There
are both difficulties and dangers in this so-called minor operation:--1.
_Difficulties_, For it is not easy to divide the constriction without
the assistance of the finger in the sac, and it is not easy to reduce
the contents with the sac unopened, except through a much freer opening
than is necessary when the bowel has been fairly exposed. 2. _Dangers_,
Of reducing sac and viscera, together with the strangulation still kept
up by tightness in the neck of the sac; or of supposing the sac is
emptied while a knuckle of bowel still remains in it, and is
strangulated; or, lastly, of reducing the intestine which has already
become gangrenous. It is very remarkable how very soon gangrene may come
on, in a case of a small recent femoral hernia, in which the fibrous
tissues constricting the neck of the sac are tense and undilatable. A
protrusion for eight hours has been sufficient to destroy the life of a
knuckle of bowel.
A note here on a certain condition very frequent in femoral herniæ,
which may occasionally give a good deal of trouble. Symptoms of
strangulation have been well marked, yet when the sac is opened
nothing is to be seen except a mass of omentum, perhaps tolerably
healthy-looking. To reduce this _en masse_ would be very unsafe;
it is necessary carefully to unravel it, and disengage the knuckle
of bowel which is almost certainly included in it, and which has
given rise to the symptoms of strangulation.
OPERATION FOR STRANGULATED UMBILICAL HERNIA.--The operation is
practically the same, whether the hernia is a true umbilical one, or one
which with more strict accuracy might be called ventral. True umbilical
hernia is a disease of infancy and childhood, being almost always
congenital, and the viscera protrude through the umbilical aperture.
This rarely requires operation, as it may generally be returned with
ease, and even cured by a proper bandage and compress. Ventral hernia,
commonly called _umbilical_, is generally a protrusion of viscera
through a new preternatural aperture in the fibrous tissues close to the
navel, may often attain a large size, is liable to strangulation, and is
not easily palliated or cured.
In either case the operation requires a very brief description. If the
hernia is small, under the size of a hen's egg, a crucial incision
through the thin skin which covers it will thoroughly expose the sac
when the flaps are dissected back. The forefinger should then be
inserted in the round opening, and the edges cautiously incised in
several directions, each incision however being very small.
If the rupture is large, a single linear, or a T-shaped incision,
exposing the base of the tumour, will be sufficient to allow the
requisite dilatation of the opening to be made. It is not at all
necessary in every case to open the sac of the peritoneum. If required,
it must be done with great caution, as the sac is generally very thin.
In cases where the hernia is chiefly omental, the sac should be opened,
lest a knuckle of bowel be inclosed and strangulated in the omentum.
OBTURATOR HERNIA is an extremely rare lesion, and a large proportion of
the recorded cases were discovered only after death. When diagnosed
during life and strangulated, some have been reduced by taxis, and only
a very few cases have been operated on, some with success. It is not
likely that a diagnosis could be made, except in very emaciated
patients, in whom pain at the obturator foramen was a prominent symptom,
and in whom it could be ascertained positively that the crural ring was
empty. An incision over the tumour, sufficient to allow the pectineus
muscle to be exposed and divided, is necessary. The hernia may then be
reduced without opening the sac, if recent; if of long standing, the sac
must be opened. One case is recorded by Dr. Lorinzer, in which, after
strangulation for eleven days, he opened the sac and found the bowel
gangrenous. The patient had a fæcal fistula; but survived the operation
for eleven months. Nuttel, Obrè, and Bransby Cooper have each diagnosed
and treated such cases.[146]
Other forms of hernia are so rare, and the treatment of each case must
necessarily vary so much in its circumstances, as not to require or
admit of any detailed account of the operations requisite for their
relief.
OPERATIONS FOR THE RADICAL CURE OF HERNIA.--The inconveniences and
discomfort caused by even the best-adjusted trusses or bandages, the
unsatisfactory support they afford, and the risk of their slipping and
allowing the hernia to escape, have given rise to many attempts to cure
hernia by operation.
Even to enumerate these would be quite beyond the limits of the present
volume; suffice it to classify a few of the most important of them
according to the principle involved in each, and then give a very brief
account of the method of operating which seems to be at once the most
scientific, least dangerous, and most permanently useful.
The question at issue is briefly this. We have, in a hernia, the
following condition:--The walls of a great cavity are at one or more
points specially weak, the contained viscera have protruded, either by
extension and stretching of a natural opening, or by the formation of a
new breach in the walls, and, in protruding, they have brought with them
as a covering a serous membrane, extremely extensible, highly sensitive
to injury, and, when injured, certain to resent it by severe, spreading,
and dangerous inflammation.
Do we desire to remedy this protrusion, we may act--
1. On the intestines themselves; but for all surgical purposes, they are
out of our reach. We cannot do more than, by diminishing their contents,
diminish their volume, and by position and rest reduce to the utmost
their tendency to protrude. This includes the medical and prophylactic
treatment of hernia, or rather of the tendency to hernia.
2. We may try what can be done with the _sac_ which the intestines have
pushed down before them. Can it be obliterated? If it can, perhaps the
intestines may be retained in their cavity. Very many plans of dealing
with the sac have been tried.
To cause obliteration of its cavity many methods have been proposed:--by
ligature of it along with the spermatic cord, involving loss of the
testicle, either by gradual separation, by sloughing, or by immediate
removal;--by cutting into it, and then stitching it up;--by constricting
it with wire, as in the _punctum aureum_; by pinching sac and coverings
up, by passing needles under them as they emerge from the external ring,
as Bonnet of Lyons did; by constricting sac alone with a double wire, by
subcutaneous puncture, as Dr. Morton of Glasgow has done;--by severe
pressure from the outside with a strong tight truss and a pad of wood,
as proposed by Richter; by setons of threads or candlewicks, as proposed
by Schuh of Vienna;--by injection of tincture of iodine or cantharides,
as by Velpeau and Pancoast;--by the introduction into the sac of thin
bladders of goldbeaters' skin, which were then filled with air, and were
intended to excite inflammation, as in the radical cure of hydrocele; or
by the still more severe method of Langenbeck, consisting in exposing
the sac by a free incision at the superficial ring, separating it from
the cord, and passing a ligature round the sac alone, leaving the
ligatured portion in the scrotum either to become obliterated or to
slough out. Schmucker of Berlin varied this, by cutting away the
constricted portion below the ligature.
The objections to these methods are various: the more gentle are
uncertain and inefficient; of the more severe, some involve mutilation,
by the loss or removal of the testicle; others, as those of Langenbeck
and Schmucker, are very dangerous and fatal, by the inflammation
spreading to the peritoneal cavity (20 to 30 per cent. died); while all
of these methods afford at best only temporary relief. And this is only
what might have been expected, for the sac was only a _result_ of the
protrusion, not a _cause_; and so long as the weakness and insufficiency
of the parietes of the abdomen remain, so long will the extensible
loosely-attached peritoneum continue to furnish new sacs for visceral
protrusions.
3. We have now only the canal left to act upon; and the operations on
the canal may be divided into two great classes:--
(_a._) Those in which the operator attempts to plug up the dilated
canal. (_b._) Those in which he tries to constrict it, by reuniting its
separated sides.
(_a._) Attempts to plug the canal have, in most cases, been made by
invagination of the skin of the scrotum and its fascia. These have been
very numerous and various in their adaptation of mechanical appliances,
but have all been designed with the same object. Dzondi of Halle, and
Jameson of Baltimore, incised lancet-shaped flaps of skin, and
endeavoured to fix them by displacement over the ring. Gerdy invaginated
a portion of scrotum and fascia into the enlarged canal, by the
forefinger pushed it up, and secured it in its place by a thread passed
from the point of his finger first through the invaginated skin, then
through the abdominal walls, endeavouring to include the walls of the
inguinal canal, causing the point of the needle to project some lines
above the inguinal ring; the same process being effected with the other
end of the thread on the other side of the finger, and the two ends
which have been brought out near each other on the abdominal wall, being
tied tightly over a cylinder of plaster. The ensheathed sac was then
painted with caustic ammonia to excite inflammation, and a pad put on
over all.
Signoroni modified this by fixing the invaginated skin by a piece of
female catheter, retained in its place by transfixion by three harelip
needles, tied by twisted sutures.
Wützer of Bonn, again, modified this, by substituting a complicated
instrument, consisting of a stout plug in the inguinal canal, held in
position by needles which are passed through the anterior wall of the
canal in the groin. Compression between plug and compress, with the
intention of causing adhesion between skin, fascia, and sac, is then
managed by means of a screw. The plug is retained for about seven days.
Modifications of this method have been tried by Wells, Rothmund, and
Redfern Davies, all aiming in the direction of simplicity; but by far
the most simple and efficacious method on the Wützer principle yet
devised is that of Professor Syme, which he described in the pages of
the _Edinburgh Medical Journal_ for May 1861, in which the invagination
of integument is both simply and securely managed by strong threads, as
in Gerdy's method, while a piece of bougie or gutta-percha, to which
the threads are fixed, replaces Wützer's expensive and complicated
apparatus. Sir J. Fayrer of Calcutta has had a very large experience of
Wützer's method, and also of a plan of his own. Out of 102 cases by the
latter method, 77 were cured, 9 relieved, 14 failed, and 2 died.[147]
Mr. Pritchard of Bristol has proposed an additional step in operations
on the invagination principle, consisting in the stripping of a thin
slip of skin from the orifice of the cutaneous canal, and then putting a
pin through the parts to get them to unite, and thus close the aperture
completely.
Now, what results follow these operations? At first they are almost
invariably successful, but the complaint is that, in most cases, the
rupture recurs. The principle is to plug up the passage by the
mechanical presence of the invaginated skin, the plug being retained in
position by adhesive inflammation between it and the edges of the
dilated ring. But the ring is left dilated, or, indeed, generally its
dilatation is increased; and as, on continued pressure from within, the
new adhesions give way, or, as often happens, a new protrusion takes
place in the circular _cul-de-sac_ necessarily left all round the apex
of the invagination, the still lax ring and canal offer no resistance to
the protrusion.
(_b._) The principle of constriction of the canal by reuniting its
separated sides. This is the principle of the various methods introduced
by Mr. Wood of King's College, and described by him in his most able and
exhaustive work.[148]
He applies sutures through the sides of the dilated inguinal or crural
canals, or umbilical openings, in such a manner as to insure their
complete closure.
1. _For inguinal hernia._--To stitch together the two sides of the canal
with safety requires attention to several points--(1.) That it be done
nearly, if not entirely, subcutaneously. (2.) That the protruding bowel
should be kept out of the way, and not be transfixed by the needle. (3.)
That the spermatic cord should be protected from injurious pressure.
These different indications are attained by Mr. Wood by a very ingenious
mode of operating, which I can describe here only briefly, and for a
full description of which I must refer to Mr. Wood's own monograph
already alluded to.
For his first twenty cases Mr. Wood used strong hempen thread for the
stitches; of late, however, he has proved the greater advantage of
strong wire.
When a large old hernia in an adult is the subject of operation, it is
thus performed by Mr. Wood:--The pubes being shaved, and the patient put
thoroughly under the influence of chloroform, the rupture is reduced,
and the operator's forefinger forced up the canal so as to push every
morsel of bowel fairly into the abdomen. An assistant then commands the
internal ring by pressure, to prevent return of the rupture.
An incision is made in the scrotum over the fundus of the sac, large
enough to admit a forefinger and the large needle used in the operation;
the edges of the skin are to be separated from the fascia below for
about one inch all round. The forefinger is then to be passed in at the
aperture and pushed upwards, invaginating the detached fascia before it,
and it must be made to enter the inguinal canal far enough to define the
lower border of the internal oblique muscle stretched over it. A large
curved needle (unarmed) is then passed on the finger as a guide, through
the internal oblique tendon, the internal portion of the ring, and the
skin of the abdomen; it is then threaded and withdrawn. Again, the
needle (now with a thread) is guided by the finger and pushed through
Poupart's ligament and the external pillar of the ring as before; while
by a little manipulation its point is made to protrude through the same
opening in the skin as before, a loop of thread is now left there, and
the needle, still threaded, is again withdrawn. The next stitch, still
guided on the finger, takes up the tendinous layer of the triangular
aponeurosis covering the outer border of the rectus tendon close to the
pubic spine; the point of the needle is then turned obliquely, so as to
protrude through the original puncture in the skin a third time, the
needle is then freed from the thread and withdrawn, thus leaving two
ends and one intermediate loop of thread all at the one opening. These
are so arranged that when they are tightened they draw together the
sides of the canal; they are then secured over a compress of lint. The
compress is removed and the stitches loosened, at dates varying from the
third to the seventh day.
Mr. Wood now uses wire instead of thread. It has the advantage of
greater firmness, excites less suppuration, and may be left much longer
_in situ_, in consequence of which there is less risk of suppuration or
pyæmia, and more chance of a good consolidation of the parts.
In congenital herniæ, and small ruptures in children and young
boys, Mr. Wood uses rectangular pins in the following manner:--The
scrotum being invaginated (without any incision through the skin)
as far as possible up the canal, a rectangular pin, with a
slightly-curved spear-pointed head, is passed through the skin of
the groin to the operator's forefinger; guided by it, it is brought
safely down the canal, and brought out through the skin of the
scrotum just over the fundus of the hernial sac. A second pin is
passed from the lower opening (still guided by the finger) in an
upward direction, transfixing in its course the posterior surface
of the outer pillar of the superficial ring, its point being
brought out through, or at least close to, the first puncture made
by the first pin. The pins are then locked in each other's
loops--the punctures and skin protected by lint or adhesive
plaster,--and the whole is retained by lint and a spica bandage.
The pins should generally be withdrawn about the tenth day.
The author has now in many cases stitched with catgut the edges of the
ring after the ordinary operation for hernia with the best effect.
2. _For Femoral Rupture._--Cases suitable for operation are very
infrequent; but should such a one be met with, Mr. Wood proposes the
following operation on the same plan as the preceding. The hernia being
fully reduced and the parts relaxed by position, an incision about an
inch long should be made over the fundus of the tumour, and its edges
raised so as to admit the finger fairly into the crural opening. The
vein is then to be pushed inwards, and the needle passed through the
pubic portion of the fascia lata of the thigh, and then through
Poupart's ligament, appearing on the skin of the abdomen, a wire is then
passed through the eye of the needle and hooked down, appearing through
the wound, it is then withdrawn, and the needle again passed through the
pubic portion of the fascia lata, but about three-quarters of an inch to
the inside of the first puncture, then through Poupart's ligament again,
and protruded through the same orifice in the skin; the other end of the
wire is then hooked down as before, leaving a loop above, at the needle
orifice, and two ends at the wound in the skin below. Both loops and
ends must be managed as before.
The author after operating for the relief of strangulation in a
case of very large femoral hernia in a girl aged 23, stitched up
the neck of the sac, and also stitched it to Gimbernat's ligament.
The result for some months was admirable, though the hernia had
been a very difficult one to replace from its size, and had been
long in the habit of coming down. Eventually protrusion occurred to
a very slight extent, but a truss keeps it completely up.
3. _For Umbilical Rupture._--The principle involved in Mr. Wood's
operation for umbilical rupture is precisely the same as for inguinal
and crural. It consists in stitching the two edges of the tendinous
aperture by wire; the needle is passed on a sort of small scoop or
broad grooved director, which at once invaginates the skin and protects
the bowel. Two stitches are thus inserted on each side. For the
ingenious method by which they are introduced subcutaneously, I must
refer to the detailed description in Mr. Wood's monograph. The wires are
thus twisted and tightened over a pad of lint or wood, drawing together
the edges of the opening in the tendon.
OPERATIONS FOR ARTIFICIAL ANUS.--In children the condition known as
imperforate anus may sometimes be remedied by exploratory operations in
the perineum, guided by the protrusion caused by the distended
intestine. There are other cases, however, in which the rectum, as well
as the anus, seems to be deficient, and in which, from the want of
protrusion, there is no warrant for attempting an operation there; in
these the only chance of life that remains is in an attempt to open the
bowel higher up.
In adults, again, absolute closure of the rectum and anus, and complete
obstruction, may be the result of malignant disease, or even, very
rarely, of simple organic stricture.
In such cases, where the patient is tolerably strong and yet evidently
doomed from the complete obstruction, an attempt at the formation of an
artificial anus is warrantable, and in many cases afford great relief,
and prolongs life for months.
Without going into all the various positions proposed for such
operations, I select the two most warrantable, which have borne the test
of experience. These are--1. Colotomy in the left loin. This is
applicable in the case of adults with rectal obstruction. 2. Colotomy in
the left groin applicable in cases of imperforate anus and deficiency of
rectum in infants.
1. _Colotomy in the left loin_, generally known by the name of
_Amussat's operation_.--The patient is laid upon his face, a pillow
placed under the abdomen, rendering the left flank prominent. A
transverse incision should then be made at a level about two
finger-breadths above the crest of the ilium, extending from the outer
edge of the erector spinæ muscle forward for four or five inches,
according to the fatness of the patient; the muscles must then be
carefully divided till the transversalis fascia is exposed. It is then
to be pinched up and divided, as in the operation for strangulated
hernia. The muscular wall of the colon uncovered by peritoneum is then
in most cases very easily recognised from its immense distension. The
bowel should then be hooked up by a curved needle, two or three points
at least secured to the margins of the wounds by stitches, and then the
bowel should be opened by a longitudinal incision of at least an inch in
length. When the distension has been great, there is generally a rush of
fluid fæces, which must be provided for, special care being taken lest
any get into the cavity of the peritoneum.
[Illustration: FIG. XXXIII.[149]]
2. _Colotomy in the left groin_, for absence of anus and deficiency of
rectum in newly born infants.--The dissections of Curling, Gosselin, and
others have shown that in infants the operation of lumbar colotomy is
very difficult, and its results uncertain, while it is comparatively
easy to open the colon in the left groin. Huguier, again, has shown that
in certain cases the colon is not to be found in the left groin, but is
accessible in the right groin. This abnormality seems, as shown by
Curling, to occur not oftener than once in every ten cases.
_Operation._--An oblique incision from an inch and a half to two inches
in length should be made in the left iliac region above Poupart's
ligament, extending a little above the anterior-superior spinous process
of the ilium. The fibres of the abdominal muscles should be divided on a
director passed beneath them, and the peritoneum should next be
cautiously opened to a sufficient extent. The colon will most likely
protrude, but if small intestine appear the colon must be sought for
higher up. A curved needle armed with a silk ligature should be passed
lengthways through the coats of the upper part of the colon, and another
inserted in the same way below, and the bowel, being drawn forwards,
should then be opened by a longitudinal incision. The colon must
afterwards be attached to the skin forming the margin of the wound by
four sutures at the points of entry and exit of the needles.
OPERATION FOR THE REMOVAL OF AN ARTIFICIAL ANUS, in cases where the
bowel is patent below.--After the operation for hernia in a case where
the bowel is gangrenous, the only hope of the patient's recovery
consists in the formation of adhesions between the bowel and the
external wound, and the presence, for a time at least, of an artificial
anus. If adhesions do form, and the patient recovers, it becomes a
matter of great importance for his future comfort that the canal of the
intestine should be re-established, and the fistulous opening allowed to
close. This, however, is by no means easy, as even when the portion of
intestine destroyed has been very small, a septum or valve remains which
directs the contents of the bowel outwards, and so long as it exists is
an effectual obstacle to any of the fæcal contents passing into the
distal portion of the bowel. This septum or éperon is formed by the
mesenteric side of the two ends of the bowel. To destroy this without
causing peritonitis is the aim of the surgeon, and it is not an easy
matter to accomplish. To cut it away would at once open the peritoneal
cavity, so the mode of treatment now adopted in the rare cases where it
is necessary is that recommended by Dupuytren. The principle of it is to
destroy the éperon by pressure so gradual as to cause adhesive
inflammation between the two surfaces, and thus seal up the cavity of
the peritoneum, before the continuance of the same pressure shall have
caused sloughing of the septum. This is managed by the gradual
approximation by a screw of the blades of a pair of forceps, to which
Dupuytren gave the name Enterotome. The process, which extends over days
and weeks, must be carefully watched lest the inflammation go too far.
Plastic operations are occasionally required to close the opening after
the passage is restored. For a good example of such an operation see
_Edin. Med. Journal_ for August 1873, in which Mr. John Duncan describes
a case.
FOOTNOTES:
[141] _Description of Sir Spencer Wells's Trocar._--"It consists of a
hollow cylinder six inches long, and half an inch in diameter, within
which another cylinder fitting it tightly plays. The inner one is cut
off at its extremity, somewhat in the form of a pen, and is sharp. The
sharp end is kept retracted within the outer cylinder by a spiral spring
in the handle at the other end, but can be protruded by pressing on this
handle when required for use. When thus protruded it is plunged into the
cyst up to its middle; the pressure on the handle is taken off, and the
cutting edge is retracted within its sheath. The fluid rushes into the
tube, and escapes by an aperture in the side, to which an india-rubber
tube is attached, the end of which drops into a bucket under the table.
The instrument is furnished at its middle with two semicircular bars,
carrying each four or five long curved teeth like a vulsellum. These
teeth lie in contact with the outer surface of the cylinder, but can be
raised from it by pressing two handles. When the cyst begins to be
flaccid by the escape of the fluid, these side vulsellums are raised,
and the adjoining part of the cyst is drawn up under the teeth, where it
is firmly caught and compressed against the side of the tube."
[142] For further details on the operations described above, reference
may be made to Sir Spencer Wells's work on ovarian disease, and to the
very valuable papers contributed by Dr. Thomas Keith to the _Edinburgh
Medical Journal_. To the latter especially the author is indebted for
much oral instruction, and for the opportunity of seeing his careful and
dexterous mode of operating.
[143] _Lect. on Surgery_, 3d ed., vol. ii. p. 998.
[144] _Operative Surgery_, p. 462.
[145] Rough diagram of abnormal course of obturator and its relation to
the neck of a hernia. Parts seen from the inside: H, femoral hernia; A,
femoral artery; V, femoral vein; E, epigastric artery; O, obturator from
epigastric (dangerous); S O, obturator from epigastric (safe); N O,
normal course of obturator; I R, internal inguinal ring; Sp C, spermatic
chord and its vessels; G, Gimbernat's ligament; +, in triangle of
Hesselbach.
[146] Holmes's _Surgery_, 3d ed., 1883, vol. ii. p. 837.
[147] _Clinical and Pathological Observations in India_, pp. 44, 325.
[148] Wood _On Rupture_, 1863.
[149] Diagram of an artificial anus, showing small sutures which unite
the edges of the gut and the skin, and the large ones stitching up the
wound beyond.