artificial anus after hernia than after wounds. If the opening in the
bowel be near the stomach, the patient will die from inanition. When
it is lower in the intestinal tube, nutrition is more perfect, and the
patient can be further supported by nutritive enemata. When no natural
cure is likely to take place, the inconvenience will be palliated by
a truss with a soil pad being worn, so as to retain the feces till a
favourable opportunity occurs for evacuation; or a soft plug of lint
may be inserted into the aperture, and retained by a compress and
roller. Prolapsus of the mucous membrane of the gut sometimes takes
place through the artificial anus, and is reduced with difficulty. The
use of a truss or tent, already mentioned, will tend to prevent the
occurrence. Great attention to cleanliness is required when the opening
cannot be closed.
Operations for other kinds of hernia, if discovered during life, are to
be conducted on similar principles with those for inguinal and crural.
The surgeon must be guided by his anatomical knowledge. No positive
rules can be given.
In _Ascites_, or accumulation of fluid in the peritoneal cavity, the
surgeon is not unfrequently called upon to relieve the patient, when
the abdominal parietes are much distended, and the functions of the
viscera of the abdomen and thorax interrupted. He must, however,
exercise his own judgment in regard to the case, and convince himself
of the propriety of operating. He must examine into the symptoms, and
ascertain that the tumour is really caused by accumulation of fluid
in the bag of the peritoneum. In ascites, the abdomen has swelled
slowly and uniformly, and distinct fluctuation is felt when the hand
is placed on one side of the swelling, and gentle tapping made at the
other. There is considerable difficulty of breathing, uneasiness in the
abdomen, usually increased by pressure, thirst, and scanty secretion
of urine. It ought to be remembered that other affections have been
confounded with ascites, and lamentable operative mistakes committed in
consequence. Trocars have been thrust into the belly for tympanitis,
either of the bowels or of the peritoneum—for solid tumours of the
viscera—for enlargement of the ovaria.
As already hinted, the operation of tapping the abdomen is to be
undertaken only when the distention is very great, when the functions
of the thoracic and abdominal viscera are interfered with, and when
diuretics, and other means of getting rid of the fluid, have failed to
diminish the accumulation. The trocar employed is either flat, with
a spring steel canula, or round; when the latter is used, and the
abdominal parietes are not very tense, a small incision is first made
with a lancet or bistoury; a large trocar with blunted edges and point
can then be readily and safely introduced; the flat one enters easily,
and requires no previous wound, but does not permit so rapid and free
a flow. The point usually chosen for the puncture is either in the
linea alba, a little below the umbilicus, the bladder being previously
emptied,—a precaution which should always be attended to, though in
general there is little danger of wounding this organ—or midway betwixt
the superior anterior spinous process of the ilium and the umbilicus,
with the view of penetrating the parietes in the linea semilunaris. The
latter situation, however, can seldom be obtained with accuracy, for
the parietes yield irregularly. Little bleeding follows the puncture at
either point; but the risk of hemorrhage is greater at the latter, for
branches of the circumflex artery may be wounded. More serious bleeding
is liable to occur, from the veins ramifying on the abdominal viscera
giving way, on removal of their support, as the serum flows off.
Fainting, also, may take place from accumulation in the branches of the
vena portarum, unless the fluid is withdrawn slowly, and the precaution
adopted of supporting the parietes with a broad band both during and
after evacuation. Bandages are made for this purpose, with tapes and
straps attached, and are well fitted for it. Three or four yards of
flannel, however, with each end split, are equally effectual, and can
always be readily obtained—a consideration of consequence in the choice
of all apparatus. After the band has been applied, a person is placed
on each side to tighten it gradually by steady pulling at the ends,
which are carefully crossed behind. An opening is made in the cloth,
opposite to where it is proposed to puncture, and the operation is then
proceeded in. Sometimes the flow is impeded by the omentum or a fold
of bowel falling forward on the canula, and closing or diminishing the
opening; this is remedied by passing a tube along the canula, closed
at the extremity, but perforated at the sides near it, and about half
an inch longer than the canula. After the cavity has been emptied, the
patient is placed recumbent, and a long broad flannel bandage applied
over the whole abdomen, and retained, so as to prevent shifting, by
straps passed over the shoulders and under the perineum.
Collections occur in the _ovaria_. The fluid is generally glairy,
sometimes thick and gelatinous, often turbid and dark coloured. Not
unfrequently the main cyst is subdivided, either by membranous septa,
or by an aggregation of smaller cysts of the nature of hydatids. The
swelling is at first on one side, and gradually rises out of the
pelvis; often it remains long moveable; it increases, becomes more
fixed, and ultimately fills the abdomen, displacing the viscera, and
giving rise to feelings of much uneasiness, deformity, and loss of
health. The cyst is generally thick; sometimes it is thin at one or
more points, and this may give way, causing effusion of the contents
into the peritoneal sac. Fluctuation is perceptible in many cases; in
others it is obscured by the thickness of the cyst and viscidity of its
contents. Many such swellings may be punctured both with advantage and
with safety, but generally the tapping requires frequent repetition.
Some patients require tapping, merely as a mean of improving the figure
and relieving uneasy feelings, once, twice, or thrice a year; their
existence is not much embittered or abridged by the disease. A large
round trocar is necessary for the purpose; and the puncture is made at
the softest and most prominent point of the tumour, a small incision
through the integument being premised.
The ovaria become enlarged by degeneration of their structure and the
addition of solid matter in great abundance. The consistence and
structure of such tumours are very various; they are sometimes, though
rarely, medullary, often fibrous, with or without cysts, sometimes
melanotic. In the majority there are cysts, varying in size, number,
and contents; sometimes the bag contains hydatids, or it is filled
with curdy matter, sometimes with glairy colourless fluid, sometimes
with a turbid and flaky serum, sometimes with blood; and in them, as
well as in the enlargement from accumulated fluid, though perhaps
more rarely, are occasionally found teeth, hair, and membranous
looking matter; some are intermixed with bone, cartilage, and fat.
The situation and attachments of such tumours cannot be correctly
ascertained by examination during life, far less can their internal
structure and dispositions be arrived at. Indeed an accurate diagnosis
is exceedingly difficult, if not impossible. Innumerable mistakes have
been made, which have led to most unjustifiable proceedings. In one
case, the abdomen was, after two or three dry tappings, opened by an
incision from the ensiform cartilage to the pubes; the viscera were
turned over and over, but no tumour could be discovered. The woman was
sewed up, and did not die. The following was a still more complete
failure in diagnosis. In a case of large tumour of the belly, many
persons accustomed to manipulate abdominal swellings considered that
extra-uterine conception had taken place; and that the child had come
to maturity and perished. The history of the case countenanced the
supposition; the symptoms had been such as indicate impregnation. The
woman, to avoid exposure, went to a distance to be relieved of her
burden, which was becoming more and more troublesome and bulky. The
usual period passed over. It was thought that the head and thorax of
an infant could then be felt readily through the parietes, and perhaps
some one might have been found heroic enough to have divided them and
explored the tumour. The young woman, however, was in the last stage
of phthisis, and soon died. A wonderfully tuberculated omentum, a very
small portion of which is here represented, filled the peritoneal
cavity; the uterus and its appendages were quite healthy.
[Illustration]
Operation has also been proposed, when, on dissection, the liver was
found to compose the abdominal swelling. Such cases, a long list of
which might be given, render the prudent surgeon very cautious in his
diagnosis of abdominal tumours, and chary of operative interference
with them. The abdomen has been opened, as already stated, and the
result has been such as to render the perpetrator indictable for
culpable homicide, and to qualify him for such punishment as his rash
and reckless conduct richly deserved. A less severe censure might have
sufficed, had not the example been followed by similar proceedings,
and equally direful results; and these have been such as to render any
condemnatory remarks not only justifiable but absolutely necessary. A
great many unfortunate women have, I am afraid, been sacrificed to a
desire for false reputation. The attempts to remove abdominal tumours
by incision of the parietes were some time ago very numerous; and,
as might have been expected, the issues were highly unsatisfactory
to those concerned. Such doings, however, were recorded in print,
represented in plates, and moreover puffed and placarded ad nauseam.
The majority of those who were thus “dissected, to see what part was
disaffected,” perished within forty-eight hours. One woman survived
for some time, after having been subjected to this _operation_,
improperly so termed. In her there was a tumour, but of such a size,
and so connected, that it could not be removed. A second survived
the extirpation of one ovarium; and the other, also diseased, was
left for a further exhibition of daring intrepidity. It is not easy
to conceive how the proposal could have been seriously entertained
by any sane individual, far less put in practice and persevered in,
when disaster after disaster crowned every attempt. It is my opinion,
and I believe that I express the sentiments of a very large portion
of the profession, that the repetition of any such incisions and
gropings would be unpardonable.—1. On account of the difficulty, nay,
impossibility, of forming a correct diagnosis; of ascertaining with
certainty what organ is involved; of ascertaining the structure and
disposition of the tumour, if any, and to what parts it is adherent.
2. Because the ovarian disease, in general, even though extensive,
does not threaten imminently a fatal termination, being slow in its
progress, and the greater number of the swellings being not of a
malignant nature. The solid tumours are sometimes of a bad kind, as
already stated; but enlargement by fluid is much more frequent in
the ovaria than that by solid and new matter. 3. If the tumour be
malignant, it will be impossible to ascertain to what extent the
parts are involved by the diseased action, or whether the lymphatics
are affected or not. There is a strong probability of the lymphatic
system being involved, even at a very early period; and then the
extirpation of the tumour—supposing the mass to be so situated as to
admit of removal without difficulty or danger—cannot be attended with
any advantage; in every point of view, therefore, interference is
unadvisable. 4. The operative attempt is attended with imminent danger.
There is almost a certainty of the patient being almost instantly
destroyed by it, as shown by the sad experience of the past. “We are
not the arbiters of life and death of those who apply to us for relief.
If people die in consequence of disease, it cannot be helped. They
submit to it because they know it is inevitable. But we had better
refrain from making such experiments as may probably destroy them, and
bring disgrace upon the profession.”
_Bruises_ of the abdomen are apt to be followed by inflammation of the
contained parts, particularly of the serous membrane. Occasionally
lacerations of the viscera, both solid and floating, but more
frequently of the former, are produced by bruising or squeezing of the
abdomen, as by a blow, or by a heavy body passing over; they may also
follow a violent concussion of the parts by falling from a height.
The liver is the organ most frequently torn, and death is commonly
the result, rapid, and principally from hemorrhage. The laceration is
generally on the convex surface; extravasation takes place under the
peritoneal covering; or this is torn, and the effusion is into the
abdominal cavity. When the quantity of blood is not so great as to
cause speedy dissolution, the patient may survive for some time, and
even ultimately recover. Reaction is slow, the patient continuing a
long time pale, exhausted, and almost pulseless; there is tenderness in
the hypogastric region, with swelling. The spleen is liable to similar
injury, and pours out a large quantity of blood.
The gall-bladder has sometimes been torn, as also portions of the small
intestines, by a blow or kick, or by a heavy body passing over the
abdomen, as the wheel of a loaded wagon. The escape of the contents is
followed by sickness, rigour, quick, weak, and indistinct pulse, most
excruciating pain, a sense of heat diffused all over the abdomen, and
rapid sinking of the powers of life; a fatal termination generally
occurs within twelve hours. The same train of symptoms supervene
when the contents of the intestinal canal have been effused into the
peritoneal cavity, through an opening in the stomach or bowel, caused
either by slow destruction of the coats, the peritoneum giving way
last, or by a rapid ulceration or sloughing process, as in hernia.
The patient may live in agony for a day or two, but death generally
takes place much within twenty-four hours. The same may be said of the
rupture of the bladder, from external violence, with effusion of urine
into the peritoneal sac. No treatment is of any avail; venesection
hastens the sinking. Fomentation over the abdomen, and sedatives either
by the mouth or by the anus, soothe the patient, and render his last
moments more calm.
Penetrating wounds of the peritoneal cavity, if they reach the solid
viscera and large vessels connected with them, are attended with
effusion of blood externally and internally, in quantities proportioned
to the size of the external aperture, the importance of the vessels
concerned, and the vascularity of the part. The patient may perish from
the bleeding, either instantly or after some time; or inflammation and
its consequences supervene in the violent form, and destroy him at a
more remote period. The mere opening of the peritoneal cavity, and to
a very slight extent, without the slightest injury of the contained
parts, is often attended with a great shock to the system, and is
followed by inflammatory action, which may run on to a fatal issue, in
spite of the most active and judicious management. The inflammatory
symptoms are to be combated by free abstraction of blood; in short,
the utmost endeavours must be made to keep the action within bounds.
When the intestines are wounded, the injured part may protrude; or the
relative size of the openings through the parietes and bowel may be
such, that the intestinal contents do not escape into the peritoneal
bag. A natural cure sometimes takes place by adhesion of the surface
of the bowel to the lining of the parietes round the wound, feculent
matter continuing to be discharged externally; after a time the
opening may contract, and the discharge diminish and ultimately
cease; or an artificial anus may be permanently established, and this
is not so easily cured as that following upon hernia. Wounds of the
intestines, whether transverse or longitudinal, attended with feculent
escape into the peritoneal cavity, are not uniformly fatal. Effusion of
lymph takes place around, gluing the wounded bowel to the peritoneal
surface of a neighbouring fold, or forming a sort of pouch within which
the extravasation is limited. The treatment consists in absolute rest,
and most rigid antiphlogistic regimen; manual interference with the
wounded part is not generally advisable.[46]
_Lumbar Abscess_ is generally chronic; the collection of matter is
gradual and slow. Sometimes it is acute, and rather rapid in its
appearance. It may originate in the sheath either of the psoas or of
the iliacus muscle; more frequently it seems to form behind these, and
is connected with diseased bone. The precursory symptoms are often
not particularly attended to; these are rigors and pain of the loins.
As the disease advances, the patient feels great pain in the erect
position, and in general the pain is aggravated by extending the thigh.
Thickening and slight glandular enlargement takes place in the groin;
there is an evident fulness there; and then swelling appears on the
inner side of the femoral vessels, beneath the pubal portion of the
fascia lata. This swelling is more prominent in the erect position,
and is also increased by exertion of the abdominal muscles; an impulse
is given to it on coughing. As it advances, and comes more to the
surface, fluctuation is perceived. This is the most common site in
which the abscess presents itself; but it is not unfrequently met with
on the outside of the vessels, either lower or higher in the thigh,
above Poupart’s ligament, in the loins over the crest of the ilium,
and occasionally the matter is insinuated under the pelvic fascia and
appears by the side of the anus. Large and neglected collections may
work their way to the surface in two or three of these situations at
the same time.
The disease is often attributable to a sprain or wrench of the loins,
or to exposure to cold and over-fatigue. Occasionally the mischief is
confined entirely to the soft parts; the vertebræ, a portion of the os
innominatum, or the sacrum, may be denuded and of irregular surface,
but this is evidently the result of the pressure of the abscess. A
striking example of this, and of the extensive destruction of parts
which this affection sometimes produces, may be shortly stated.—A very
large lumbar abscess formed within a few weeks, in consequence of
great and continued fatigue and exposure to bad weather. At first it
had been trifled with. At last it was opened in the usual situation in
the thigh, and a vast quantity of matter evacuated. Thirty-six hours
afterwards, the patient was suddenly suffocated by a flow of purulent
matter into and through the air passages. On dissection, the cavity
of the abscess was found to be immense, opening through the diaphragm
into the lung which was adherent, and communicating with the bronchi.
The forepart of the lumbar vertebræ was exposed, and in some parts
stripped of the theca; but there were no cavities in the bone, and no
disease of the interposed cartilages. Such cases are now and then met
with, of abscess in the loins not originating in any vice either of
the bones or of any other part of the apparatus of the spinal column.
Most frequently, however, the collections have their foundation
in ulceration of the bodies of the vertebræ. The patient has had
tenderness in the part, weakness of the back and of the lower limbs,
and increase of pain on pressing or striking some particular spinous
processes—perhaps slight excurvation. Then pain in extending the thigh
supervenes, followed by swelling and other signs of abscess. This is
preceded generally by deposit of tubercular matter in their cancellated
texture. Sometimes the disease seems to originate in the ligaments
and articulating surfaces; occasionally portions of the bone perish,
and are found lying in the cavity of the abscess, as seen in this
specimen, taken from a young subject. When the bodies of the vertebræ
are attacked by ulcerative absorption, and sometimes the disease is
very extensive, involving perhaps four, five, or six of the bones,
there is more or less curvature of the spine outwardly—excurvation.
If the disease affects one or two bones, and their bodies are almost
destroyed, then the projection is sharp and angular. When the disease
is more extensive the curve is greater, and more gradual ulceration
sometimes exists to a considerable extent in one articulation, without
change of form externally in the spinal column, and sometimes without
any great collection of pus. When curvature commences there is very
generally more or less weakness of the limbs, though curvature,
whether from ulceration or interstitial absorption, is by no means of
necessity attended by any degree of paralysis. The power of motion of
parts supplied by nerves in the neighbourhood of disease is diminished
earlier in general than the sensation, in consequence, possibly, of the
mischief commencing in the anterior part of the bodies of the vertebræ.
It is wonderful to what extent disease may extend in the vertebral
column, without much impairment of the functions of the spinal chord,
and how perfectly the functions are restored in cases where it has
suffered. The lumbar vertebræ are those most frequently affected,
but the ulceration may also be either in the dorsal region or in the
pelvis. Disease of the last lumbar vertebra at its connection with
the sacrum, or disease of the sacrum itself, is attended with abscess
around, which descends into the pelvis, displacing the bowel, and
appearing by the side of the buttock.
[Illustration]
[Illustration]
Such abscesses may have been allowed to come to the surface, and to
discharge their contents spontaneously; or they may have been at
a late period opened either at one point or at several. In these
circumstances, the discharge is generally profuse, long-continued, and
attended with exhaustion and hectic, gradually but surely destroying
the patient. But, by good management, a perfect and permanent recovery
may in many cases be obtained. When the vertebræ are affected, absolute
rest must be enjoined and enforced; and a drain is to be established
by the sides of the spinous processes, either by moxa, potass, or
seton—it is immaterial which. The discharge is kept up by occasionally
dressing the issue for a few hours with an acrid ointment, so as to
reproduce a slough. When the abscess begins to present, it should be
opened as early as possible, and a free exit allowed to the matter; the
discharge should be at no time confined. The opening of the cavity, and
again shutting it up, however carefully conducted, is in almost every
instance followed by alarming and hazardous results. Rapid accumulation
of putrid and bloody matter takes place, and air is extricated within
the cavity; the vessels of the cyst, being unsupported, part with
their contents; irritative fever is lighted up, with rapid pulse,
anxious countenance, and delirium. These symptoms are relieved only
by immediate evacuation of the fluid. Some slight constitutional
disturbance follows the making of a free opening, but quickly subsides;
then the discharge improves in quality, becomes more pure and unmixed,
diminishes in quantity, and gradually ceases. During the discharge the
strength requires support; and the attention to the original mischief
must not be neglected or intermitted.