A Manual of the Operations of Surgery, Joseph Bell [suggested reading .txt] 📗
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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 The pins should generally be withdrawn about the tenth day.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abdomen, a wire is then passed through the eye of the needle and hooked down, appearing through the wound, it is then withdrawn, and the needle again passed through the pubic portion of the fascia lata, but about three-quarters of an inch to the inside of the first puncture, then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.
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.
CHAPTER XII. OPERATIONS ON PELVIS.Lithotomy.—However interesting and even instructive it might be, any history of the various operations for the removal of calculi from the bladder would be quite out of place in a manual such as this. It will be sufficient here to describe the operations
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