UULUMDIM l-ll HEALTH SCIENCES STANDARD HX00055182 RECAP L B. HOttit" ;dical Books .50th St., N. Y. KT>3-Z. •//t>- Cdumbia (Hnit>ers(ttp intlieCitpofBrttjgork CoUebe of ^l)p£(inan2! anb ^urgEOitJS %ihraxv THE OPERATIONS OF SURGERY Digitized by the Internet Archive in 2010 with funding from Columbia University Libraries http://www.archive.org/details/operationsofsurg02jaco THE OPERATIONS OF SURGERY INTENDED ESPECIALLY FOR THE USE OF THOSE RECENTLY APPOINTED ON A HOSPITAL STAFF AND FOR THOSE PREPARING FOR THE HIGHER EXAMINATIONS W. H. A. JACOBSON M.CH. OXON., F.R.C.S. SURGEON guy's HOSPITAL R J. STEWARD M.S. LONDON, F.R.C.S. ASSISTANT SURGEON GUY'S HOSPITAL AND THE HOSPITAL FOR SICK CHILDREN, GREAT ORMOND STREET SURGEON IN CHARGE OF THE THROAT DEPARTMENT, GUY'S HOSPITAL FOURTH EDITION WITH FIVE HUNDRED AND FIFTY ILLUSTRATIONS VOL. II PHILADELPHIA P. BLAKISTON'S SON & CO. 1012 WALNUT STREET 1902 QxU^^^ PARDON AND SONS, PRINTERS WINE OFFICE COURT, FLEET STREET IfoZ »/, 2. CONTENTS OF VOLUME II. PART IV. OPERATIONS ON THE ABDOMEN. CHAP. PAGE I. Ligature of Vessels. — External iliac. — Common iliac— Internal iliac. — Gluteal. — Sciatic. — Abdominal aorta ..... 1-32 II. Operatioxs on^ Herxia. — Operations for strani^iilated hernia. — Radical cure of hernia ........ 33-84 III. CoLOTOMY. — Lumbar or posterior colotomy. — Inguinal, iliac, or an- terior colotomy. — Eight inguinal colotomy.^Making an artificial anus in the ciecum. — Making an artificial anus in the transverse colon , . . . . . . . . . . .85-112 IV. Operatioxs ox the Kidxey axd Ureter. — Nephrotomy. — Nephro- lithotomy. — Nephrectomy. — -Nephrorraphy. — Operations on the ureter 113 172 V. Operatioxs ox the Ix'testixes. — Acute intestinal obstruction. — Appendicitis. — Perforation of gastric ulcer. — Perforation of duo- denal ulcer. — Perforation of tyi^hoid ulcer. — Abdominal section in peritonitis. — -Enterostomy. — Formation of an artificial anus in the small and large intestine. — Union of divided or injured intestine by suture or otherwise. — Modifications of circular enterorraphy. — Aids to its performance, or means of replacing it.^Resection of intestine.— Enterectomy. — Colectomy. — Intestinal anastomosis. — Short circuiting. — Lateral anastomosis. — Closure of ffccal fistula or artificial anus. — Enteroplasty 173 280 VI. Operative Ixterferexce ix Gl-xshot axd other Ix.ti'ries of THE Abdomex. — Rupture of the Ixtestixe .... 281-295 VII. Operatioxs ox the Stomach. — ^Gastrostomy. — Gastrotomy. — Digital dilatation of the orifices of tlie stomach. — Pyloroplasty. — Pylorec- tomy. — Excision of the pylorus. — Gastrectomy. ^Gastro-jejunos- tomy. — ^Gastroplication — Duodenostomy. — Jejunostomy . . 296-341 VIII. E.xcisiox OF the Spi.eex 342-345 vi CONTENTS OF VOLUME IT. CHAP. PAGE IX. Operations on the Liver and Biliary Tracts. — Operations for hydatids. — Hepatic abscess. — -Hepatotomy. — Removal of portions of the liver for new growths. — Operations on the biliarj^ tracts : Cholecystostomy. — Cholecystotomy. — Cholelithotrity. — Choledo- chotomy.— Cholecystenterostomy. — Cholecystectomy. — -Treatment of biliary fistula 346-369 X. Operations on the Pancreas. — Treatment of pancreatic cysts. — Acute pancreatitis 370-374 XL Operations on the Bladder. — Removal of growths of the bladder. — Operative interference in tubercular disease of the bladder. — Partial prostatectomy. — Lateral lithotomy. — Supra-pubic litho- tomy. — Median lithotomy. — Lithotrity. — Litholapaxy. — Perinseal lithotrity. — Litholapaxy in male children. — Treatment of stone in the bladder in the female. — Cystotomy. — Ruptured bladder. — Puncture of the bladder 375-434 XII. Operations, on the Urethra and Penis. — Ruptured urethra. — External urethrotomy. — Choice of an operation for the relief of stricture-retention. — Internal urethrotomy. — -Ectopia vesicae and epispadias. — Hypospadias. — Epispadias. — Circumcision. — Ampu- tation of the penis . . . . . . . . . . 435 46 XIII. Operations on the Scrotum and Te,sticle. — Radical cure of hydrocele. — Varicocele. — Castration. — Orchidopexy. — Vasectomy. 464-486 XIV. Operations on the Anus and Rectum. — Fistula, — ^Hjemorrhoids. — Fissure. — Ulcer.— Prolapsus. — Excision of the rectum. — Im- perforate anus. — Atresia ani. — Imperfectly developed rectum . 487-520 XV. Ruptured Perineum 521-525 XVI. Operations on the Ovary. — Ovariotomy. — Removal of the uterine appendages ......... 526-549 XVII. Operations on the Uterus. — Removal of the myomatous uterus by abdominal section. — Cancer of the uterus. — 'Removal of a cancerous uterus by abdominal section. — Removal of a can- cerous uterus per vaginam.— Caesarian section. — Porro's operation. • — Ectopic gestation . . . . . . . . . 550-576 XVIII. Sacro-iliac Disease. — Arthrectomy 577 PART V. OPERATIONS ON THE LOWER EXTREMITY. I. Operations on the Hip-Joint. — Amputation at the hip-joint. — Excision of the hip 578-602 II. Operative Interference in Dlslocation of the Hip . . 603-606 CONTEXTS OF \'OLUME II. vii CHAP. p^GE III. Operations ox the Thigh. — Ligature of the common femoral. — Ligature of the superficial femoral in Scarpa's triangle. — Ligature of the femoral in Hunters canal. — Punctured and stab wound in mid-thigh. — Amputation through the thigh. — Amputation immediately above the knee-joint. — Removal of exostosis from near the adductor tubercle. — Ununited fracture of the femur . 607-631 IV. Operations involving the Knee-Joint. — Amputation through the knee-joint. — Excision of the knee-joint. — Arthrectomy of the knee-joint. — Wiring the patella. — Eemoval of loose cartilages from the knee-joint. — Slipped fibro-cartilages .... 632-659 V. Operations on the Popliteal Space. — Ligature of the popli- teal artery 660-662 v VI. Operations on the Leg. — Ligature of ti)e posterior tibial artery. — Ligature of the anterior tibial artery. — Ligature of the peroniBal artery, — Amputation of the leg. — Operation for necrosis. — Treatment of compound fractures. — Operation for simple fracture. — Excision of varicose veins ...... 663-686 VII. Operations on the Foot. — Ligature of the dorsalis pedis. — Syme's amputation. — Roux's amputation. — Pirogoffs amputation. — Sub-astragaloid amputation. — Excision of the ankle. — Era.sion of the ankle. — Excision of bones and joints of the tarsus. — Excision of the astragalus. — Excision of the os calcis. — More complete tarsectomy for caries. — Removal of wedge of bone and other ope- rations for inveterate talipes. — Chopart's amputation. — Tripiers amputation. — Amputation through the metatarso - phalangeal joints. — Amputation of the toes 687-721 VIII. Osteotomy. — Of the femur, for ankylosis of the hip-joint. — For ^'enu valgum. — Of the tibia ......... 722-720 IX. Tenotomt. — Of the tendons about the foot. — Syndesmotomy. — Of the hamstring tendons. — Of the sterno-mastoid . . . 730-734 X. Operations on the Nerves. — Nerve suture. — Nerve stretching . 735-741 PART VI. OPERATIONS ON THE VERTEBRAL COLUMN. Spina bifida. — Laminectomy. — Rachiotomy. — Partial resection of the vertebrae. — Tapping the spinal theca 742-754 PART lY. THE ABDOMEN. CHAPTER I. LIGATURE OF VESSELS. EXTERNAL ILIAC. COMMON ILIAC. INTERNAL ILIAC. GLUTEAL. SCIATIC. ABDOMINAL AORTA. LIGATURE OF THE EXTERNAL ILIAC (Figs. I, 2, and 3). Indications. — Cliiefly : I. Some cases of aneiiiysm of the upper part of the femoral, or of the femoral encroaching on the external iliac itself. — Mr. Holmes (R.C.S. Lect., Lancet, 1873, vol. i.) shows that in ilio-femoral anenrysms it is often very difficult to say whether the aneurysm is or is not limited to the iliac or femoral — i.e., whether it is wholly above or below the place where the deep epigastric and circumflex iliac come off, or whether the mouths of these vessels open out of the sac. In the former case the aneurysm would be purely iliac or femoral ; in the latter, ilio-femoral. Thus, ligature of this vessel is indicated where pressure, rapid or gradual, has failed to command the circulation, where it is intolerable, where it cannot be made use of owing to the abundance of fat. froui failure of pulse and breathing under an anaesthetic, or from the height at which the aneurj'sm involves the external iliac (it being increasingly difficult to apply pressure in these cases without dangerous interference with the peritoneum and its contents), where the patient from chronic bronchitis is quite unfit for a prolonged trial of continuous pressure under an anaesthetic, or in cases where the increase of the aneurysm is very rapid. Before deciding on relinquishing the idea of pressure for ligature, the surgeon should refer to a paper by Mr. Wheelliouse (Clin. Soc. Trans., vol. vii. p. 57). This case is one of the most interesting in all surgery. The patient, a publican, and syphilitic, had previously been cured by ilr. 'Wheelliouse VOL. II. 1 2 OPERATIOXS OX THE ABDOMEX. of a right-sided popliteal aneurysm.* by means of continuous pressure for eight hours with a Porter's femoral-compressor. A few months later he was admitted into the Leeds Infirmary with a large right iliac aneurysm,! reaching from Poupart's ligament to within two inches of the umbilicus, and extending outwards almost to the spine of the ilium. The swelling, about the size of a small cocoa-nut, was hard and firm below, soft above ; it appeared to be wholly connected with the external iliac, but to extend above and overlie the common iliac. Pressure could not be made on the latter vessel sufficient to stop the beating, as the tumour was too much in the way, but it was easily controlled by pressure on the abdominal aorta. The patient was kept under the influence of ether for five hours, Listers tourniquet being very slowly screwed down just over the umbilicus. By the end of the time the patient was black in both limbs, and blue as far as the tourniquet. This had been slightly relaxed twice. No other unpleasant symptom arose during the whole time. A quarter of an hour was taken in relaxing the pressure — a quarter turn of the handle being made every minute. The tumour had ceased to pulsate, and was firm and hard. Pulsation gradually recurred with nearly its old force, but was less " disteusile," and slowly ceased altogether, an excellent recovery being made.J 111 riiptitred femoral aneurysm the old operation (facilitated by the application of a tourniquet above) would usually be indicated, but Mr. Southam (Brit. Med. Journ., 1 883, vol. i. p. 818) has briefly reported a case in which he tied the external iliac successfully in a patient whose femoral aneurysm suddenly ruptured and became diffuse. The effused * It is very possible that the strain thrown on the artery above during the treatment by pressure on the femoral was the cause of the aneurysm higher up. The liability of patients with one aneurj^sm to develop another may often baffle the surgeon. Mr. Clutton (^Brit. Med. Journ.. 1880, vol. i. p. 441) records a case in which a femoral aneurysm was cured by the use of Esmarch's bandage applied up to the tumour, and a Petit's tourniquet adjusted over the brim of the pelvis. The first attempt lasted an hour; at the second trial the bandage was removed in an hour, and the tourniquet con- tinued for nine hours, ansesthetics not being given. The aneurysm ceased to pulsate and began to shrink, but still fluctuated. Nine days after leaving the hospital, the patient died suddenly of an aortic aneurysm rupturing into the pericardium. f Dr. Diver, of Southsea, has put on record a case in which the external iliac was tied in a case in which a popliteal and an inguinal aneurysm co-existed on the right side. Gangrene followed, a line of demarcation forming in the lower third of the leg. Amputation through the thigh was performed, and the patient recovered. A similar case of double aneurysm is reported by Mr. Hilton {Med.-Ckir. Trans., vol. lii. p. 309). A tourniquet was first applied to the right common iliac for six hours withoitt effect on the aneurysms. A second trial of pressure was made later on, with a tourniquet again on the common iliac and one on the femoral at the apex of Scarpa's triangle. In abotit nine hours both aneurysms were cured. Chloroform was used on both occasions. X Cases of Dr. Mapother's and Mr. Holden's, in which ilio-femoral aneurysms were cured by pressure on the common iliac and the aorta, will be found recorded by Dr. Mapother in the Dub. Med. Press, March 29, 1865 ; and by Mr. Holden in ,S'^. Barthol. Uosj). Bep., vol. ii. p. 190 ; Syd. !^oc. B'len. Retr., 1865-6, pp. 306, 307. In Dr. Mapothers case, instrumental pressure on the right common iliac (about an inch below and half an inch to the right side of the umbilicus), kept up for twelve hours under chloroform, had failed. A second attempt, with a Signorini's tourniquet on the end of the abdominal aorta, and a Skey's tourniquet on the femoral just as it left the sac, pressure being kept up for four hours and a half, made the tumour solid and pulseless. Two rigors followed, and a carbuncle formed at the site of the first compression. In Mr. Holden's patient the aneurj'sm was also large, and double aortic valvular disease was present. Chloroform was given here continuously for an hour and a half, and then with cautious intermis- .sions, owing to the state of the pulse and breathing, for the rest of the treatment, which lasted four hours. LIGATURE OF THE EXTEEXAL ILIAC. 3 blood was quickly absorbed, and there was never any tendency to gan- grene. Comjjlete power over the limlj was regained. 2. Wounds. — A wound of the external iliac is so rare as to be almost Tinknown.* It has been frequently tied for hasmorrhage from parts below — e.f/., for secondary- haemorrhage after wounds of the femoral high up, after ligature of the femoral, and after amputation at or near tlie hip. The futilityf of this treatment is thus shown: Dr. Otis QMed. and Surg. History of the War of the Rebellion, pt. iii. p. 788) gives a .summary of twenty-six cases in which the external iliac was tied for such cases as the above. Of these, twenty-three ended fatally, a mortality of 88-4 per cent. The useless- ness of trusting to ligature of the external iliac in such cases, instead of either securing the wounded vessel itself, or trusting to well-applied pressure, was long before this insisted on by Guthrie.;}: This question is alluded to again below, but in proof of the above statement a case may be mentioned here, in which hieraorrhage returned after ligature of the external iliac, and was arrested by well-applied pressure. The patient had been wounded, January 15, 1865, by a minie ball, entering at the upper and inner part of the thigh, and emerging near the knee. The wound becoming sloughy, haemor- rhage occurred (March 23 and 31), and the external iliac was tied. April 21, haemorrhage recurred from the upper gunshot wound, and was successfully restrained by a horseshoe tourniquet, constantly kept on for two weeks, when it was omitted, without any sub- sequent hemorrhage. The wounds were now healing kindly, when (May 31) dysentery set in, carrying off the patient, .June 15, two and a half months after the operation of ligature. 3. Elephantiasis. — Ligature of the external iliac or femoral (when the condition of the soft parts admits of it) has been extolled by some surgeons in the treatment of this affection. § A larger experience shows, however, that when cases thus treated are watched, the cures cannot be * The only case with which I am acquainted is one quoted by Mr. Erichsen from Yelpeau (^Noiiv. EUm. de Med. Ojjer., t. i. p. 175), in which the above French surgeon was suddenly caUed upon to tie the external iliac for a knife-wound. Though there had been no preliminary dilatation of the collateral circulation either by pressure or by the presence of an aneurysm, the result was successful. f It is fair to state that Mr. Bartleet, of Birmingham, published a case in which the external iliac was tied successfully after secondary hajmorrhage from the common femoral, the latter having been tied for aneurysm of the femoral artery. Previous to ligature of the external iliac, " sponge-pressure " and pressure by means of a Martin's bandage were tried, but no details are given. It is noteworthy that the catgut ligature applied to the femoral in this case came away on the seventh day (the first day of the haemorrhage) unobserved, and surrounding a small slough of the arterj'. It had been tied " tightly." X Wonnds and Injuries of the Arteries, Lects. v. and vi. § An apparently successful case is reported by Mr. Leonard, of Bristol. Measure- ments are given nearly three years after the opeiation, showing that the success was then maintained. Five years later the patient reported that " his leg was much the same" as at the last report. Bandaging does not appear to have been made use of here. Prof. Buchanan QUrit. Med. Journ., Nov. 23, 1867; Si/d. Soc. Jiicn. Iletr., 1867-8, p. 300) reports a case, seven months after the operation, apparently cured by ligature of the external iliac, after failure of rest and methodical compression (this was before the introduction of Martin's bandage). Three months later it is candidly stated that the disease had recurred to a considerable degree. Dr. "White, of Harvard University ilnternat. Encycl. of Surg., vol. ii. p. 631), quotes Wernher (reference not given) as having followed up thirty-two cases ; in all there was an immediate reduction of size. but the relief was permanent in three only. Dr. Pinnock, of Jlclbourne (^Lancet, 1879, vol. i. p. 44), gives a case in wliich no permanent benefit followed on ligature of the iemoral artery. 4 OPERATIONS ON THE AEDOMEX. relied upon as permanent. Moreover, too little value has been attached^ in reported cures by ligature of the main vessel, to the thorough rest and elevated position entailed by tying the artery. This operation should, I think, be reserved for those cases (which will be very few) in which Martin's bandages cannot be applied, owing- to cracks, foul ulcers, or burrowing sinuses. Here the ligature may be used after explaining its ]-isks to the patient, but only as a subsidiary measure. The bandage will have to be used as well later, and persisted in. during the da}^ at least, probabl}^ for life. 4. As a distal operation in aneurysm of the common iliac. — Ligature of the external iliac has been so unsuccessful here as to call for no further comment. Surgical Anatomy. Extent. — From the lumbo-sacral articulation to a point just internal to the centre of Poupart's ligament. Length — 3^ to 4 inches. Surface Marking. — From a point an inch below and to the left of the umbilicus to a point just internal to the centre of Poupart's. ligament. Relations: — In Front. Peritonaeum, small intestines. Iliac fascia. Lymphatic glands and vessels. Genito-crural nerve (genital branch). Spermatic vessels } Crossing artery near Poupart's Circumflex iliac vein j ligament. Outer Side. Inner Side, Psoas (above). External iliac Iliac fascia. Iliac fascia. artery. Vein. Behind. Iliac fascia. Vas deferens (dipping A'^ein (above). from internal ring Psoas (below). to pelvis). Collateral Circulation. Deep epigastric with Internal mammary, lower in- tercostals, and lumbar. Deep circumflex iliac ,, Ilio-lumbar, lumbar, and glu- teal. Gluteal and sciatic ,, Internal and external circum- flex. Comes nervi ischiadici ,, Perforating branches of pro- funda. Obturator ,, Circumflex arteries and epi- gastric. Internal pudic ,, External pudic. Operation. — (i) By the lower and more transverse incision of Sir A. Cooper. (2) By the higher and more vertical incision of Abernethy. The two are compared at p. 7. (3) By the intra-peritonosal method (p. 22). LIGATURE OF THE EXTERNAL ILTAC. 5 (i) Incisiox of Sir A. Cooper. — This is the method more frequently made use of. The diet having been limited, and the bowels having been freely moved for some days before the operation, the parts shaved, iind the hip slightly* flexed, an incision is made 4 inches long (4^ to 5, if there be very much fat, or if the parts are pushed up by a contiguous aneurysm), parallel with Poupart's ligament, and nearly an inch above it, commencing just outside the centre of the ligament and extending out- wards and upwards beyond the anterior superior spine. f The superficial fascia and fat, varying in amount, being divided, and the superficial circumflex iliac vessels secured, the external oblique, both fleshy and ii]ioneurotic, is cut through, and then the fleshy fibres of the internal ()l)lique and transversalis. This is done either by using the knife alone, lightly and carefully, or by taking up each layer with forceps, nicking it. and slitting it up on a director. If the wound be sponged carefully.:}: a layer of cellular tissue can usually be seen between the muscles, however thin they are. Any muscular branches should be secured with Spencer Wells's forceps as soon as cut; and in pushing a director beneath the muscles as little damage as possible should be done, owing to the prone- ness to cellulitis later on, and to the proximity, in a thin patient, of the peritonaeum. The fascia transversalis, when exposed, will be found to vary a good deal in thickness and in the amount of fat which it contains. It is to be divided very carefully, § and the extra-peritongeal fat, if pre- sent, will next come into view. First one and then two fingers being introduced, the peritonaeum is to be gentl}^ stripped up from the iliac; fossa towards the middle line — i.e.. upwards and inwards as far as^ the inner border of the psoas. || In doing this care must be taken, especially in the dead body, not to separate the iliac fascia and the vessels from their position on the psoas, not to tear this muscle, and not to lacerate * So that the skin may not be too much relaxed before being incised. Later ou, to relax the parts, the hips may be more strongly flexed, t The incision may have to be made higher than usual, owing to the upward extension of the aneurysm, to enable the surgeon to tie either the upper part of the external or the common iliac. Ou this point see the remarks on the comparison of Cooper's and Aber- nethy's operations, p. 7. Often in these cases of upward extension of the aneurysm the sac is found to involve the lower part of the artery, and to have overlapped the upper portion. X In some cases where the circulation has been much interfered with by an aneurysm, most copious hiemorrliagc. especially venous, has been met with in the earlier steps of this operation. ^^ Dr. Sheen {]}rit. Med. Joiirn., 1882, vol. ii. p. 720) thus writes of the accident which may happen here : •■ I made the incision somewhat too high, and, in consequence, opened the peritonaeum, which I mistook for transversalis fascia. Even then I was in a little doubt, because some (omental) fat presented itself, which very much resembled the fat .seen in the previous case (fat around the vessel), but, in pushing this up gently, a knuckle of bowel came into view, which settled the matter." The wound in the peri- tonseum was sewn up with two fine carbolised sutures, and the case did perfectly well. II Great care is needed here if the peritonaeum be adherent. This condition, when present, is usually found above. It is especially likely in long-standing cases, and where the aneurysm has caused irritative and inflammatory changes. By some it is held that the transversalis fascia can always be stripped up along with the peritonieum. As this fascia is thickened and attached, close to Poupart's ligament, to form the deeper orural arch and front of the femoral sheath, it is very doubtful if it can ever be detached unless it be divided or torn through. The latter is very easy on an aged corpse. 6 OPERATIONS ON THE ABDOMEN. the peritonEeum. As soon as the peritonosum has been well raised, an assistant keeps this and the npper lip of the wound well out of the way by means of broad retractors. The surgeon then feels for the pulsation of the artery on the inner border of the psoas, and carefull}^ opens the layer of fascia which ties the vessel to the psoas, and forms a weak sheath to it. This should be done i;^ inch above Poupart's ligament, so as to lie Avell above the origin of the deep epigastric, which usually comes off j or i inch above Poupart's ligament, and the needle passed from within outwards, carefully avoiding the vein on the inner side and the genito-crural nerve oiitside and in front.- In difficult cases the liga- FlG. I. To show the incisions for — A, Ligature of the external iliac artery. B, Ligature of the common iliac artery. C, Ligature of the common femoral artery. D, Stran- gulated inguinal hernia. E, Strangulated femoral hernia. (Heath.) ture (of sterilised silk, or kangaroo-tail) must mainly be passed by touch, but a free incision, adequate use of retractors, and light thrown in bj^ a large mirror will usually allow the surgeon to see what he is doing. The effect of tightening the ligature being satisfactory, it is cut short and dropped in, the divided muscles are then brought together with buried gut sutures, sufficient drainage provided, and the superficial wound closed. The parts must be kept relaxed by propping the chest up slightly and flexing the knees over a pillow, but too much flexion of the groin is to be deprecated as causing a deep sulcus from which possible discharges ma}' escape with difficulty. The limb is evenlj^ bandaged from the toes upwards, raised, and kept covered in cotton-wool, with hot bottles placed in the bed.* In case of threatening gangrene, assistants should persevere * If the patient be restless, as in delirium tremens, a long splint should be applied. LIGATURE OF THE EXTERNAL ILL\C. 7 in a trial of friction of the limb fi'om below upwards. Where there is a history of syphilis, appropriate remedies should be given after the operation. (2) Incision of Abernethy. — In his first operation this surgeon made his incision in the line of the arterj' for about 3 inches, commencing nearly 4 inches above Poupart's ligament. Later on he modified his incision by making it less vertical and more curved, with its convexity downwards and outwards, and extending between the following points — viz., one about i inch internal and i inch above the anterior superior spine to li inch above and external to the centre of Poupart's ligament. Fig. 2. Anatomy of 1. Abdominal aorta. 2. Spermatic vessels. 3. Inferior vena cava. 4. Ureter. 5. Obliquus extei-nus. 6 Geuito-crural nerve. 7 Obliquus internus. 8. Psoas fascia. 9. Transversalis. the iliac arteries and hernia. 10. External cutaneous nerve. 11. Epigastric vessels. 12. Iliac fascia. 13. Spei-matic cord. 14. Section of transversalis. 15. External abdominal ring. 16. Section of obliquus internus. 17. Saphenous opening. 18. Section of obliquus externus. The respect i\e advantages and disadvantages of the methods of Cooper and Abernethy appear to be the following: Cooper's is rather the easier, interfering, as it does, with the peritonaeum less and lower down. It is most suitable to those cases which do not extend far, if at all, above Poupart's ligament. On the other hand, where the extent to which the aneur3'sm reaches upwards is not exactly known, Abernethy's operation, hitting off the artery, as it does, higher up, or some modi- fication of that given (p. 16) for ligature of the connnon iliac, will be found preferable. 8 OPERATIONS OX THE ABDOMEN. Difficulties and Possible Mistakes. (i) Too short an incision. Here, as in colotomy and other deep operations on the abdominal wall, every layer must be cut to the full extent of the superficial ones. Otherwise the operator will be working at the bottom of a conical, confined wound. (2) A wrongly placed incision — i.e., one which, by going too near the middle line, opens the internal abdominal ring, or which, if too low, may come too near the cord. (3) Disturbing the planes of cellular tissue needlessly or roughly. (4) Wounding the periton{:eum, owing to a hasty incision through a thin abdominal wall, by rough use of a director, especially if the peri- tonaeum is adherent in the neighbourhood of the sac, or fused with the transversalis fascia. The peritonasum is often difficult to distinguish; it Fig. 3. Ligature of the right external iliac artery, i, External oblique aponeurosis. 2, Fleshy fibres of internal oblique arid transversalis. 3, Transversalis fascia. 4, Peritonffium (drawn up by the retractor), n, Artery, r, Vein, p, Psoas muscle. (Farabeuf.) is bluish in aspect, but of course not smooth, being covered with cellular tissue which connects it to the extra-peritonasal fat. (5) Stripping up the peritonaeum roughly and too far. (6) Detaching the artery from the psoas. (7) Lacerating the psoas. (8) Tying or injuring the vein. (9) Including the genito-crural nerve. (lo) An abnormal position of the artery. This may be due to an exaggeration of that naturally tortuous condition of the artery which is especially likely to be met with in patients advanced in life. Another unusual cause of displacement may be met Avitli in extravasated blood when an aneurysm has given ^^'ay. Sir W. Fergusson briefly reported (^Brit. Med. Journ., 1873, vol. i. p. 286) an instance of this kind, in which the sac gave way after repeated manipulation. Causes of Failure and Death. I. Giangrene. — In some cases, where the limb does not become gan- grenous, the vitality is very feeble and requires much attention. Thus, iu Mr. Eiviugton's case QClin. Soc. Trans., vol. xix. p. 45), loss of sensation was LI(4ATURE OF THE EXTEIIXAI. IIJAC. 9 ■noticed on the fourth day, followed by paralysis of most of the muscles. Tliough gangrene did not appear, and the patient survived five and a half months, the limb was -" on the verge of gangrene," as shown by sores appearing on the heel and great toe.* 2. Secondaiy haemorrhage. — This is especially likely if the wcmiicl becomes septic and if 'catgut is used. This fatal result may be long ■deferred. Thus, in Mr. llivington's case (loc. supra citS), the patient died of secondary haemor- rhage five and a half months after the operation ; the wound had been found septic at the first dressing ; a catgut ligature was used. Early recurrence of pulsation may be ominous of secondary ha3mor- rhage. In a case of Sir A. Cooper, the hiemorrhage which proved fatal a fortnight after the operation was found to be due to a large collateral — viz., an abnormal obturator arising immediately above the site of ligatitrc (Roux, Parallele dc la Chir. an/jlaisc nrcc la Chir. francaise. S)T., pp. 278, 279). 3. Cellulitis. Septicaemia. Pyaemia. — Owing to the number of planes of cellular tissue met with here, any needless or rough dis- turbance of the parts, inadequate drainage, or a septic condition supervening are extremely to be deprecated. The wound should be opened up at once if any collection of fluid is suspected. 4. Peritonitis. 5. Tetanus, from including the genito-crural nerve. 6. Phlebitis and secondary haemorrhage from injury to the external iliac vein. 7. Sup- puration of the sac with its attendant dangers of septic infection and secondary haemorrhage. t — This accident is far from uncommon in eases of inguinal aneurysm after ligature. Xo pains should be spared to prevent its occurrence by taking every step to keep the wound strictly aseptic from first to last, and thus to secure early and sound healing. Absolute rest should also be enforced upon the patient. If suppuration take place it will usually be within two months of the date of ligature. The symptoms need not be alluded to here be^'ond pointing out that pulsation is one of very grave omen. When it is evident that suppura- tion, if not established, is inevitable, the surgeon should so arrange his time as to choose a suitable occasion, both as to assistance and a good light, for interfering. Allowing the suppurating sac to open spon- taneously should not be thought of, not only because of the risk of haemorrhage, the want of preparation. &c., but because septic infection is now made very probable. The operative steps are much the same as in the old operation for aneurysm, for which the reader is referred to p. 27. It may be here pointed out that in this case there is more •chance of the haemorrhage taking the form of a general oozing from the sac, and not that of a gush or spirt of blood. Moreover, if the collateral circulation has Ijeen well establislied, there is also the probability of the sac being fed by some additional branch, which, perhaps, entering deep down, may be a cause of much embarrassment. 8. Kecxarrence of * In one of Dr. Sheen's cases already referred to, four days after the operation a large patch of skin on the outer side of the thigh was noticed to be darkish in colour, ami to pit on pressure, though normal as to sensation. The case did quite wclL t Very occasionally secondary Inemorrhage may take place to a slight amount, and leave oii spontaneously. Thus, in one of Dr. Sheen's cases, five weeks after the operation '' about an ounce of bright-red blood came from the slight remaining wound, and a slight oozinsraeain after a few da vs. but there was no further hfemorrhage." lO OPERATIONS OX THE ABDOMEX. pulsation. — This is especiall}- likely to occur when a catgut ligature has- been used and given way. owing to its being softened by suppuration. Over-free collateral circulation will cause recurrence of pulsation cjuickly ; and melting down of soft coagulum (this appearing to be all that the blood can do in the way of clotting) will bring about the same cause of failure later on. In these cases the following courses are open in the- matter of the external iliac — viz., well-adjusted and carefully-maintained pressure, and the old operation. Ligature of the vessel lower down — i.e.,. between the first ligature and the aneurysm — and amputation are not available here.* Two other conditions which may supervene and prove troublesome should be mentioned here — viz. : 9. Formation of ia ventral hernia. — This should be prevented as far as possible by ensuring primary union, and by the use of deep chromic-gut sutures in the cut muscles. Later on, if this complication threaten, an appropriate belt should be worn. 10. Coming away of the ligature long after the operation, through a persistent sinus or re-opened wound. — This may happen,, even in a wound kept sweet from first to last, if a silk ligature has not been properly sterilised, or if one of too close textiire is used, 8ee footnote, p. 552, vol, i. LIGATURE OF THE COMMON" ILIAC (Figs. 4 and 5). Indications. — ^ ery few : I . Aneurysms. — Especially" those inguinal aneurysms which aifect the external iliac in its upper part, above the origin of the deep epigastric, occupying the iliac fossa and lower part of the abdomen. When such aneurysms are progressing steadily, when they have resisted a trial of pressure, and are not thought amenable to the old operation, ligature of the common iliac is indicated. The following remarks by one of the chief living authorities on aneurysm, Mr. Holmes (R.C.S. Lectures, Lancet, 1873, vol. i. p. 297)^ will aid the surgeon in coming to a decision in this most important matter : '• Allowing that an iliac aneurysm is amenable to all three methods of treatment — the Hunterian, by ligature of the aorta or common iliac ; the old operation, by laying open the sac and securing the artery or arteries opening into and out of it ; and the method of compression applied to the aorta or common iliac, — I think no one could deny that the number of cures by the latter method bear.s a very large proportion to the ni;mber of cases treated, while the cures by the Huutcriau method are very rare, and the other method is as yet pretty nearly untried. " But this is far from settling the question ; compression, doubtless, often succeeds but it also often fails. It is not without its risks. It usually requires the prolonged use of chloroform, and this cannot always be borne by the patient. '• The qitestiou of applying the old method in preference to the Hunterian in those '• In one case ^Syd. Soc. Bien. Retr., 1873-4, p. 220), after ligatitre of the external iliac for a femoral aneurysm with catgut, and premature absorption of this on the fifth day (the wound suppurated freely, and antiseptic precautions do not appear to have been taken), pulsation returned, and the swelling enlarged. The patient was operated upon again, and a stout carbolised hempen ligature made use of, one end being left long. Though, owing to the close matting of parts, the peritonaeum was wounded twice^ and intestines and omentum protruded, the patient recovered. LIGATURE OF THE COMMON ILIAC. II cases (rare, it may be, but which must sometimes be met with) in which pressure has failed, is one which Mr. Sj'me's brilliant operations have put in a totally new light. And I must say, for my own part, that, looking at the a^^•ful mortality which has attended the ligature of the common iliac for aneurysm, and the uniform fatality of the same operation on the aorta, I think Mr. Symc's suggestion ought to be put to the test of more extended experience, although the facts and reasonings which I have adduced will show that I am not insensible to the risks which attend the performance of the operation, to the probability of secondary hajmorrhage, and to the extensive injury which must be inflicted upon parts in the immediate neighbourhood of important organs." Mr. Holmes then, in proof of the great fatality of the Hunterian operation on the common iliac, quotes the list collected by Dr. Stephen Smith (^Amer. Jonrn. Med. Sci.. July i860, vol. xl.), in which, out of fifteen cases in which that vessel was tied for aneurysm, only three can be reckoned as definitely cured. Mr. Holmes's belief that subsequent experience has not been more favourable is supported by a table of 65 cases, tabulated hj Dr. Packard.* Of these 65 cases, no fewer than 51 died, only 14 recovering, giving a general mortality of 78-46 per cent.f Mr. Holmes goes on to discuss the old operation, and, in answer to the objection that, though the Hunterian operation has been attended with "a\\"ful mortality" here, we are not made more secure by operating on an artery, perhaps not much more than three inches lower down, and already involved in disease, writes : " I reply that if we grant the artery where it is involved in the sac to be healthy enough to bear the ligature, many advantages may be found in the old operation over that of Hunter. . . . First, the clot is removed and the sac laid open ; consequently, that softening of clot and inflammation of a closed sac lying in proximity to the peritonaeum, which is so surely fatal, is obviated. Next, the ligature will probably be placed on the external iliac instead of the common, and thus the chances of gangrene will be greatly diminished, since the internal iliac and its branches are left open. Thirdly, the artery is tied at a point where most likely the peritonseum and viscera have been pushed away from it by the sac, so that there is less risk of hurtful interference with these latter in the operation. And, lastly, the total excision of the tumour precludes any such relapse as occurs sometimes after the Hunterian operation. " Against these advantages must be set the undoubted risks of secondary haemorrhage, even in cases where the immediate dangers of the operation have been surmounted. ■\Miat this risk is we have no means of judging until our experience of this operation becomes greater ; but I am under the impression that Mr. Syme much underrated it, in consequence of having operated chiefly upon traumatic aneurysm." Farther on, Mr. Holmes writes, while •" maintaining- that the old doctrine on which the superiority of Hunter's operation is based is quite true in general, I should have no objection in the particular instance of iliac aneurysm to follow Mr. Synie's practice; at least, until further experience of it should show that it is wrong : only tlie less dangerous expedient of rapid compression of the trunk artery under chloroform, or gradual compression, with or without chloroform, should first be tried." * Trans. Amer. Surg. Assoc, vol. i. p. 234. Sixty-seven cases are given, but the result is not stated in two. f Grouping these cases into classes, after Dr. Smith's example, in order to obtain more satisfactory deductions, Dr. Packard concludes as follows : — (i.) Those cases in which the operation was done for the arrest of hiemorrhage : 22 cases, of which 19 died and 3 recovered ; mortality, 86-36 per cent, (ii.) Those in which it was done for the cure of aneurysm : 35 cases, of which 24 died and g recovered, the result not being stated in 2 ; mortality in 33 cases, 72-72 per cent, (iii.) Those cases in which tumours simu- lating aneurysm led to its performance : 5 cases, 4 of which die^l and 1 recovered (iv.) Those in which the vessel was secured to prevent hiemorrhage tluring the removal of a morbid growth : 5 cases, all of which died. 12 OPERATIOXS OX THE ABDOMEN. The same authority, when, later on. discussing the value of pressure, l3rings out the following facts. That, while rapid compression under chloroform is a mode of treatment by which most gratifj^ng success has been obtained in iliac as well as aortic aneurysm, it exposes the patient to serious dangers. Amongst these are enteritis and peritonitis from bruising of small intestine, mesentery, meso-colon, and sympathetic; hoematuria; failure of pulse and breathing when the pad is screwed down. On account of these very real dangers, which every dexterity may not obviate. Mr. Holmes advocates a trial of gradual compression, as safer though less efficient, and he points out that the relations of the common iliac are less complicated than those of the aorta, and " as we get further to one side, there is more chance for the intestines to slip out of the wa}"."* 2. Wounds. — These may be gunshot or ba3'onet wounds, or knife- stabs of the vessel itself, or the internal iliac or its branches, usually the latter. The luemorrhage calling for ligature seems to be usually secondary.! Gunshot wounds of the common iliac have a fresh interest now. owing to the recent advances in surgery in the treatment of gunshot wounds of the abdomen. Dr. S. Smith J: gives two cases of ligature of the common iliac for wounds : One was from a musket-ball which injured the vessel itself, passed through the intestines, and lodged in the sacrum. The operation was performed by opening the peritonjeal cavity. Peritonitis soon set in ; secondary haemorrhage recurred repeatedly, and the case ended fataUy on the tif teenth day. The other case is of great interest, as the common and internal iliac were here tied for severe haemorrhage after a stab in the inguinal region. A large quantity of blood was found in the peritomeal cavity, and the patient died ten hours after the operation. At the necropsy it was found that the deep epigastric "was the wounded vessel. Dr. Otis§ records four cases of ligature of the common iliac during the American Civil "War : In one, a gunshot wound, in which the baU entered the groin and came out at the buttock, the external iliac was first tied, the repeated haemorrhages being believed to be from the profunda ; but as the bleeding persisted and evidently came from the sciatic, the wound was prolonged and the common iliac tied. Both ligatures came away, and the operation wound healed, but the f.atient died about three months later of exhaus- tion, associated, apparently, with necrosis in the gluteal region. In the second case the common iliac was tied for a gunshot wound believed to be of the gluteal artery, in which the haemoiThage was not arrested by tying the internal iliac. The hajmorrhage recurred, and death took place two days later. The third case was one of diffuse aneurysm of the right buttock and iliac fossa resulting from a bayonet-stab in the * Mr. Holmes draws attention also to this most important point — i.e., that rapid coagulation in an aneurysmal tumour cannot be regarded as in itself a means of cure, but only as the commencement of a process which, if not interrupted, may result in cure, and that thus, while pulsation may diminish soon after a trial of compression, it may not absolutely cease for quite a month. f It would naturally be thouglit that haemorrhage from a wound of the common iliac would be fatal before a ligature could be applied. Dr. Otis gives a case in which this vessel was wounded by a ball entering from the buttock through the sacro-iliac .synchondrosis. Death took place from hemorrhage on the second day. J Amer. Jonrn, Jtlcd. Sci., i860, vol. xl. p. 17. § Med. and Sury. Hist, of the Mar of the lU-hdlion. pt. ii. p. 333. LIGATURE OF THE COM3iOX ILIAC. 13 former region. Death took place four days later from gangrene of the sac. The old operation is considered by Dr. Otis to have been preferable in this case, but as the necropsy showed that the anterior trunk of the internal iliac had been wounded, %\-ithin the sacro-sciatic notch, by the bayonet, it is difficult to see how the case could have been treated save by ligature of the internal iliac, either outside or ^vithin the peri- tonteum, and then by opening and filling the aneurysmal sac with aseptic gauze or sponges. The fourth case was one of aneurysmal varix of the femoral vessels from a punctured wound two inches below Poupart's ligament. In this case, owing to the impossibility of separating the peritonaeum, this was incised, and the common iliac thus secured. Peritonitis proved fatal four days later. Here ligature of the arterr lower down, above and below the original seat of injury, would have been better treatment. 3. For the arrest of haemorrhage apart from aneurysm. — SiTch cases may be met witli afrer amputation near the hip. follo^^•ed by secondary htemorrhage from the branches of the internal iliac in what is usuallv the posterior flap. Mr. Listen QLond. Jled. Gaz.. April 24, 1830) published a case of this kind in which, after amputation below the trochanter minor for necrosis of the femur, haemorrhage occurred from the stump on the seventh day. As this could not be arrested, the common iliac was tied, but the patient died twenty-four hours later. Dr. Packard iloc. supra cit., footnote, p. 10) treated a somewhat similar case in the same way, successfully. This case is especially interesting, as the haemorrhage occurred from branches of the internal iliac after a Furueaux .Jordan's amputation, a method which has latelv come largely into vogue, and which would usually be expected to do awav with the above risk.* Hjemorrhage occurred from the stump on the sixth day, and. as pressure failed, the common iliac was tied. The patient ultimately did well. It will not. it is hoped, seem a hasty criticism on the above if I sav that in future cases opening up the flaps and plugging with aseptic gauze, or the application, for some days, of Spencer Wells's forceps, aided by even pressure on the flaps and pressure on the common or external iliac, would be preferable to submitting the patient here to the severe and risky operation of ligature of the common iliac. 4. For pulsating tumours simulating aneurysm. — As these growths from the iliac fossa and the Avails of the pelvis have been found to be malignant, it is of the utmost importance to form a correct diagnosis in these cases, and thus save a j^atient who has a certainly fatal disorder from being submitted to an operation which is most dano-erous, and almost certain to be useless.f As mistakes have, however, been made in these cases by excellent surgeons, J the chief points of diagnosis, as * In Dr. Packard's case the Furneaux Jordan's amputation was performed probably higher up than iisual, owing to osteo-myelitis, after a previous amputation for growth, at about the middle of the thigh. t In Guthrie's case, a pulsating tumour in the right buttock, the size of an adult head, diminished by one-half in a month. Two mouths later it again cidarsed. and the patient dying eight months after the operation, an immense encephaloid tumour wiis found occupying the right iliac region. % E.g.. Guthrie ^Lond. Med. Gaz.. vol. ii. 1S34) ; Stanley QMed.-CJiir. Tram., vol. xxviii.) ; Moore (ibid., vol. xxxv.). 14 OPERATIONS ON THE ABDOMEN. given by Mr. Holmes,* maybe briefly mentioned here: (i) The bruit is usually less well marked ; (2) the pulsation is less heaving and less expansile ; (3) the condition of the bone with which the swelling is connected ; thus a plate of bone may be found in the supposed aneu- rysmal sac ; the supposed aneurysm may be found both on the gluteal and the iliac aspects of the pelvis, the bone being expanded b}^ the growth. (4) Cancerous cachexia may be present, and perhaps secondary growths as well. 5. For haemorrhage, not the result of a wound. — Ligature of the common iliac has been employed in some cases of this nature, usually secondar}^ hfemorrhage after ligature of the external iliac, the gluteal and sciatic, or after rupture of the external iliac. Ligature of the main trunk has been so fatal here that it should be abandoned ; carefuU}'- applied pressure, aided by pluggiiig with aseptic gauze, or the old operation, being certainly preferable. Mr. Morrant Baker has put on record t a case of great interest in diagnosis, in which an abscess from sacro-iliac disease ulcerated into branches of the internal iliac artery, and when opened gave rise to hiemorrhage calling for ligature of the common iliac. A gardener, aged 17, had felt pain a month previously while digging. A tense, elastic swelling, distinctly fluctuating, and acutely tender, occupied all the right buttock. It was opened, and a small stream of apparently arterial blood escaped without jets. On further exploration the finger entered a large cavity between the iliac bone and the glutei. The iliac fossa was full and tense, and on examination per rectum a swelling was found in the right ischio-rectal fossa. On enlarging the gluteal wound a steady stream of arterial blood welled up through the great sacro-sciatic foramen. This was firmly plugged, and the common iliac tied. On removing the plug some bleeding still occurred, but was easily arrested. The gluteal wound became offensive, and this region, together with the upper part of the thigh, became gangrenous, the leg and foot remain- ing unaffected. The patient died forty hours after the operation. At the necropsy the sacro-iliac joint was open, with surrounding caries. The remains of a large abscess were found, involving the branches of the internal iliac. There was no trace of aneurysm. 6. Preparatory to the removal of caries of pelvis. — Where, after amputation at the hip-joint, pelvic caries persists, leading steadily to lardaceous disease, I think an attempt should be made to remove all of the innominate bone which is diseased. Such profuse oozing follows that the common iliac should first be tied. I adopted this course in a boy aged 9, eleven years ago. The common iliac was most easily tied by the free anterior abdominal incision given below, and the pubic part of the bone removed the same day. A little later I removed the ischium and the acetabu- lar portion of the ilium, leaving the upper half. Bronchitis (increased, I fear, by the ether given at the second operation) carried off the child three weeks after ligature of the common iliac. The bleeding was slight and easily arrested, the chief difficulty met with here being the detachment of the soft parts in the neighbourhood of the pubes, tuber ischii, and sacro-iliac joint. The thickening of the pelvic fascia, present in these advanced cases, shuts off the contents of the pelvis. Surgical Anatomy. — The common iliacs, coming off on the left side of the fourth lumbar vertebra, incline downwards and outwards to * Sj/st. of Surf/., vol. iii. pp. 44, 145. The reader should also consult Mr. Holmes's article, " On Pulsating Tumours which are not Aneurysmal, and on Aneurysms which are not Pulsating Tumours" QSt. Georr/e's Hosi). Rep., vol. vii.). t St. liarthol. JIo.) even if it is repeated only at long intervals, and all other signs are absent or little marked; (c) it must be remembered that vomiting may be stopped by drugs, strangulation persisting, or the intestines may be empty. iv. Tympanites and other evidence of peritonitis. These will not. of course, debar the surgeon from operating, but the}- will lead him to warn the friends that relief will probably come too late. STRANGULATED FEMORAL HERNIA (Fig. 7). Operation.* — The parts being shaved and thoroughly cleansed, a little iodoform rubbed in around the genitals, the limbs being kept warm with blankets and a hot bottle or two if the patient's vitality is low, and the knee flexed slightly over P^^. a pillow, an incision two and a half to tlu-ee inches long is made vertically on the inner side of the swelling. Some small branches of the superficial external pudic occasionally require torsion or ligature. The cribriform fascia and the fascia propria (femoral sheath and septum cruralcj are next divided in the same vertical line, with or without a director,! according to their thickness and the experience of the operator, all the incisions made going quite up to and above the top of the swelling, so as to lie over the seat of strangulation, usually Gimbernat's ligament. In the operation without opening the sac,^ the site of stricture must next be found. The varieties here are best given in Sir James Paget's words (he. supra cit., p. 132): " In some instances, as you trace up the neck of the sac, 3'ou find it tightly banded across by a layer of fibrous tissue called Hey's ligament — a layer traceable as a falciform edge of the fascia lata, where that fascia, bounding the upper part of the saphenous opening, is connected with the crural arch, and is tlience continued to Gimbernat's ligament. Sometimes a fair division of this fluid, nor even by the absence of all vomiting, nor under-estimating the importance of occasional vomiting as a signal for operation. * While general auc^sthesia will be preferred in most cases from the more certain loss of sensibility and' the relaxation of the parts, a case related by Dr. Mason iBrit. Med. Journ., vol. i. p. 834) shows how valuable cocaine may be as a local aniesthetic. A woman who had suffered from heart disease for many years required operation for a strangulated femoral hernia. Three four-minim injections of a 4 per cent, solution of cocaine were given, the first under the skin over the centre of the tumour, the second above and the third below the tumour, as deeply towards the femoral ring as was thought safe. It was only during actual division of the sac and the insertion of the sutures that any pain was complained of. The wound healed by first intention. t The operator can also manage very well with scissors, keen-edged but blunt-pointed, first nicking each layer, and then separating it from the next with the closed points. + Cases best suited for this plan are those where the strangulation has been short ; its symptoms not very severe—*?.^., the vomiting only bilious ; where the hernia is small in size and without mi.xed contents ; where the patient is in good condition, and any previous taxis has been gentle and brief. 36 OPERATIOXS OX THE ABDOMEX. layer of fibres up to the edge of the crural arch is sufficient to render the hernia reducible But in more cases this is not sufficient, and you may feel the stricture formed by bands of fibres which encircle the neck of the sac, and which must be divided, band by band and layer bj^ layei', till none can be felt. These fibres are part of the deep crural arch. Ver}^ rareh*. however, even the division of these is not sufficient, for the stricture is formed by thickening of the mouth of the sac itself. This condition, which is a common cause of stricture in inguinal hernia, is very rare in femoral ; but it certainly does occur, and in any case well suited for the operation, without opening the sac, you may try to thin the mouth of the sac withoiTt opening it, and thus to make it extensible enough for the return of its contents. You ma}^ try this, but the chances of success are small. You are much more likely to cut into the sac at some thin place, and when j^ou have done this you had better enlarge the opening and divide tlie stricture from within."* Operation by Opening the Sac. — This, with very few exceptions, is the method to be employed. For many reasons it is better and more satisfactory, and of these the two following, apart from others, will justify its performance in the majority of cases: i. The importance of inspecting the bowel; 2. It renders an attempt at radical cure possible. In this and in the former case much difficulty is occasionally met with in deciding as to whether the sac is reached or no. The causes of difficulty here are mainl}- — (i) An altered condition of the soft jiarts from the pressure of a truss, or from long strangulation ; (2) from meeting with fluid outside the sac ; (3) from the extreme thinness of the patient, which leads to the sac being reached iin- expectedly ; (4) from the opposite condition, much fat being met with in several of the deep layers, making it uncertain which is the extra- peritonasal laj^er, the fat in these cases being often soft, and readily breaking down under examination ; (5) an apparently puzzling number of la^'ers — this condition is usuallj^ due to "hair-splitting" over- carefulness on the part of the operator, at other times it is brought about b}^ a much thickened fascia propria separated into imperfect layers by its softened condition or inflammatorj^ matting ; (6) by the absence of a sac.f Aids in Recognisijig the Sac in Cases of Difficulty. — Several of those ordinarilj'- given (Erichsen, loc. supra cit.) — e.g., " its rounded and tense appearance, its filamentous character, and the arborescent appearance of vessels on its surface " — are, I think, quite fallacious. So, too, with regard to the escape of fluid from the sac, for this is often dry in femoral hernise, and occasionally fluid is met with before the sac is reached. A smooth lining characteristic of its inner surface is more reliable, but the * In trying to divide points of stricture outside the sac, attention should be paid to the following: — (i) First reaching the sac itself, if possible, by a careful division of all the overlying structures in the vertical incision carried well upwards ; (2) carefully drawing down the sac, so as to expose any fibres constricting its neck ; (3) gently insinuating the point of the director under any bands met with. f A sac is said to be absent in some cases of hernia of the ciecum, and where the patient has been operated on before. This, however, was not the case in three hernise containing the caecum, and in two which had been operated 011 before, that have come under my care. STRANGULATED FEMORAL HERNL\. 37 inner surface of the fascia propria is sometimes remarkably smooth. Two points remain wliich will help to solve the doubt — (a) To draw gently down the doubtful structure, whether sac or bowel, and to examine whether it is continuous above and below with the structm-es of the abdomen and thig-h, like the other covering's of the hernia, or whether it has a distinct neck to be traced into the abdominal cavity ; (Ji) To see if the point of a Key's director can be insinuated along this last doubtful layer into, and moved within, the peritonaeal cavit}^ or no. In a very few cases the surgeon, if still in doubt, incises carefully the suspected layer, and tries if he can pass in a probe and move it from side to side ; if this can be done, he is still outside the bowel, not between the peritonaeal and muscular coats of intestine. The sac being carefully nicked with the scalpel-blade held horizontally at a spot where it can best be pinched up with dissecting-forceps — a matter of much difficulty at times, owing to its tenseness — is slit up on a director, and its contents examined. If omentum first present itself, this is drawn to one side and unravelled, and intestine sought for. This usually takes the form of a small, very tense knuckle, of varying colour and condition. If it will facilitate the manipulations needful for reduction, the omentum may be first dealt with, (i) If this be volumin- ous and altered in structure, it should be tied,* bit by bit, with reliable chromic gut or silk, and then cut away, the scissors being applied so close to the ligatures as to leave holding-room, but no excess to mortify or slough. After the return of the intestine, the stump is also replaced within the abdomen. (2) If the omentum be small in amount and recently descended, it may be merely returned. (3) In a few rare cases when the omentum is intimately adherent to the sac, and the patient's condition does not admit of delay, the otnentvim must be left in sihi. As, however, this course very much interferes with the satisfactory wearing of a truss, and as it is likely to lead to a fresh descent of bowel, it should never be followed if it can be avoided. Reduction of the Intestine. — As soon as this is exposed, the surgeon examines with the little finger-nail, or a Key's director, the tightness of Gimbernat's ligament. In a few cases reduction may be at once effected by gentle pressure backwards on the bowel with the tip of the little finger. But in the large majority the above site of stricture will need division — a point requiring much carefulness for fear of injuring the intestine or important surrounding structures. If the degree of tightness of the parts admit of it, there is no director so safe and satisfactory as the index or little finger of the left hand passed up to the stricture, and the nail-tip insinuated beneath this, the hernia-knife being introduced along the pulp of the finger (Fig. 8). But there is rarely room for this, and a Key's directorf must usually take the place of the finger. * For security's sake the ligatures should be made to interlock. If haemorrhage occur from the omentum after it has been replaced, the surgeon must remember tliat returned omentum generally escapes far from the wound. It will thus be usually needful to extend the wound upwards along the linea semilunaris. t This director is broad, so as to prevent any intestine curling over and reaching the knife ; blunt-pointed, so as not to damage the contents of the peritonaeal cavity ; finally, its groove does not run quite up; to the end, so that the knife-point shall be stopped before it conies in contact with the important parts. 38 OPERATIONS OX THE ABDOMEN. Fig. 8.t The tip of this instrument being insinuated into the periton^eal cavity just undei' Gimbernat's ligament, the hernia-knife* is introduced obHquely or flat-wise upon it, its end slipped under and beyond the ligament, its edge turned towards the constricting fibres, and a few of these gently cut through in an upward and inward direction. In doing this it is well for the surgeon to draw doA\'n the edges of the cut sac close to its neck, and to ask an assistant to hold these, thus facilitating the passage of the director and the knife by preventing the sac fall- ing into folds before them. Occasionally, also, a knuc- kle of intestine persistently This is best met by patience, by (Fergussou. coils over the edge of the director. drawing it out of the wa}' b}' the carbolised finger-tip of an assistant, or by pressing it down with the handle of a pair of dissecting-forceps. The direction and the extent to M'hich the stricture must be cut are matters of much importance. The upward and inward line is the only l^ath of safety. Directly outwards lies the femoral vein ; b}^ cutting upwards, the spermatic cord, and, if upwards and outwards, the epi- gastric artery, would be endangered ; behind are the peritonasum and pubes. The incision upwards and inwards must be of the nature of a nick ; otherwise, owing to the imperfect healing of the fibrous structure, the ring will be left large and gaping, thus facilitating the re-descent of the hernia, producing much difticulty in fitting ti'usses, and causing certain discomfort and probable peril to the })atient, especially if she belong to the poorer, hospital class. Gimbernat's ligament having been carefully and sufficient!}^ nicked, the bowel is replaced either b}^ gentle squeezing between the finger and thumb, so as to empty it of its contents, or with the pressure of the little finger ; the sac being now kept stretched with forceps so that no folds interfere with the return of the bowel. If pressure on one part of the intestine fail, it must be tried at another point. After the reduction of the intestine the tip of the little finger should be introduced through the crural canal into the peritonseal cavity to ascertain that the gut is absolutely safe ; a little sterilised iodoform is then dusted on to the stumps of omentum, and these too returned, if this has not been done. If the patient's condition and age admit of it, and if the adhesions are not too firm, the sac should next be taken away by carefully separating it with the finger or a director from its attachments. It should then be pulled well forwards, an aseptic finger introduced up * A curved one will be fouud most useful. The cutting blade is usually too broad and the tip too massive. On the other hand, a worn-down blade has been known to break while dividing a tense Gimbernat's ligament. The intestine may thus be ■wounded, or the fragment of the knife escape into the peritonreal cavitj'. t The cutting blade of the knife shown here is needlessly long and unguarded. STRAXGULATEU FEMORAL HERNIA. 39 to its neck, this part next ligatured with stout silk as high up as possible, the finger then withdrawn, and the sac cut away half an inch below the ligature. If the surgeon is at all doubtful about the safe ligature of an)- stump of omentum, he should keep this down and transfix it and the neck of the sac with a double silk ligature, the ends of which are afterwards cut short. Sufficient drainage is now provided by a small tvdje or a bundle of horsehair, and the superficial wound closed. The dressings must be applied with sufficient care to keep the wound secure from obviously close sources of contamination. It is well to place a separate pad of carbolised tow or salicylic wool over the anus and genitals, and to draw the water off before the patient leaves the table. The thigh should not be kejot too much Hexed, otherwise the escape of discharge from the drainage-tube will be interfered with. The account of an ordinary operation having been given, it remains to consider certain complications. These are chiefly : 1. Adhesions of Bo\\el to the Sac or Omentum. — The treatment of this uncommon com])lication must vary with (a) the character and position of the adhesions. (/3) the condition of the intestines, and {7) the state of the patient. Owing to the difficulty of fitting on a truss if an}* of the hernia is left unreduced, every attempt shoiild be made to free the contents by separating the adhesions with the point of a steel director, the finger-nail, or a blunt-pointed bistoury. When near the neck they must always be divided, sufficiently nicked, or stretched. No intestine and omentum still adherent to each other should ever be returned. A few cases remain in which adhesions should be left alone. When gangrene is threatening, but the operator is too short- handed to face resection of the affected intestine, the presence of adhe- sions, especially about the neck of the sac, is the chief safeguard against extravasation into the peritona^al cavity. In some cases of large hernia, if the patient be much collapsed, so long as any recentl}^ descended loop is returned, any long-adherent intestine may be left. And in other cases of collapse from delay of the operation, where there is much difficulty in returning a loop of intestine, especially if this be not in good condition, it may be left, after the stricture has been sufficiently divided. It occasionally happens in these cases of deeply congested bowel, especially in inguinal hernia, that after an otherwise successful herni- otomy the patient passes profuse and blood}^ stools. This condition may prove fatal. In one or two cases of this kind which have come under my notice the operator was, most unfairly, blamed for having incised the bowel. Mr. Kough (^Liuiret, Oct. 11, 18S4) records a case iu which a patient died in collapse two hours after the reduction of a very large scrotal hernia. The pelvic cavity was full of blood-stained serum ; ten feet of intestine were found dark purple in colour, but uninjured. On laying the gut open about a pint and a half of blood escaped. 2. Tightly Constricted or (langrenous Intestine. — In spite of all that has been taught about the importance of early operations, cases do still occur in which returning the bowel is doubtful or out of the question. In most cases of doubt, as long as the stricture is sufficiently divided and the intestine placed only just within the crural ring (the wound 40 OPERATIONS OX THE ABDOMEN. being left open and the sac not ligatured), the interior of the abdomen is the best place for the intestine. And this is true of congested intestine, however deeply loaded with blood onl}^, as long as there is some shade of red present. But on these points nothing will surpass the advice of Sir J. Paget (he. supra cit., p. 138): "You are to judge chiefly from the colour and the tenacity. Use your eyes and your fingers ; sometimes your nose ; very seldom your ears, for what you may be told about time of strangulation, sensations, and the rest is as likely to mislead you as to guide aright. As to colour .... I am disposed to say that you may return intestine of any colour short of black, if its texture be good; if it feel tense, elastic, well filled out, and resilient, not collapsed or sticky ; and the more the surface of the intestine shines and glistens, the more sure you may be of this rule. When a piece of intestine is thoroughly black, I believe you had better not return it, unless you can be sure that the blackness is wholly from extravasated blood. It may not yet be dead, but it is not likely to recover ; and, even if it should not die after being returned, there will be the great risk of its remaining unfit to propel its contents, and helping to bring on death by what appears very frequent^ distension and paralysis of the canal above it. But, indeed, utter blackness of strangulated intestine commonly tells of gangrene already ; and of this you may be sure if the black textures are lustreless, soft, flaccid or viscid, sticking to the fingers, or looking villous. Intestine in this state should never be returned. Colours about which there can be as little doubt, for signs of gangrene, are wdiite, grey, and green, all dull, lustreless, in blotches or complete over the wdiole protruded intestine. .... Then as to the texture of the intestine : it should be, for safety of return, thin-walled, firm, tense, and elastic, preserving its cylindrical form, smooth, slippery, and glossy. The further the intestine deviates from these characters, the more it loses its gloss and looks villous, the more it feels sticky and is collapsed and out of the cylinder form, the softer and more yielding, the more pulpy, or like wet leather or soaked paper, the less it is fit for return. And when these characters are combined with such bad colours as I have described, the intestine had better be laid open, that its contents may escape externallv and do no harm." In other long-standing cases of femoral hernia the chief stress of the constriction is shown, not on a dying Ioojd of intestine, but in ulcera- tion, partial or nearly ring-like, at the neck of the sac, under the sharp edge of Gimbernat's ligament. Where this condition, owing to the duration of the case, is suspected, the intestine shoiild be very gently drawn down, and, if ulceration be found, laid oi^en. If the mischief be localised, and the adjacent intestine fairly health}^ and not fixed, it will be well to stitch it to adjacent parts to prevent it slipping up into the peritongeal cavity. The treatment of gangrenous intestine in a hernia is fully dealt with, later on, under the heading of Resection of the Intestine. I will only say here, that wherever possible, i.e., in cases where the condition of the patient, and the experience, and help ready to the surgeon's hand, admit of his taking this step, the gangrenous intestine should always be resected. In a few cases where the above conditions are absent, the surgeon must rest content with opening the intestine and leaving it STRAXGULATED FEMORAL TTERNIA. 4I in situ. The quickest way will be to draw the whole loop that is damaged outside the peritonaeal sac, and keep it in place by a sterilised bougie or glass rod of appropriate size, as in inguinal colotonw (q. v.). It has been much disputed whether, in these cases. A\hen the intes- tine is unfit to be returned, it is safe or needful to divide the stricture in addition to laying open the intestine. On the one hand, M. Dupuy- tren, Sir A. Cooper, Mr. Kej', and Sir J. E. Erichsen have advocated this step being taken ; on the other, Mr. Travers and Sir W. Lawrence were against it. The following words of a very brilliant writer* will probably convince most that this step is not only injurious but un- needed : " The only result of this is that the protecting barrier, which divides the still aseptic peritongeal cavity from the putrid sac, is broken down, and putridity spreads upwards into the abdomen and kills the patient by rapid septicjemic poisoning. Why break down this valuable wall ? If it is argued that, iTuless the stricture is divided, the contents of the bowel cannot escape, then the reply is that expe- rience proves this to be utterly untrue. In a very short time both tiatus and fasces find their way out. As everyone knows, the nipping of the gut is not produced by a sudden narrowing of the hernial ajier- ture, but by a swelling of the loop of gut ^Vhen the gut is slit up, its contents are set free, and its inflammatory juices escape, ^vith the result that its swelling goes down, and room enough is soon per- mitted for wind and ffeces to pass, more particularly as the faeces are invariably quite liquid."" 3. Wound of Intestine. — This may be due to (a) carelessly incising thin, soft parts ; (/>) great difficulty in making out the sac and the intestine in a fat patient, with the parts matted, especially if the light is bad ; (c) to the intestine being allowed to curl over the edge of the director while the stricture is being divided, or to this being cut with careless freedom, or, lastly, to a loop Ij^ing out of sight just above the constriction, and to the hernia-knife coming in contact with this. Any bubbling of flatus or escape of fseces must lead to a careful search for the wound. The oi>eration wound being freely enlarged, the wound in the intestine found, temporarily closed with a Spencer Wells's forceps, and drawn quite out of the abdomen, the intestines around are carefully cleansed and packed out of the way, and protected with tampons of iodoform gauze or flat sponges. When the wound in the intestine is small, it may usually be tied iip around a pair of dissecting- forceps Avith carbolised silk, the ligature not being tied too tightly, and the ends cut short. If the opening be larger, it should be closed by Lembert's suture (see Suture of the Intestine). Whichever method is used, the injured part should be replaced just within the peritonjeal cavity, and in a severe case the sac should not be taken away or the wound closed. The patient should be kept under the influence of opium, and liquids restricted. 4. Wound of Obturator Artery. — The position of this vessel when it rises by a common trunk with the deep epigastric instead of from the internal iliac, which occurs in two out of ever}'' seven (Gray), may bear * Sir W. Banks, Clinical 2^'uL'S on Two I'mrn' Surtjical Work in the Livcrj)ool Royal Infirmary, p. 96. 42 OPERATIONS OX THE .IBDOMEX. a very inipoitant relation to the crural ring. In most cases "vvlien thus arising abnormally, the artery descends to the obturator foramen close to the external iliac vein, and therefore on the outer side of the crural ring and out of harm's way. In a small minority of cases the artery in its passage do^vn^^-ards curves along the margin of Gimbernat's liga- ment, and may now be easily wounded. The treatment is mainly preventive — i.e., by making the smallest possible nick that will be sufficient into any point of stricture, such as Gimbernat's ligament, a point the importance of which has alreadj'' been alluded to (p. 38), and by using a hernia-knife that is not over- sharp. If the arter}^ has probabl}- been wounded, the following points are of interest: — (i) The hasmorrhage may not at once follow the wound. It may not make its appearance till the bowel is all reduced, or even until a quarter of an hour after the wound has been stitched up. In one case, that of Dupuytren, no haemorrhage occurred, and the division of the artery was discovered for the first time at the necropsy three weeks after the operation. (2) It may occur when the sac has not been opened. (3) As is shown by Dupuytren's case, it is not neces- sarily a fatal accident. (4) Very various means have served to arrest the heBmorrhage. (a) Pressure, as in the cases of Sir W. Lawrence, Mr. Hey, and Mr. Barker.* This means was successful in two out of the three cases in Avhich it has been employed. It should only be resorted to when the patient's condition does not admit of the wound being enlarged, and the bleeding points found and dealt with by ligature or forci-pressure. When pressure has to be trusted to, it should be effi- ciently employed b}' means of tampons of iodoform gauze wrung out of carbolic acid lotion (i in 20) and secured on silk. (^8) Ligature of the vessel, usually the proximal end. Of five cases given by Mr. Barker, this was successful in four ; it is only stated in one that the distal end Avas also secured. The ligature had been applied in some cases Iw con- tinuing the M'ound upwards ; in others by making an incision parallel with Poupart's ligament, as if for tying the external iliac. This step should always be taken when the patient's condition is satisfactorj-.f In two of Sir W. Lawrence's cases the fainting of the patient appears to have decided the cessation of haemorrhage. Both of these recovered. (7) In the event of ligature being really impossible, it might be worth while, before taking other steps, to try the application of a pair of Spencer Wells's forceps. These should be left in situ for three or four days, and would favour drainage. 5. Hernise with Unusual Contents. — These may be (a) Fat hernige. Both in the inguinal and femoral regions, but especially in the latter, the extra-peritona?al tissue near the rings may become increasingly fatty. Gradually projecting towards the surface, it drags down the peritonaeum to which it is loosely connected. I have operated on one * Clin. Soc. Trans., vol. xi. p. 180. This paper ^vill well repay perusal. Most of the above informatJon is taken from it. t Mr. Hulke (^Lancet, 1885, vol. i. p. 746). by freely opening up the wound and using large retractors, found a comparatively large atheromatous artery spouting freely. From its position this was a large communicating artery between the deep epigastric and obturator, lying just behind Gimbernat's ligament. Both ends were secured with very great difficulty. The patient did well. STRANGULATED FEMORAL HERXIA. 43 such case in a girl, aged 19, in whom the fitting of a truss was un- satisfactoiy. Here I expected to find an omental hernia. Into the pouch so formed intestine or omentum maj' present. In other cases, if the extra-peritona?al fat thus protruded become absorbed, the hollow thus left may produce a space for the peritonasum to project into. (IS) Hernia of the ovary. This is much more commonly met with in inguinal hernias. The chief points in the diagnosis of these difiicult oases are the characteristic oval shape and size of the swelling; the peculiar sickening pain when the swelling is pressed upon; the swelling being larger and the tenderness greater during menstruation ; the swelling maj' sometimes be made to move when the uterus is displaced laterally with a vulsellum, and the ovary of that side is not to be made out per rarjinam. AVhere other treatment has failed, where the swelling is irreducible and prevents the fitting of a truss, where the symptoms are suflSciently urgent to cripple a young life, the displaced ovary should be removed. The operation should be rigidly aseptic. Adhesions are not uncommon. (7) Hernia of vermiform appendix. I met with a case of this early in 1890, in a lady, aged 43, a patient of Dr. Fraser's, of Eomford. The femoral hernia was here irreducible, dull, gave a feel of omentum, and curved upwards and outwards in the usual way. As no truss was satisfactory, and as the patient, the vrife of a missionaiy, was to be much abroad, a radical cure was advised. The sac contained much fluid, but no omentum. In the outer part of the hernia lay a thick fleshy body, tubular and expanded at its end. Near Gimbernat's ligament it was constricted and distinctly abraded. After notching the above ligament, this body, which proved to be the appendix, was easily returned. The sac was removed. The case did excellently. In another case I should remove the appendix if there were time for making the necessary suturing secure. (8) Hernia with more than one sac. This may be due to the presence of membrane, inflammatory in origin, \\hich has divided the original sac. Causes of Herniae not doing well after the Operation. — (1) Peritonitis, usually from the operation being performed too late. (2) Enteritis. This may be told by the tympanites, tenderness and vomiting being much less marked, and often the presence of diarrhoea. {3) Septic trouble, erysipelas. The eight following are the causes of intestinal obstruction after operations for hernia : (4) The descent and re-strangulation of the bowel. (5) So much damage to the intestine that it lies paralysed in the peritona?al cavity.* (6) Cica- tricial stricture of the intestine. (7) Fixing of the bowel, after its reduction, by adhesions to the abdominal wall.t (8) Formation of a band out of the above adhesions. (9) Fixing of the two ends of a loop of intestine by adhesions. (10) Formation of an omental band in the neighbourhood of one of the hernial orifices, a band so formed causing ■obstruction later (Brit. Med. Journ., 1879. vol. ii. p. 491). (i i) A very rare condition. The sac may be multilocular ; when the intestine is reduced it may be returned into one of these cavities instead of within the abdomen. Mr. Bellamy has published such a case (Lancet, 1886, * I have recorded (7inY. Jlcd. Journ.. 1879, vol. ii. p. 491) an instance of this in which, ten days after an operation for intestinal obstruction by bands, death took place from the intestine never having recovered itself. f This and the next three are given by Mr. Treves, Laiwct, 1884, vol. i. p. 1022. 44 OPERATIONS ON THE ABDOMEN. vol. ii. p. 433). A good illustration of this is given in Mr. Holmes's Surgery, p. 698, Fig. 322 ; the patient here died eight daj^s after an operation for strangulated hernia. STRANGULATED INGUINAL HERNIA (Figs. 9 and 10). Operation. — In considering this it will not be needful to go again into detail, as in the case of Strangulated Femoral Hernia ; the chief points of difference and those of imj^ortance will be considered carefully. The parts being shaved and cleansed, and the thigh a little flexed, an incision four inches long at first is made in the long axis of the tumour, with its centre (in an ordinary scrotal case*) over the external abdominal ring. This incision may be made either by pinching up a fold and cutting from within outwards, or by cutting, in the usual way, from without inwards. The pressure-forceps ma}' be left on the external pudics (both superior and inferior), these vessels being finally closed by the sutures which unite the wound. As the layers are divided, the knife being kept strictly in the same line throughout, some arching fibres of the inter-columnar fascia may be seen above, but the first layer usually recognised is the cremasteric fascia, often much thickened. After this the transversalis fascia, also much thickened and vascular- looking, is slit up, and any extra-peritongeal fat overlying the greyish- blue sac looked for. The surgeon now sees if he can find any constricting fibres outside the sac, and slits them up on a director. The more voluminous the hernia the more important it is to avoid exposure and manipulation of its contents by opening the sac.f But in the majority of inguinal hernise the surgeon must be prepared for opening the sac. As soon as this is done, with the precautions already given (p. 37), the contents are examined, omentum got rid of if this step will give more room, and the site of stricture found with the finger- nail or tip of the director. It is next divided with the hernia-knife manipulated under it in a direction straight upwards, so as to lie parallel with the deep epigastric, whichever side of the hernia this vessel occupies.:}: During this stage the steps given at p. 38 must * In a strangulated bubonocele the centre of the incision should lie over the internal abdominal ring, and in the deeper part of the incision the deep epigastric must be felt for, and avoided. f The site of the stricture in inguinal hernia varies. In both varieties, in old cases of long duration, it is usually situated in the neck of the sac itself, owing to contrac- tion and thickening of this and the extra-peritonajal tissue. In other cases of oblique hernia the stricture is found in the infundibuliform fascia at the internal ring, just below the edge of the internal oblique in the canal, or at the external ring. In a direct hernia the constricting point, if not in the sac, is probably caused by the fibres of the conjoined tendon. In many cases the parts are so approximated and altered that in the short time given for an operation it is not so easy to tell exactly in what tissues lie the strangulation, as to relieve it. Finally, in many cases of young subjects and acute strangulation, muscular spasm — e.f/., of the internal oblique — must be borne in mind. X Of course, if the surgeon is certain that he is dealing with an oblique hernia, he may cut outwards, and, in the case of a direct hernia, inwards, so as to avoid the deep epigastric. In all cases the cut should be of the nature of a nick dividing only those fibres which actually constrict, any additional dilatation being usually now effected by the tip of the director or finger. STEAXGULATED INGUINAL HERNIA. 45 be taken to avoid any injury to the intestine. The constricting- point being divided and dilated, the next step is reduction of the intestine. This, in bulky inguinal hernige, is often a matter of difficulty and time. The chief causes of difficulty here are — (i) A large amount of in- testine, one or two coils of small and some large intestine being not very uncommon. (2) The distension of these with flatus, &c. (3) In- sufficient division of the stricture ; or there may be a point of stricture higher up than the one divided, and overlooked. (4) During attempts at reduction one bit of intestine may get jammed across the ring instead of slipjiing up along it, and against this the rest of the con- tents are fruitlessly pressed. (5) Folds of the sac may in much the same wa}^ block the opening. Aids in Difficult Cases. — First, that part which lies nearest the ring should be taken — e.g., mesenter}^ before intestine. After each part is got up, pressure should be made on it for a few seconds before another is taken in hand. If the surgeon find, after a while, that he is making no progress with one end of a coil, he should take in hand the other Fig. q. (Fergusson.) end, or another coil altogether if more than one be ])resent. Much of the difficulty met with in the reduction of the intestine is due to the surgeon not first unravelling the coil or coils, not duly tracing up the intestine to the ring so as to make out the relations of the two, and, above all, to his not making up his mind which end of the coil it is exactly which he intends to begin reducing. During the manipulations the thigh should be flexed and rotated a little inwards, and the cut edges of the sac drawn tense with forceps, so as to prevent any folding or i)ush- ing up of this before the intestine. If the intestines are much distended, attempts should be made to return some of their contents first into the abdominal cavity. If, after gentle squeezing with the finger and thumb, and careful pressure upwards on each successive bit of intestine, it all appears to be returned, the little finger must be passed into the abdominal cavity to make certain that no knuckle remains in the canal or internal ring. Another Method. — In the case of large scrotal hernias, where opening the sac in the ordinary way involves much exposure of peritona^al sur- faces, I believe the following to be preferable : A small opening, just 46 OPERATIONS OX THE ABDOMEX. large enough to admit the left index finger (previously rendered aseptic)^ is made in the sac just below the seat of constriction. This is then divided on the finger as a director, from vithoid hurards. The sac should not be again opened here, but after all the constricting bands have been felt and perhaps heard to give way, the finger easily dilates the communication with the peritongeal cavity and then reduces the contents of the sac. I have used this method twice, and with excellent results. It reduces the necessary disturbance of peritonseal surfaces to a minimum. Where from long strangulation or the acuteness of the symptoms it is advisable to inspect the contents of the sac, or where these are adherent, the sac must be more freely opened. Cases will occasionally be met with, where, owing to the low condition of the patient, the large amount of intestine down, its great distension^ Fig. 10. (Skey.) its altered condition, still red and only congested, but softened, with the peritonjeal coat shaggy rather than lustrous, and tending to tear easily, it is clear that reduction will not be effected by manipulation only. If the distension is due to flatus, punctures may safeh" be made with a ver}- fine hj^drocele trocar. Where fluid fascal matter is present the above step is dangerous, and a small incision, carefull}- closed by Lembert's sutures, the inversion being thoroughly carried out, will give the best results. Where the intestine is much congested and softened, though not yet gangrenous, or where the surgeon has not skilled assistance and all the aids of modern surgery ready to his hand, he had better leave the intes- tine in the sac after a free division of the stricture.* This method, while * This will all gradually and slowly return into the peritoujeal cavity. On this point the following case by South (Chelius's Surgery, vol. ii. p. 40) is of interest : — " I know by STRANGULATED IN(;U1XAL HERNIA. 47 uiiclei' the above conditions tlie safer, prevents, of course, any attempt at relieving the patient, at one operation, by a radical cure. During any prolonged manipulation of the intestines these should be kept covered as much as possible by iodoform or plain sterile gauze wrung out of hot normal saline solution. It is wise also that the patient should be well under the anaesthetic now, and breathing quietly. If vomiting occur, the surgeon must wait, keeping up pressure on what he has reduced. When the intestine is all reduced, any ligatured stumps of omentum are returned, and, if the condition of the patient admit of it, the sac is detached, one of the methods of radical cure given at pp. 63 to 79 made use of, the precautions as to the cord and other points given at p. 62 being carefully followed. Ln this, as in other operations, the wound should be carefully sponged with mercury perchloride solution (i in 4000), and left exposed as little as possible, especially the parts near the opening into the peritonjeum. In providing drainage after an operation on a large inguinal hernia, where the parts have been much handled either before or during the operation, it is well worth while to bring the lower end of a drainage- tube out at the lower part of the freshly sterilised scrotvmi, by means of a counter-puncture there, thus ensuring efficient escape of the discharges, and syringing out of the wound if needful. After thus considering the chief points in the operation, it remains to draw attention to some special points connected with inguinal hernia. I. Varieties. — In addition to the oblique and direct varieties, both of which are acquired, there are some others of much practical importance — e.i/., («) The congenital. The tubular process of peritonaeum is open from abdomen to fundus scroti, and the contents lie in contact with the testis. (/>) Hernia into the funicular process of peritonaeum. Here the tubular process of peritonteum is divided into a shut vaginal sac below and an open funicular process above. Into the latter the contents descend, but are not in absolute contact with the testis, (c) Hour-glass contraction of the sac. Here the tubular process is open as in («), but an attempt at closure has brought about a constriction which may be at the external abdominal ring or lower down in the scrotiim. If the contents pass through this constriction, and get low enough, they will be in actual contact ■\^•ith the testis, (d) Encysted hernia of the tunica vaginalis. Here the funicular process is closed at its upper extremity — i.e., at either ring or in the canal — and open below to the testicle. The hernial protrusion as it comes down either ruptures this septum (when of sudden descent), or gradually inverts it. or comes down behind it. These experience that if strangulation be relieved, it is of little consequence how much intes- tine be down. In reference to this point, I recollect the lar^i^est scrotal rupture on which I have operated, and in which, before the division of the stricture, there was at least half a yard of bowel down, filled with air ; and, after the stricture had been cut through, at least as much more thrust through, so that I almost despaired of getting any back ; yet, after a time, I returned the whole. To my vexation, however, next morning I found that my patient had got out of bed to relieve himself on the chamber-pot. and. as might be expected, the bowel had descended, and in such quantity that the scrotum was at least as big as a quart pot. and the vermicular motion of the intestine was distinctly seen through the stretched skin. Nothing further was done than to keep the tumour raised to the level of the abdominal ring, and by degrees it returned, and the patient never had an untoward symptom." 48 OPERATIONS ON THE ABDOMEN. cases are rare, but may be puzzling when they occur, as the operator has more than one layer of peritongeum to incise before reaching the contents. That the above varieties have an importance bej^ond that of anatomical puzzles is shown by the fact that in (/>), (c), and (d) strangulation may be very acute and urgent. Again, though the defect is a congenital one, the hernia does not, in many cases, make its appearance till the patient has. in early adult life, been subjected to some sudden strain. Finally, in these cases an)^ prolongation of the taxis will be not onl}^ futile, but actuall}" dangerous, owing to the tightness of the strangulation and the facility with which, from the delicac}" of its adhesions, the sac may be separated or burst. II. Bed'udion en Masse, and Allied Conditions. — These have been chiefly met with in inguinal hernise owing to the loose connections of the sac and, sometimes, to the force used in attempts at reducing large sj^ecimens. Strangulation may persist after {a) displacement, or (6) rupture of the sac. In the former, the sac, still strangling its contents at its neck, is displaced bodily between the peritoneeum, usually, and extra-peritongeal fascia. In the latter the sac is rent, usually close to its neck and at its posterior aspect, and some of its contents are thrust through into the extra-peritongeal connective tissue. The chief evidence of these accidents is : though the swelling has disappeared, perhaps completely, this has taken place without the characteristic jerk or gurgle. On close examination, though the bulk of the hernia is gone, some swelling, often tender, is usuall}^ to be made out, deep down, in the neighbourhood of the internal ring. Above all, the s3'mptoms persist, perhaps in an intensified form. The treatment is immediate exploration of the inguinal canal and the internal ring. If the cord is exposed, the whole sac has probably been detached. If any of the sac is left above, a rent in it should be sought for. Supposing the index finger, passed through the internal ring, fail to find an}' swelling, aided by pressure from above, a vertical incision must be added to the upper end of the oblique one, and the neighbour- hood of the internal ring explored.* III. Betained Testis sionulating Hernia. — Such a testis, when inflamed, may closel}' simulate strangulated hernia. A testis, perhaps, has never descended ; a truss has been worn and laid aside. The patient presents himself with a tender swelling in one groin, with indistinct impulse. The abdomen is tense and full, constipation is present, and perhaps vomiting of bilious fluid. Such a swelling should be explored and the testis removed, as it is certain, later on, to cause serious trouble, even if the present urgent symptoms subside with palliative treatment. In other cases a retained testis may draw down an adherent loop of intes- tine which ma}' become actually strangled. f STRANGULATED UMBILICAL HERNIA. Two distinct forms of strangulated hernia will be met with here. One, more rare, is of small size, with a single knuckle of intestine acutely * As this will probably involve abdominal section, the steps given later should be referred to. t For fuller information on these matters I would refer my readers to The Diseases of the Male Orr/am of Generation, chapter ii. p. 72. STRANGULATED UMBILICAL HERNIA. 49 strangled in the navel-cicatrix. The other, the more common, is often huge, its contents mixed, intestine both large and small, and omentum. Such herniiie soon become, in part at least, irreducible ; when in this condition, any unwise meal may readily bring about obstruction, a condition requiring much care to tell from strangulation.* In other cases a large irreducible hernia may easily become strangulated from the descent of some additional loop of bowel. The adequate fitting of a truss is often a matter of much difficulty here, owing to the large size of the abdomen, the presence of adherent omentum, and, frequently, of an habitual cough. Practical Points before Operatioii. — (a) The sac usually communicates directly with the general peritonteal cavity by a large opening. (/3) The contents are not only mixed, but of long standing, and often adherent. (7) The patients are. often advanced in life, obese, flabby, and not infrequently the subjects of chronic bronchitis. (5) The coverings are ill nourished and slough easily. Operation. — In view of the delicacy of the skin and the intertrigo which is often pi'esent, the cleansing must be thorough but gentle. An anesthetic having been administered, an incision two to three inches long is made over the lowerf part of the swelling in the middle line, the hernia being pushed upwards to facilitate this.;!: The thinness of the cover- ings must be remembered. Search should be made for any constricting bands of fibres outside the sac. If it be needful, the sac must be opened, with the knife held horizontally, and slit up, care being taken now and throughout the operation, in cases of large herniee, that protrusion of intestine be prevented by the means given a little later. The contents having been examined, any intestine is gently displaced upwards, while the surgeon turns the curved surface of a Key's director over the lower edge of the opening, and, guiding the hernia-knife on this, di\4des the constricting edge downwards. If sufficient space is not given, the down- ward nick may be repeated, or the director turned against the lateral or upper aspects of the ring, and fibres here also divided. Adhesions of the contents of the sac are not infrequently met with. * Amongst the most important points will be the vomiting, whether early in onset, constant, and showing signs of becoming fssculent, and the constipation, whether absolute, even to the passage of flatus. In doubtful cases the rule should be to operate. " The risk of operating on a hernia which is inflamed and not easily reducible is very small in comparison with the risk of leaving one which is inflamed and strangulated ; and even if you can find reasons for waiting it must be ^^•ith the most constant over- sight, for an inflamed and irreducible hernia may at any time become strangulated, and will certainly do so if not relieved by rest and other appropriate treatment" (Sir J. Paget, loc. supra cit., p. 106). j- The lower part is here recommended because, in Mr. "Wood's words (^Intern. En^i/cL of Surg., vol. v. p. 1165), "the point of strangidation in an adult umbilical hernia is most frequently at the lower part of the neck of the sac, where the action of gravity, the dragging weight of the contents, and the superincumbent fat, together with the pressure and weight of the dress or an abdominal belt, combine to press downwards upon the sharp edge of the abdominal opening. It is here that adhesions and ulceration of the bowel are most frequently found, and here the surgeon must search for the constriction in cases of strangulation." An incision here also gives better drainage. X If the surgeon intends to attempt a radical cure, and if the skin is diseased, much thickened with old abrasions, he should remove this area by two elliptical incisions. VOL. II. 4 50 OPERATIONS ON THE ABDOMEN. If they are very close and dense, and if the condition of the patient is unsatisfactory, and if the surgeon be short-handed, he should be con- tent with a free division at one or two places of the consti'icting ring, and with reducing an}^ portion of intestine that has clearly only recently come down, and leave the rest undisturbed. A complication of large umbilical hernige is thus well descrilied by Mr. Wood (loc. sup-a cit., p. 1 168) : " In corpulent persons, in whom the operation has been delayed until peritonitis has begun, the operator has frequently to contend with a rush of bowels out of the abdomen. This should be restrained bj^ receiving them in warm towels* wet with carbolic lotion, and applying pressure by the hands of assistants. If it can be managed, all the operative proceedings within the sac should be done before such a rush occurs ; but if a cough, or vomiting, or anaesthetic difficulty occurs at this juncture, this is sometimes impossible, and the surgeon is compelled to do the best he can. In such cases the operation becomes a formidable one indeed, and is comparable only to laparotomy under conditions of distension of the intestines. The bowels and omentum should always, if possible, be kept in the warm wet towels, and not indiscriminately handled by the assistants, whose arms should be bared and well purified with carbolised lotion. The intestines should always be returned before the omentum, which should, if possible, be spread outf over them before the stitches are applied." All the intestine and the remains of the omentum, carefully ligatured, having been returned if possible, the surgeon now, if the patient's con- dition admits of it, removes the redundant sac and skin. The opening into the abdominal cavity is closed in the following manner : — The sac is carefully separated all round till its neck is cleared, the redundant part is cut away, and the peritonreum closed b}^ means of a continuous suture of fine silk. The edges of the ring are now drawn firmly together in the same wa}' by means of a continuous silk suture ; if and, finally, the skin edges are united with horsehair or fishing-gut. It will be seen from the above account that three methods may be pursued in the reduction of a strangulated umbilical hernia: (i) The division of the stricture outside the sac (p. 35). Where the surgeon is short-handed, this should always be tried, but is rarely successful here. (2) If the sac has to be opened, the opening is made as small as possible, and the ring freely divided at one or two points, but the contents disturbed as little as possible, any recently-descended intestine being returned, but thickened omentum and adherent intestine (esiDCcially large) being left undisturbed. (3) Free opening of the sac, examination * Large squares of iodoform gauze wrung out of hot sterile salt solution are to be preferred. f Mr. Wood prefers leaving the edge of the omentum so arranged as to become adherent to the lower margin of the hernial opening, so as to prevent, if possible, any- future protrusion, to tying it and cutting it short. J Mr. Barker (^lirif. Med. Jmirn., 1885, vol. ii. p. iioi) advises the use of a double row of sutures — the first as given above, to unite the edges of the ring ; the second, to give extra strength to the scar, are passed through the anterior layer of the sheath of the rectus on each side, at about one-third of an inch from the edge of the ring. On these being brought together, a considerable fold of fibrous tissue is inverted and brought into contact in the middle line, over the first row which closed the ring. STRANGULATED OBTUEATOE HERNIA. 5 I and separation of its contents, return of all intestine, and of omentum after ligature and resection. While the third of these courses has the great advantage of leaving the patient permanently in a more satisfactory condition, as it admits of something like a radical cure,* the surgeon can only rightly decide between this and the second course hy a careful consideration of each case. The following points may aid in judiciouslj' selecting either operation: — (i) The size, long standing, previous attacks of incarcera- tion and obstruction of the hernia, all these tending to bring about adhesions and alterations in the parts. (2) The condition of the patient — viz., the degree of flabby fatness, chronic bronchitis, probable renal and hepatic disease, amount of depression by vomiting and pain. (3) The facilities for carr^nng out, during the operation and later, strict antiseptic precautions. (4) The presence of the skilled help so essential in these cases. (5) The way in which the an;esthetic is taken. (6) The amount of experience of the ojDcrator. Thus a hospital surgeon, frequently operating and ^^•ith all instruments and assistance at hand, may readily incline to one course, while the other may as wisely be followed by a surgeon who has to operate under very different circumstances.! STRANGULATED OBTURATOR HERNIA. This form of hernia has occurred too frequently to be entirely passed over. It maj^ be so readily and fatally overlooked that a few words on its diagnosis will not be out of place. (i) Position of the swelling. This appears in the thigh below the horizontal ramus of the pubes, behind and just inside the femoral vessels, behind the pectineus, and outside the adductor longus. (2) On careful compai-ison of the outline of Scarpa's triangles, a slight fulness is found in one as compared with the hollow in the other. (3) Pain along the course of the obturator nerve, down the inner side of the thigh, knee, and leg. (4) Persistence of symptoms of strangulation, ±\\e other rings being empty or occupied by reducible hernia. (5) A vaginal or rectal examination. Operation. — Two different ones present themselves : (i.) by cutting down on the sac, as in other hernice ; (ii.) by abdominal section, and withdrawing the loop from within. (i.) The parts having been duly cleansed and slightly relaxed, an incision is made parallel to and just inside the femoral vein. J The * It will be remembered that it is not so essential to try and ensure a radical cure in the usual subjects of umbilical hernia as in children and young male adults, with the prospect of a long and active life before them. f Mr. Clement Lucas (^C'lin. Soc. Trans., vol. xix. p. 5) advocated more radical measures, such as excision of the sac and redundant skin, with suture of the ring, in .all cases of umbilical hernia. Two successful cases are recorded, both excellent instances of this treatment, and one of especial interest, as the patient had bei'ii previously thrice tapped for ascites, and the operation allowed three pints and a half .of fluid to escape. X Mr. Birkett (Joe. supra cit., p. 830) says the incision " may commence a little above Poupart's ligament, at a point midway between the spine of the pubes and the spot -where the femoral artery passes over the ramus of that bone." 52 OPERATIONS ON THE ABDOMEN. saphenous opening being probably exposed in part, the fascia over the pectineus and the fibres of this muscle having been divided transversely for one and a half or two inches, the obturator muscle covered by its fascia and some fattj' cellular tissue is next defined, and the hernial sac probably now comes into view, either between the muscle and the pubes, or between the fibres of the muscle. If the case is a recent one, attempts are now made to reduce the hernia without opening the sac. If the sac has to be opened, and an}* constriction divided, the knife should be turned either upwards or downwards, the latter being the easier if any constricting fibres intervene between the sac and the bone. As the obturator vessels lie usually on one side or the other, a lateral incision must be avoided. Care must be taken to keep the femoral vessels drawn outward with a retractor, while any branches of the obturator or anterior crural nerve are drawn aside with a l)lunt hook, the same precaution being taken with the saphena vein. When by the passage of the little finger into the abdomen it is certain that the intestine is reduced, if the condition of the patient admits of it, the sac is separated and ligatured close to the thyroid foramen and removed. Drainage must be provided with aseptic horsehair or a fine tube. (ii.) The operation of abdominal section will, perhaps, be more fre- quently performed in the future. An obturator hernia was thus reduced by Mr. Hilton in a case which simulated intestinal obstruction. Some empty intestine being found and traced downwards, led to the detection of an obturator hernia, which was reduced by gentle traction aided by firm pressure made deeply in the thigh. The patient, who was not operated on till the eleventh day, died of rapid peritonitis. Sir J. E. Erichsen briefly mentions a case operated on by this means in 1884 by Mr, Godlee. The hernia was reduced without dilficulty. but the patient, who was much collapsed at the time, died in about twenty-four hours. Question of the advisability of reducing Strangulated Hernia by- Abdominal Section. This question having arisen here may be dealt with once for all. Cases will occur from time to time, such as Mr. Hilton's {loc. supra cit.), in which, evidence of acute intestinal strangulation existing and no- hernia being detected externallv, on the abdomen being opened the cause will be found to be a piece of a small intestine nipped in part of its circumference, probably in either one of the femoral or obturator rings. Still more rarely, a surgeon may find such difficulty in reducing an obturator hernia from without, that he feels himself driven to resort to abdominal section. In such a case an incision should be made along the corresponding linea semilunaris, and brought as Ioav down as possible. When the abdomen is opened, if there is any difficulty in withdrawing the gut, the intestines should be pushed upwards out of the pelvis, and the neighbourhood of the ring shut off with sponges or iodoform gauze tampons, while the condition of the strangled loop is inspected, and this either reduced, or treated by resection, or hj the making of an artificial anus, according to the condition of the patient and the surroundings of the operator. vSome years ago it was suggested that it should be the rule to reduce hernife, and perform the radical cure by abdominal section. Thus, at the meeting of the British Medical Association in 1891 (Brit.. RADICAL CURE OF HERNIA. 53 Med. Juurn., Sept. 26, 1891), this question was discussed, tlie late Mr. Lawson Tait introducing the subject. As might be expected, the pro- posal to abandon the old operation and treatment by median abdominal section met with no support from those surgeons who know anything of operations for strangulated hernia in hospital practice, especially in males. Save in the rarest cases, such as those belonging to the category I have mentioned, such a step is to be condemned in the strongest terms, for the following reasons: (i) Operations for relief of strangulated hernia must sometimes be performecl by general practitioners. The old and well-established operation is one, j^^"'' se, of but slight severity, and one that usually can be kept extra-peritonfeal by an operator of ordinary skill and of average anatomical knowledge. Those who would substi- tute abdominal section forget that, however safe they may consider themselves, with their especial experience, to be in preventing pe/77o7r/fts — a ver}- different standpoint from that of a general practitioner — neither they nor anyone else can prevent the shock which goes with intra-peritonaeal operations, a complication which is certainly to be avoided in patients exhausted by a strangulated heniia. (2) The reduction of the intestine which is spoken of as so easy after abdominal section by those who advocate this method, is liable to be prevented by adhesions to the sac, &c. ; when such exist — and no one can foretell this point — the sac must be explored in the usual way. (3) There is a very grave risk that the intestine is tightly nipped, and often may give way when pulled upon through a median incision. Those who advocate abdominal section will say that the resulting extravasation can be met by flushing, &c. It will be well for all such to remember the following advice, tersely put by Sir W. Bennett (Clin. Led. on Hernia, p. 122): " Let it be noted that it is generally far more easy to soil the peritonaeum than to cleanse it." The same surgeon points out (ibidem, p. 121) that the fluid found in the sac of hernia, when strangulation has long existed, is sometimes dark and ill-smelling, though no lesion may be apparent in the gut itself. B3' an ordinary herniotomy such fluid is thoroughly drained away from the peritonaeal cavity, and any such intestine is cleansed before it is put back, or otherwise appropriately dealt with, (4) All operating surgeons are agreed that, whenever the condition of the patient admits of it, an operation for strangulated hernia should be com])leted by giving the patient at least a chance of radical cin^e. I am distinctly of opinion that no intra-])eritonasal operation yet described will secure radical results in inguinal heniiae. (5) Those who think they are improving matters by substituting abdominal section for the old-established herniotomy, object to the latter on account of its ten- dency to weaken the abdominal wall by the incision made to reach and relieve the constriction. Such advocates forget the criticism pithily put forward during the above discussion by Mr. Keetley, that treatment of herniee by abdominal section created two potential hernial apeitures where there was originally but one. RADICAL CURE OF HERNIA. Before describing the diflferent methods, the following points claim attention ; and while the improvements of modern surgery have esta- blished radical cure on a sound scientific basis, many questions remain 54 OPERATIONS OX THE ABDOMEN. still iTiidecided. The chief of these are : (i) The justifiability of the operation. (2) The use of the terms " radical cure " and " jjermanency of the cure." (3) The earliest age at which the operation is advisable in children. (4) The advisabilit}' or need of wearing a truss afterwards. (5) The best material for suture. (6) The best form of operation. (i) The Justifiability of the Operation. — Before we can answer this in the affirmative we must be able to honestly feel that the operation is safe, (a) as regards the fatieni's life, (8) as regards the testicle. Only those surgeons who have had experience in operating, who are thoroughly acquainted with the needs of modern surgery, and who will pay the needful attention to every detail, can promise the above safety. (a) The safety of tJie patient's life. — The following recent statistics show what modern surgery and experienced hands can do. Drs. Bull and Coley {Annals of Surgery, vol. xxviii., 1898, p. 604) have compiled a list of 8594 cases under the care, be it noted, of well-known operators, with seventy-eight deaths, giving the very low mortality rate of -g per cent. (/3) The safety of the testide.—TYna is dealt with at p. 62. (2) The Value of the Term " Radical Cure," and the Permanence of the Cure after Operation. — Present results give the promise of great improvement here. A few years ago some of the best authorities were not using the term '• radical."' Thus, Sir W. M. Banks,* one of the earliest and foremost workers on the subject, and a writer who has given his results with honest frankness, considers the term radical cure " misleading. It is popularly understood that a patient upon whom the radical cure has been performed need never again wear a truss nor ever again be in danger of his hernia coming down. This is, unfor- tunately, far from being the case. The instances in which a light truss can be dispensed with are in the minority." A few years later (Brit. Med. Journ., 1893, vol. ii. p. 1044) he wrote somewhat more hope- fully. Of 168 cases he had traced for very considerable periods 113 ; "of these 79 remain quite sound, 19 are partial successes, and 15 are complete failures." In America — where, as with oophorectomy and removal of the appendix, this operation has been resorted to more freely than in this countrj' — warnings have been given by some of the best- known surgeons that the use of the term " radical cure" may be pre- mature. Amongst the chief of these has been Dr. W. T. Bull,t Surgeon to the Hospital for the Euptured and Crippled, of New York. Dr. Bull has collected 137 cases operated on for radical cure in which a relapse had taken place, and he adds that these relapsed cases •• probably represent but a small proportion of those operated on." Mr. JNIacready. Surgeon to the City of London Truss Society, writes the following weighty words on what he calls the unsatisfactory nature of the evidence as to efficacy of the radical cvire (A Treatise on Ruptures, p. 234) : " The evidence brought forward by one surgeon after another in favour of these operations is alwajrs of the same character. A number of cases are given in which the operation has been performed, and in which the result has been Avatched for periods varying usually from a * Pamphlet; Med. Timts and Gciz., 1884; Brit. Med. Journ., Dec. 10, 1887. f N.Y. Med. Journ., May 30, 1891; Med. NeivH, 1890; Annals of Surr/cry, 1893. vol. i. p. 534 et mj. R.U)ICAL CURE OF HERNIA. 55 few months to four or five years. Very few cases are under observation so long as five years ; for the patient changes his residence or declines to show himself. M. Terrier on one occasion wrote to twenty-five old patients, and received only two replies. It must not be supposed that a patient is cured because he does not come for inspection. The relapsed cases at the Truss Society have almost all been asked if they have visited the operator to show him the result. In the great majority of cases they prefer not to go back, and very often, alas ! express themselves as if a Fig. II. Dissection of iiiguinal canal. I, External oblique turned down. 2, Internal oblique. 3, Transversalis. 4, Conjoined tendon. 5, Rectus abdominis ■with its sheath opened. 6, Triangular fascia. 7, Cremaster. (Heath.) deception had been practised upon them. It is much to be regretted that patients should feel this reluctance to face the operator again, for in consequence the surgeon is apt to form too favourable an opinion of the efiicac}^ of his plan. Sometimes a patient, after remaining cured for a number of years, passes from under observation and again becomes ruptured All that we can say of the operations, involving complete removal of the sac, is that they all give immunity to a certain number for a certain time." AMiile opinions like the above, candidly expressed by operators of wide 56 OPEEATIONS OX THE ABD03IEN. experience, will carry special weight with all thoughtful surgeons, it is probable that the work of the last few years, and still more that of the coming decade, will place the radical cure of hernia on a firmer and more satisfactory basis. We are now learning more distinctly the principles on which this operation is to be conducted. Two or three methods have now been emploj'ed on such a large scale, and with such excellent results, that it seems probable that a permanent cure can be promised in a large number of favourable cases. Tliis cpialified statement requires explanation. By a " permanent cure," I mean a cure which will last a lifetime. By •' favourable cases," I mean children, young subjects, hernise of moderate size, where the rings and canal are still present and not stretched and converted into one large direct gap into -s^'hich the tips of two or three fingers can be easily placed ; cases where the patients operated on have sense enough to give the newly repaired structures sufficient rest for their consolidation, and where, if they must follow employment or exercise that involves much straining, they will give the parts the support of a truss of light pressure or a belt* (vide infra). If this is not done we shall see, if cases are carefully followed up and candidly reported, that radical cures will not last a lifetime, and that the term will have to be largely replaced by the following, according to the degree of cure obtained — viz., " complete successes," " partial successes," " complete failures." Since Bassini published, in 1888, the description of his operation, this method, either as first described or modified in some slight degree, has become more and more popular, and. at the present time, its adoption may be said to be almost universal. Drs. Bull and Coley (Joe. siqrra cit.) have given the results of the operations by Bassini's method which they have performed up to September 1898. In all there are 343 opera- tions with only three relapses. It is true that some of these operations had been done quite recently, and the true result in these could not therefore be finally decided ; nevertheless, since many of the operations had been done over five years before publication, the results, taken as a whole, must be considered very satisfactory, and more excellent than any large collection of cases yet published. Drs. Bull and Coley also give an analysis of 360 cases of relapse after operations for radical cure, that were seen at the New York Hospital for Ruptured and Crippled. In no less than 80 per cent, of the cases relapse had taken place within twelve months of the operation ; on the other hand, in five cases the period was between ten and twenty-two years after operation. It may be said, therefore, that after one year the chances of relapse are not great, although no absolute time limit can be given after which cure ma}'' be said to be absolute. From the above it is clear that, when consulted as to the performance of a radical cure by patients the subject of hernia, they can be assured * Many will say that if any truss or support is worn afterwards the cure is not radical ; I admit this, but reply that until published series of cases have been watched for a much longer period, we shall, as relapses may occur five or eight years after operation, do wisely to advise the above class of patients to support the restored region with a well-fitting truss of light pressure, and so bring about a permanent cure instead of a liability to relapse. EADICAL CURE OF HERNIA. 57 as to the safety of the operation and the probable permanence of the cure in favourable cases (vide siqmi). Furthermore, it is certain that if a relapse should occur the majority of patients will be better off than before the operation. The protrusion that appears will be smaller than the original rupture, more readily kept within bounds like a bubonocele, and a truss will be worn with greater comfort. On the other hand, if suppuration occur, and a thin- walled feeble cicatrix, sure to 3'ield increasingly as years go on, is the only result, the outcome of the operation may leave the patient worse off than he was before. A question that often arises relates to the wearing of a truss and the possibility of the hernia being cured by this means alone. The answer deciding between the wearing of a truss and an operation for radical cure will depend greatly on the mind of the surgeon consulted. If he is one of those who believe that this operation is too indiscrimi- nately resorted to, he will hold that no operation, save for special reasons (vide Indications for Operation), is to be advised where the hernia can be kept up by a truss, and that a light and well-fitting truss is not the bugbear it is too often made out to be by those who advocate operation as the rule. It would be well if surgeons would spend some of that pain and trouble in ensuring that the ti'uss fits, before it is thrown aside, which they give to inventing or modifying operations for radical cure, and if patients would exert a little more trouble and pains in getting a proper and well-fitting truss at a duly qualified instrument-maker's, instead of the first cheap trash which they see in a chemist's shop. I have pointed out below, under the heading Indications for Operation, the cases where this question of wearing a truss does not arise.* "When this question, whether the wearing of a truss will effect a radical cure, arises in the case of infants and children, these cases may he divided into the following groups. In one — and this is the largest of the three — the careful wearing of a truss by a child will permanently cure the rupture. In a second group — a large one — the hernia, though not cured, will be perfectly controlled with very slight inconvenience to the patient. In the third — a very small one — there is no tendency to spontaneous cure even when a suitable truss has been diligently worn. On this follows naturally the next tjuestion : (3) What is the earliest age at which an operation should be performed ? Iklow 1 have stated my opinion that while it is occasionally justifiable to operate in the second year of life, where a persisting hernia is large, it is, as a rule, better to defer operation till the age of four or later. In this connec- tion the following expressions of opinion by Mr. Langton (Brit. Med. Jouni., April ;9."i899. p. 472) may be quoted: ''The cases requiring operation are comparatively rare, and ojieration should not be recom- mended in infancy." And again : '-Experience proves that hernia occurs at an age ill suited for operation, and that if properly treated (by truss) it is usually cured long before any question of operation arises." (4) The Advisability or Need of wearing a Truss afterwards. — The tendency of the present day to condemn offhand or to deprecate * An ill-fitting truss is, of convse, worse than useless, and may mat together the tissues. 58 OPERATIONS ON THE ABDOMEN. strongly the use of a triiss after an operation for radical cure is, I think, a great mistake. Each case must be judged separately, With regard to children, from an experience of my cases, I think that if the recum- bent position be insisted on for three months after the operation, so as to give the newly restored parts time to consolidate firmly, a truss will not be subsequently required, so great is the tendency to repair in early life. Umbilical hernise I am inclined to make an exception. The com- munication which has here been closed has been relatively so large, the stress thrown upon it after repair in expiratory efforts (as when the child cries every time at the approach of the surgeon or dresser during the after-treatment) is so direct, that the scar should, I think, have support for some time in the form of a well-fitting belt.* In adults the objection usually made to a truss is that its pressure will produce absorption of the scar. While it will be granted at once that any continuous pressure in the form of a pad with a strong spring w-ill tend to weaken and remove the inflammatory thickening resulting from the operation, I am distinctly of opinion that some well-fitting slight support in the form of a truss or belt should be worn in the following cases — viz., where the abdominal walls are very fat, flabby and pendulous ; wdiere there is heavy work either done continuously or by fits and starts ; where any silk has worked out, or wdiere the wound has healed by suppuration (vide siqjra, p. 57) ; in some cases where the radical cure has been done after an operation for the relief of strangula- tion, and the surgeon has perhaps been hurried, or has operated at night ; and, of course, in cases where there is any return of the hernia. Other cases are umbilical hernise, Ijoth in adults and children, for the reason I have given above ; in femoral hernias, owing to the difficulty, in many cases, of doing more than twisting, tying, or inverting the sac (p. 79), and also because the sex and dress of the patient usuall}^ make the A^-earing of a truss less irksome. On the other hand, in early congenital cases, in boys, in young adults without laborious work, or where the reparative power is good, where sufficient rest has been taken after the operation, and where primary union has been secured and remains fii'm, no truss need be worn. But the importance of intelligent supervision at intervals should be insisted upon. The presence of a cough, carelessness about constipation, or a stricture will, of course, be duly weighed ; and I may remind my readers of a warning vittered at p. 55, that relapse may take place as late as four or even eight years after a skilfully performed operation. On the other hand, it is only fair to say that the opinion on this matter expressed by others is widely divergent on some points from that given above. For instance, Drs. Bull and Coley (loc. supra cit.) say : '• Personall}^ we never advise a truss in children after operation, and we consider the recumbent position for three months entirely vinnecessar}^ Our experience, based on a series of upwards of 600 cases of hernia in children under fourteen years of age, has shown that two, to two and a half weeks is ample time for the child to remain in bed. The subsequent history of these cases has been traced with scrupulous care, and some of them have been well upwards of seven years. Even in adults we very seldom advise a truss after operation. There are, however, some cases in * Any phimosis or cough should, of course, be treated. RADICAL CURE OF HERNIA. 59 which a permanent cure will be more likely to be obtained if a support be worn after operation. Such cases are those beyond middle age, with poorl}' developed and flabby abdominal muscles and a superabundance of fat. We would also include cases in which the hernia is of unusual size in adults past middle life." Lockwood (Hernia, Hydrocele, and Varicocele), again, does not order a trviss after operation, except in cases in which some support is specially called for. He says : " So far as I can see, it is time enough to order a truss when signs of recurrence appear. After radical cure has been done, relapse seldom occurs suddenly. When the sac has been thoroughly obliterated by the operation, the hernial protrusion has to make for itself a new one ; this is usually a slow process and accompanied by pain from the beginning." This practice is clearly justified by results, for Lock- wood's list of cases shows only five relapses in ninety-one cases, in periods varying from six months to seven years. It may be noted, also, that in each of these five cases the relapse occurred within twelve months. (5) The Best Form of Suture. — Though hitherto I have used silk, I am of opinion that kangaroo-tendon, if a suitable specimen, duly sterilised, can be obtained, will be found preferable, and I intend to make trial of this in future. Silk is most satisfactory to work with at the time ; it can be obtained at once, it is soon sterilised, it is strong, and it lends itself readily to easy tying and a secure knot. But the after-result is, in my opinion, less satisfactory, owing to its liability to come away, often persistently. There is a tendency to believe and teach that wherever silk comes away after an operation, it must always be due to some deficient sterilisation of the silk, or to some failure to keep the wound aseptic. While these are leading causes, they are not, I am persuaded, the only ones ; the site and the character of the tissues concerned play a very important part. Inside the peritonasal cavity, where the ligatm'e lies deep and is surrounded by a serous membrane, as in an ovarian pedicle, we are certain our silk ligature will give no trouble ; in ligature of the carotid or femoral artery, where the ligature also lies deep and is surrounded by vascular structures, we have rarely trouble with our silk ligatures ; but here, where any silk used lies comparatively superficially and embedded in fibrous tissues such as the conjoined tendon or Poupart's ligament, its surroundings are so different that a surgeon need not always blame himself for deficient asepsis or faulty tying when his silk comes away. I am aware that many surgeons, higher authorities than myself, claim that silk, wire, salmon-gut can all be used as buried sutures without any further trouble. In a certain aiid large proportion I know from experience that silk can be used, but in a considerable number this and the other materials most certainly cause trouble later on. The wound runs an aseptic course, heals without suppuration, and then, after a varying period, a sinus appears, and one or more of the sutures have to be removed. Prof. Macewen uses chromicised catgut, prepared by himself. Drs. Bull and Coley, in the paper referred to above, used kangaroo-tendon in 342 cases, and though the interval between the date of operation and that of publication is in very many of them far too brief for the cure to deserve, in my opinion, the term " radical," the constancy with which primary \niion was secured speaks very strongly, I think, for the use of kangaroo-tendon in preference to silk. 60 OPERATIONS OX THE ABDOMEN. Indications. — -The following are given only as types of appropriate cases. Many others will suggest themselves : i. Cases of irreducible hernia where other treatment has failed, where an active life is interfered with, or where attacks of inflammation have occurred, or strangulation is threatened. Subjects of inguinal hernia with adherent omentum are never really safe, esjDecially if of active life : from this, however, they are usually debarred. Femoral hernias containing irreducible omentum should also be operated on. These hernioe are difficult to fit with trusses ; the omentum keeps the ring open, and thus paves the way for the descent of bowel on any sudden exertion. AVhere irreducible hernise are small, and the adhesions easily separated, great relief will be given the patient with very slight risk. But it is other- wise where the sac is very large, or the contents adherent, especially about the neck of the sac. In either case the risk of the operation is increased, in the one case from the direct opening into the peri- tonseal cavity which may be present, the large amount of contents which have to be manipulated, and the difficulty of keeping the operation extra-peritonasal. Again, intricate adhesions about the neck of the sac may either lead the surgeon to abandon the operation, or to lay open the abdominal wall in order to deal \\'ith them. This last step not only increases the risk of peritonitis at the time, but may bring about, some time later, a hernia very difficult of control, the ultimate improvement in the patient's condition being thus of a very limited nature. ii. Cases of strangulated hernia, where the patient's condition admits of the oi:)eration being prolonged. iii. Cases where a hernia is not controlled by a truss, but slips beneath it. Such cases would be extremely rare if patient and surgeon alike showed sufficient pains and patience in securing a well-fitting truss, iv. Cases of hernia with ectopia testis where the fitting of a truss to keep the hernia up and the testicle down fails. Castration should always be performed when the condition of the testis is useless or doubtful. V. Cases where the hernia can be controlled by a truss, but the use of this is irksome to a patient of very active life, where he wishes to join the army or navy, or where he may, as a colonist, be far removed froin surgical help. vi. Children of poor, ignorant, and incompetent parents, with large hernise, where jiroper attention to the use of a truss cannot be secured, or Mhere the persevering use of this has failed, and where all such causes as phimosis, cough, &c.. have been removed. It will probably be justifiable to go further than this, and to operate for radical cure in most cases of hernia? in the children of the poor in which the hernia is still large at four to six years of age.* By this time the parts are better developed and more easily kept aseptic. The sac is more easily dealt with now than later. The presence of any conditions ^^"hich call for explora- tion — viz., hydrocele, adherent omentum, the presence of the appendix — will also be indications for operation in children. On this point, operation for radical cure in little children,! I will quote Mr. Macready * This age is mentioued above as giving time for sufficient trials with a truss. t Before deciding that a well-made truss will not keep up a difficult case — e.f/.. a double inguinal hernia — the hernia should be completely reduced with the aid of an anaesthetic. RADICAL CURE OF INGUINAL HERNIA. 6 1 {loc. supra cit., p. 256). We may all envy his special experience and strive to imitate his skill. '• Uncontrollable ruptures in childi*en under fifteen are very rare ; to me, indeed, the}' are as yet unknown. I hope it does not imply any lack of charity to say that one can measure with fair accuracy a suro'eon's skill in the management of trusses by the number of curative operations he performs on children." vii. Large herniee, even colossal, Avhere tlie patients, unfitted for work of any kind, are a burden to themselves and others,* and perhaps willing to run great risks ; for it cannot be denied that these are very grave cases : " The operation usually difficult and prolonged, and the dangers to be met and overcome both numerous and various "' (Banks). The chief of these is the direct and gaping communication M-ith the peritontcal cavity and the difficulty in keeping the operation extra-peritonaeal. The best proof of this is given by Sir W. M. Banks' sei'ies of sixteen very large and enormous herniaB : of these he lost four, two from septicaemia. In another, even his hands failed to complete the operation. viii. I consider ten to twenty-five years of age the most favourable time, as combining parts easy to handle, the possibility of keeping the wound aseptic, probable absence of any difficult adiiesions, and good vitality and health. Choice of Operation. — The following have been brought pro- minently before the pi'ofession, viz.: i. Operation by Open Method. ii. Subcutaneous Methods — e.ti.. Prof. Wood's and Mr. Spanton's. iii. Injection of Astringents — e.i/.. Oak-bark. Of these, only the operation by open method will be described, as it is the one of all others which is generally chosen, owing to the excellent results which it has given, the precision with which the structures concerned can be avoided or manipulated, and its safety when aseptic precautions are strictly oliserved. i. The Operation by Open Method, t — The patient having been kept in bed for some time before, according to the size of the hernia, and any cough attended to, only liquid diet is given for the few days preceding the operation, and the bowels are duly emptied. Before describing the different methods mostly in vogue, I will allude, for the sake of my younger readers, to a few points which are always of importance, whichever method is selected. The thigh being a little flexed, an incision is made over the inguinal canal, and extending an inch below the external abdominal ring. This divides skin and fascire and several branches of the external pudic arteries ; these should be secured with Spencer Wells's forceps, which will also open out the wound. In j'oung males, especially, where these vessels are of considerable size, care must be taken that each point is firmly closed either by the forci-pressure or catgut ligature ; otherwise free bleeding may readily take place in the lax tissues of the groin, pre- * As iu three cases given by Sir W. II. Banks : one, a labourer, unfitted for work, had become an inmate of a workhouse ; the second was a wine merchant, who had been obliged to give up his business, rarely venturing out, and then obliged to conceal his deformity under a large overcoat ; the third, a glass-blower, reduced to perfect helpless- ness, had to depend on his wife for his support. t The following remarks apply to inguinal hernia. 62 OPEEATIONS OX THE ABDOMEN. venting ])i-imaiT union, and perhaps leading to most troublesome tension and suppuration. The aponeurosis of the external oblique and the cremasteric fascia having been next divided, the site of the cord is made certain of, and the sac most carefull}^ defined. This, if empty, is by no means always eas}", especially in young subjects. In defining the sac, care should be taken to work carefully and without any needless disturbance of the parts, or separation of the planes of tissue here met with. So, too, with the cord — great care must be taken in the next step, when the sac and this structure are separated; hasty work may lead to needless haemorrhage from ruptured veins, injury to the sac, or subsequent epididymo-orchitis, and even sloughing of the epididymis with part of the testicle. The sac having been accuratel}^ defined, is opened so that an aseptic finger may make sure that it is empty ; otherwise any intes- tine is completely reduced or omentum dealt with according to the steps given at p. 37. If the question arise, whether the sac should always be opened, I should answer " Yes." Even if it appear empty below, it is satisfactory to be assured by digital examination that nothing lies within the neck before this is twisted or tied as high up as possible. A case of Busch's {Klin. Med. Woch., 1882, No. 31, p. 473) shows the importance of taking this step. Operating on a boy 2f jears old for a right inguinal hernia, Busch tied the sac before opening it. When it was cut into below the ligature the vermiform appendix was found included. This was released and returned. Some time later Busch was operating on the left side, and again found that he had included the appendix in his ligature round the sac. When the emptied sac is next separated from the cord and adjacent parts,* care must be taken, if the patient strain at this time, that no escape of intestine occur, an assistant maintaining pressure over the in- ternal ring. The cord must be treated with the precautions given above, and care must be taken that the testicle is not dragged needlessly out of its bed. The sac is now treated, and the canal closed by one of the methods given in detail below. The wound having been thoroughly dried out, and some sterilised iodoform dusted into its recesses, it is closed with sutures of salmon-gut or horsehair, care being taken that no inversion of the edges is present, and, of far more importance, that all haemorrhage has been entirely stopped, including those points from which Spencer Wells's forceps have been removed. If absolute dryness of the wound has been secured, and the operation has been aseptic throughout, no drainage is needed. A slip of green protective out of carbolic acid lotion (i in 20), and some strips of iodoform gauze wrung out of the same, are then placed next the wound, and covered by any of the antiseptic gauzes or wools. It is important to keep the scrotum well up on the pubes, and thus minimise the risks of oedema of the scrotum and epididymo-orchitis. To the above general remarks I have onl}^ to add that it is always well, when the radical cure is performed in patients with long-standing- hernia (with important parts and the sac perhaps very adherent), or a voluminous one, for the operator to obtain leave beforehand to sacrifice the testicle ; and the same course will be taken when a retained testicle * If much difficulty is met with here, the surgeon should begin high up, as near the internal ring as possible, di\'iding the external oblique aponeurosis. RADICAL CURE OF INGUINAL IIEEXIA. 63 is found to be probably fuiictionless. If it is AA-orth wliile to fix this again in the scrotum, this should be done according to the steps given under the heading of Orchidopexy. Any child or restless patient should be secured in a long outside splint. Finally, if any stitch-sinus appear, that part of the wound should be well scraped out at once, and made to heal from the bottom. The different methods that have been elaborated are very numerous, and only those which are chiefly in vogue at the present time can be described here in full. Brief mention Avill, however, be made of some of the others. It will be seen, if these various methods be compared with one another, that, whereas most of them are alike in aiming at recon- stituting, in some degi'ee. the original valvular condition of the inguinal canal, on the other hand, they differ chiefly as regards the method of dealing with the hernial sac. Taking the latter point first, it will be seen that the various special methods that have been devised for dealing with the sac aim chiefly at converting the normal depression, or peritonaeal fossa, at the position of the internal abdominal ring, into a prominence with its convexity towards the abdominal cavity. Even if the operation does succeed in attaining this, it must surely be only temporary, for, clearly, the sac wiU rapidly shrink and undergo partial absorption. Moreover, since there is normally a slight depression in this position, and since only a very small proportion of all individuals suffer from inguinal hernia, it is clear that the removal of the depression at the site of the internal abdominal ring is not to be looked upon as the most important part of an operation for the radical cure of a hernia. This contention is borne out by the results of operation, for in Bassini's operation, which is so successful as to be almost considered perfect (vide p. 56 for results), the sac is simplv ligatured at its neck, and the rest removed, leaving, therefore, a depression in the peritonseum opposite the ligature. With regard to the question of the inguinal canal, it is clear that the normal valvular arrangement (ru/g Fig. 12) of the canal is extremely satisfactory in preventing the descent of an inguinal hernia, since such a very small proportion of all individuals sufier from this condition. This would lead one to expect that that operation which most satisfactorily and simply reconstitutes the original condition of the inguinal canal will be attended with the most satisfactorv results. Bassini's operation practicallv does reconstitute the normal ingiiinal canal, and moreover justifies the above argument, since the results are so satisfactory and its adoption is so ^^'idespread. Other advantages of Bassini's method are, that it is easy and straightforward to perform, and that the whole length of the canal is exposed to view, thus allowing (as pointed out b)'- Lockwood) the removal of any conditions which may be liable to dis- tend the inguinal canal, such as lipomata of the cord or inguinal vari- coceles. For these reasons Bassini's operation will be described first. (l.) Bassinis Method (Fig. 14). — An oblique incision, at least four inches long in an adult, somewhat less in a child, is made over the position of the inguinal canal, and ending below opposite the pubic crest. The fascia having been divided, the external oblique aponeurosis is exposed and the external abdominal ring identified. The external oblique is now divided along the length of the canal, and flaps separated in both directions for a short distance, thus thoroughly 64 OPERATIONS OX THE ABDOMEN. exposing the whole length of the ingumal canal. The sac is now identified and cat-efully separated from the cord well np to the level of the internal ring. It is then opened and carefully emptied, all adhesions being carefully separated, and omentum either ligatured and removed or reduced. The neck of the sac having been somewhat pulled down, is transfixed and ligatui'ed ^^'ith silk or kangaroo-tendon at the highest jDOssible point, then divided about half an inch below" the ligature, and the rest of the sac removed. Next, the cord is raised carefully from its bed, and, supported in a loop of gauze, is held forward by an assistant while the sutures are introduced. At this stage any lipomata of the cord or an inguinal varicocele may be i-emoved, as advised by Lockwood. The posterior wall of the inguinal canal is now repaired by means of sutures. These will vary in number from two to five, according to the size of the gap between the internal oblique or conjoined tendon on the one hand, and Poupart's ligament on the other (i-ide Fig. 13). These sutures consist either of kangaroo-tendon Fig. 12. Fig. 13. A normal inguinal canal. Arciform fibres compressing the cord against Pou- part's ligament. (Lockwood.) Inguinal canal in case of liernia. The arciform fibres are displaced upwards, the normal valvular condition of the canal being thereby destroyed. (Lockwood.) or silk, and are passed in the following manner: — The needle is first passed through the deep aspect of I'oupart's ligament, then beneath the uplifted cord, and finally through the lower margin of the internal oblique or conjoined tendon. In order to avoid wounding the perito- naeum, the needle is passed through the conjoined tendon from its deep to its superficial aspect {cide Fig. 14). Sufficient suture's having been passed, they are tied carefully and cut short, and the cord allowed to fall back into its place. The divided edges of the external oblique are now united by means of a fine continuous suture, and the external ring, if large, partially closed at the same time. All bleeding having been carefully arrested, the skin is sutured and the dressings applied. (2.) Maceiven's Operation"''' (Figs. 15 to 21). The object of this is tw^ofold: (i) So thoroughly to separate the sac * Ann. of Surg., Aug. 1886; lirit. Med. Journ., Dec. 10, 18S7. HADICAL CURE OF INGUINAL HERNIA. 65 fls to allow of its being completely reduced into the abdominal cavity, there to rest on the inner surface of the ring, and acting as a bulwark- like pad to "shed the intestinal waves away" from it. Prof. Macewen thinks that if the sac be merelj* tied, however carefully and high up this is done, there remains a fun- nel shaped puckering, the apex of which presents in the internal ring, and that this ])0uch gradually becomes a wedge, tending to open up the canal. Thorough separation of the ■sac, and carrying this well within the peritoneal cavity, is absolutely needful, for if the sac be left in the canal it Fig. 14. Fig. 15. Bassiui's operation. Showing the method of inserting the deep sutures. (Lockwood.) Maceweu's operation. The index finger, in- serted along the inguinal canal, is separating the peritonteum from the internal aspect of the internal ring. The folded sac is behind. In this and the following figures a flap of skin and cellular tissue has been reflected, and the external oblique opened up so as to expose the canal and internal ring. will act as a plug, keeping it open. (2) Again, to close the dilated •canal and restore its natural valve-like condition by a particular mode of insei'ting sutures which bring the conjoined tendon in close apposi- tion with Poupart"s ligament, beginning with that part of the ligament \\hich is on a level with the lowest part of the internal ring. The first object is thus ensured : — The external ring having been •exposed, the internal ring and site of the deep epigastric are examined, and the sac next freed and raised. When this has been done it is kept pulled down while the index-finger separates the sac from the cord, the canal, and finally for half an inch around the abdominal aspect of the internal ring* (Fig. 15). The sac is now folded on itself (Figs. 16, 17) by means of a stitch which is firmly fixed in the distal end of the sac. The free end, threaded on a hernia-needle (Fig. 17), is introduced through the canal to the abdominal aspect of the fascia transversalis, and there penetrates the abdominal wall about an inch above the * The object of this is to refresh the abdominal aspect of the internal ring so that Adhesions may form between it and the pad of sac. VOL. 11. 5 66 OPERATIO^'y ox THE ABDOMEN. internal ring (Fig. i6). The wound in the skin is pulled upwards,* so as to allow the point of the needle to project through the muscles without penetrating the skin. The needle being withdrawn and un- threaded, by traction on the thread the folded sac is drawn still further backwards and upwards. Traction having been kept up on the thread while the sutures closing the canal are introduced, it is finally secured by passing it several times thi'ough the external oblique muscle. The second part of the operation, closure of the inguinal canal, is now undertaken. The fin- ^^°- 1 6- ger, passed into the canal and lying between the in- ner and lower border of the internal ring in front of and above the cord, makes out the position of the deep epigastric artery so as to avoid it. The hernia-needle, carry- ing chromic gut, then, guided by the index, is made to penetrate the conjoined tendon in two places : first, from without inwards near the lower border of the conjoined tendon; and secondh', from within outwards, as high up as possible in the inner aspect of the canal : this double penetration of the conjoined tendon being' accomplished by a single screw-like turn of the in- strument (Fig. 1 8). One* end of the suture is then withdrawn, and the needle, with the other end, is re- moved. Thus, a loop is left on the abdominal aspect of the conjoined tendon, which is penetrated twice (Fig. 19). Secondly, the other hernia-needle, threaded with that part of the suture which comes from the lower part of the conjoined tendon, guided by the index in the inguinal canal, is passed from within outwards Maceweii's operation. The hernia-needle is carrying the suture, threaded through the sac, througli the abdominal muscles, from behind for- ward, about an iuch above tlie internal ring. * Beginners will find it best to divide the aponeurosis of the external oblique, and so obtain sufficient room for rightly dealing with the sac. This requires an additional row of sutures, and may weaken the abdominal wall. On the other hand, beginners will always find it difficult, however much the upper angle of the wound is pulled iip, to get the sac detached really high up, and to put the needful sutures into the conjoined tendon with the limited incision which is sufficient for the experienced hands of Prof.. Macowen. RADICAL CURE OF IXGUINAL HERNIA. 67 through Poupart's ligament, which it penetrates at a point on a level with the lower suture in the conjoined tendon (Fig. 20). The needle is then completely freed from the sutiire and withdrawn. Thirdly, the needle, now threaded with that part of the catgiit which protrudes from the upper border of the conjoined tendon, is passed from within outwards through the transversalis and internal oblique muscles and the aponeurosis of the external oblique at a point on a level with the upper stitch in the conjoined tendon. It is then quite freed from the suture and withdrawn. There are now two free ends in the outer surface on the external oblique, continuous with the loop on the abdominal surface of the conjoined tendon (Fig. 21). The two free ends being drawn together tightlv, and tied as a reef-knot, the internal Fig. 18. Fig. 17. On the left is one of Prof. Macewen's needles.* Thej' are made of one piece of steel. To the right is the sac, trans- fixed and thrown into a series of folds bj' a thread which should be shown emerging above as well as below. Macewen's operation. A hernia-needle (loaded^ has been made to penetrate the conjoined tendon in two places. ring is firmly closed. The same stitch may be repeated lower down in the canal, especially in adults, with wide gaps. The pillars of the external ring may likewise be brought together. In the gieat majority of cases the first or uppermost stitch is all that is re((uired. The cord should lie behind and below the sutures and be freely movable in the canal. It is advisable to introduce all the sutures before tightening any of them. They may then be experimentally drawn tight while a finger is introduced into the canal to learn the result. During the operation the skin is drawn from side to side to bring the parts into * These are two in number, one for passing the thread from right to left, and the other from left to right. I have found Mr. AVatsou Cheyue's modification of the above neeiUes, in which the instrument is angular instead of curved, much more convcnicn:. for picking up the conjoined tendon and external oblique. 58 OPERATIONS OX THE ABDOMEN. Fig. 19. view. The skin falling into position, the wound is opposite to the external ring, the operation being partly subcutaneous. In congenital hernia the sac is first separated from its connection with the canal. It is then opened, and divided transversely' into two parts, care being taken to preserve the cord. The lower part forms a tunica vaginalis. The upper is pulled down as far as possible, split behind longitudinally, so as to allow the cord to escape, and its lower end closed by a stitch or two. It is then dealt with quite as the sac of an acquired hernia. The following points deserve attention. The method has been objected to as complicated and difficult, and as inapplicable to infants on account of the dithculty of making out any conjoined tendon at this age. The above objections will dis- appear with practice. As Prof. Macewen has stated, a skilled finger will detect the conjoined tendon even in early life. Smaller needles must, of course, now be used. Other difficulties are met with in this method when the sac is unusualh' coarse and thick, or when it is extremely thin ; such sacs are, no doubt, diffi- cult to manipulate satisfac- torily, so as to get the pad well within the internal ring. Professor Macewen kindl}^ forwarded to me the following statement (July 1 895) as to his results : " I have had 164 completed cases of operation for oblique inguinal hernia. Regarding radical cures, one must neces- sarily be guarded in drawing conclusions w^hen dealing with large numbers, as many of the patients pass from observa- tion, and, though asked to report themselves, do so only a few times, and then cease. Thus out of 164 there are 55 who have dropped entirely out of view. Many of these had previously been seen three to nine months after operation, when they had firm occlusion of the abdominal wall. Two children died after the operation — one from scarlet fever, epidemic at the time, and one from measles and meningitis, the latter rather a weak child. This leaves 107; of these, five are known to have had return. Two of these M^ere steel workers, doing the heaviest kind of work. One was cured during eight years, and then a slight bulge appeared near the seat of the former hernia. He now has a bubonocele. The other was two years free from hernia, and then had a slight rupture. Each of those wear belts — Macewen's operation. A loop has been left ou the inner surface of the conjoined tendon. PtADICAL CURE OF INGUINAL HEIIXIA. 69 light ones, which retain the hernia even during their work. A third remained well for two years, then had an attack of what was stated to be enteric fever, and sulDsequently became affected with tubercle of the lungs. He had a distinct recurrence of the hernia. A fourth I have heard of as having a return to a slight extent, and a fifth wrote to say that he had a return. Fig. 21. Macewen's operation. The thread from the lower part of the coujoined tendon has been carried through Poupart's hgament. Macewen's operation. Two of the threads which are to draw the conjoined tendon over to Poiipart's Hgameut are in position ready for tying. " If we strike off nine cures under two years, which are well, but which are too recent to be judged as cures, this leaves — 20 reported or seen cured — no truss — at 10 years and over. 18 „ „ „ „ 6 „ 29 5' " " ;> 4 '5 >» ■^ 5 " " " > J 2 , , , , 93 Some of the older ones have been good enough to keep me well informed as to their state. Two have gone through a great deal of hard riding in Cape, for many months at a time, and have never been bothered with their old enemy. One, a surgeon in the Cumberland district, rides a great deal and never is troubled. He says he has forgotten that he ever had a hernia." 70 OPERATIONS ON THE ABDOMEN. Although in Prof. Macewen's hands this method has been attended with good results, A\'hen performed Ijy other surgeons the results have not been so satisfactory. It is clearly a more difficult and complicated pi'ocedure than Bassini's, and moreover the results of Bassini's method are better (vide supra, p. 56). Probably it is for these reasons that Bassini's method is preferred by the majority of operators. (3.) BaWs Method {Brit. Med. Journ., Dec. 10, 1887). — Here the sac is twisted, the fundus cut away, and the stump stitched in the ring. I have placed this method next because I consider the method of treating the sac by torsion much simpler than any other, and very efficient. I always treat the sac thus myself, though instead of leaving it in the canal I return it within the internal abdominal ring after Macewen's method, and I also make use of Macewen's method for closing the canal. Mr. Ball advises that the sac be completely isolated right up to th^ internal ring, and having been ascertained to be empty, gradually twisted up by a broad catch-forceps grasping its neck, while the left forefinger frees the upper part of the neck.* In ordinary cases, four to five com- l)lete revolutions are sufficient, but this must depend on the thickness of the sac. the torsion being continued till it is felt to be quite tight and likel}' to rupture. An assistant now, holding the torsion-forceps, maintains the twist while a stout catgut ligature is tied tightly round the twisted neck and cut short. Two sutures of stout aseptic silk are now passed through the skin about half an inch from the edge of the wound, through the outer pillar of the ring, through the twisted sac in iVont of the catgut suture, and then through the inner pillar and skin. As the sac now cannot untwist, it is cut off in front of these sutures, Avhich are tied over leaden plates that lie at right angles to the wound. From investigations on the dead body, Mr. Ball finds that the result of the above procedure is to throw the peritonaeum into a number of special folds, radiating from the internal ring in all directions. The ring, instead of being depressed, is rendered more prominent than the neighbouring peritonaeum . I have used this most simple and efficient method very largely, but with some modifications of the au^thor's plan. Thus, before twisting the sac and after freeing it below and from the cord, I endeavour to separate it all around the abdominal aspect of the internal ring. After twisting it up as high and as tightly as possible, I alwa^ys, if it be thick enough, transfix it instead of merely encircling it with a gut ligature. It is then pushed ^^'ell within the peritonaeal cavity, as I should fear leaving it in the canal lest it act as a wedge and dilate it. Finally, I al\va3'S supple- ment torsion of the sac by closing the canal with sutures introduced by Macewen's method. Torsion is verj^ quickly and simph' done ; moreover, it does away with the need of bringing a thread through the abdominal wall. Another advantage is the crushing together of serous surfaces, which tends by plastic effusion to make a plug ver3^ efficient in blocking the internal ring, aided b}" the slight effusion which is set up by the separation of the sac around the abdominal aspect of this aperture. * Where the hernia is congenital, the sac must be cut through lirst above the testicle, freed from the cord, and then twisted. RADICAL CUliE OF INGUINAL HERNIA. 7 1 (4.) Method of Banks.* — This has the merit of extreme simplicity. The sac having been made certain of, is separated, with the precautions given above (p. 62), from the cord, and detached through the external ring up in the canal as high as the internal ring, the finger keeping note all the time of the position of the cord. If the sac is clearly empty, its neck is now ligatured with stout chromic gut or carbolised silk as high up as to leave no neck, orifice, or dimple at the internal ring. The fundus is then cut away about half an inch below the ligature. As to sutures of the ring and canals, it would appear from his latest paper that the author is now satisfied with suturing the external ring. •' In inguinal hernife, in addition to this " (dissecting out and removing the sa(3 as high up as possible), '" the pillars of the external ring have been pulled together by two or three silver wire sutures, which are left in position after their ends have been cut very short. They thus constitute three small silver rings, which never appear again, and are less irritating than any other form of suture. I do not put them in ^^•ith any object of securing a permanent closure of the external ring, but simply to make sure that the hernia shall not descend for a considerable period, so that the inguinal canal (if it be in fairly normal case) may have a chance of contracting. Unless some extensive ' rawing ' of the walls of the canal is done, I believe all stitching of it to be of just as much use in securing permanent union as stitching the edges of a cleft palate would be without freely refreshing them. I do not believe it possible satisfactorily to accomplish a. 'rawing' of the inguinal canal, while in a very large proportion of severe cases there is no inguinal canal at all ; nothing but a big hole into which three or four fingers can be crammed, whose edges are as thin as cardboard, and from which all anatomical relations have disappeared. My reason for adhering to the operation which I have hitherto used is that it is the simplest of any that has yet been devised." While all will agree as to the simplicity of the above method, there is an increasing belief that ligature of the sac alone is not to be trusted — parti}'- because a sac thus treated is not strong enough to resist future strains ; partly because, as pointed out above by Prof. Macewen, it is extremely difficult, if not impossible, to tie the sac so high up that no dimple is left on the peritonteai aspect of the internal ring. To take another very important point. Sir W. Banks seems to have given up attempting to draw the canal together with sutures, because these will not ensure adhesiou of the walls. But surely there is a fallacy in his comparison. What we want here is not the adhesion of the two walls of the canal as in the halves of the soft palate, but a permanent narrowing of the canal again so that it may be once more a mere chink or valve instead of a short wide tunnel, or. as in severer cases, a gaping ring. Even if it were possible, adhesion of the walls of the canal would be undesirable for the sake of the cord. With regard to suturing the external ring alone, this is, I fear, from cases I have seen, quite inadequate. Some attempt should always be made to narrow the internal ring and canal, as by the method of * Papers bj' the above surgeon, one of our earliest and foremost workers at the subject will be found in the Med. Times aiifl iiaz., 1884; Brit. Med. Journ., Dec. 10, 1887, and Nov. II, 1893, 72 OPERATIOXS OX THE ABDOMEX. Bassini. Final!}', most surgeons have been less fortunate than Sir W. Banks in their experience of silver wire. It is verv readily sterilised, most easily used, but often fails to become encysted. (5.) Barker's Method* (Fig. 22). — Here the upper part of the sac is drawn up into the abdomen and fixed there, but the lower part is always left in sihi, as Mr. Barker thinks its removal unnecessary and even mischievous, " as during the dissection the nervous and vascular supply may be seriously damaged." The rings are then sutured. The neck and upper part of the sac having been separated from adjacent parts, and proved to be empty, two ligatures of strong, fine carbolised silk are carried under the neck and tied about half an inch Fig. 22. Barker's method, i, i, Skin incision, c, Spermatic cord, s, Lower part of sac left in situ, ss, Sutures to invaginate the tipper part of tlie sac. s.jj, Sutures for drawing the walls of the canal together. apart, and the sac divided between them. The upper ligatures are left long. The left forefinger, introduced into the canal and through the internal ring, is made to press its anterior wall forwards. One of the silk threads left long on the upper stump of the sac is now threaded on a needle with a handle, and carried up the canal, inside the internal ring, and through the abdominal wall above and external to the external ring. The other is similarly' passed through the abdominal wall about half an inch to the inner side of the first. These sutures are then knotted tightly, and by this means the stump of the sac is drawn up into the abdomen and fixed there. The external ring- is then closed * Jjrif. Med. Jnvrn.. Dec. \i Soc, vol. Ixxiii. p. 273. J/(7«. of Opcr. Si/rff., p. 334, Fig. 51 ; Trnyu. Med.-Cklr. EADICAL CURE OF INGUINAL HERNIA. 73 by sutures which should, if possible, take up the conjoined tendon as well. (6.) Bennett's MetJtod* (Fig. 23). — Here also the lower part of the sac is left in situ, for reasons similar to those given above ; the upper j^art of the sac is invaginated through the internal ring, and the canal sutured in the usual way. The sac is exposed and carefully isolated from its connections just below the external ring (the lower part being left entirely undis- turbed) ; it is then opened, and the contents reduced into the abdomen, if they have not already returned spontaneously. The sac is now divided just below the external ring, the distal Fig. 23. portion being allowed, after all bleeding has been stopped, to drop back into the scrotum. The proximal part of the sac is next separated from the sides of the canal as high up as the internal ring by gentle manipulation. One finger (or more if the ring is large) of the left hand havino- been intro- duced into the abdominal cavity through the neck of the sac, any bowel lying near the internal ring- is pressed back out of the way. An ordinary pile-needle on a handle (unthreaded) is then made to enter the abdominal aponeuroses about three-quarters of an inch above the upper margin of the external ring, a little to the outer side of its middle line, and transfixes the whole of the aponeuroses and peritonaeum, impinging on the end of the finger which occupies the neck of the sac. The needle, guided by the finger, is passed down the inside of the sac and made to pierce its outer wail at a point about half an inch from the cut edge. The needle having been threaded with a tendon or catgut suture, previously prepared, and not less than twelve inches long, is withdrawn, taking one end of the suture with it. The result is that one end of the suture is seen passing into the abdominal aponeuroses above the external ring, while the other issues from the outer wall of the proximal part of the sac, near its cut edge. The needle, again un- threaded, is now made to transfix the abdominal aponeuroses and peri- toneum about half an inch internal to the point at which it entered before, traversing the sac in the same way, finally piercing the inner wall at about the same distance from the cut edge as it had done on the outer side. After havino- been threaded with the lower end of the Bennett's method. The pillars of the external ring are shown. Some distance above them the two invagination sutures are seen to emerge through the aponeu- roses, while below they pass through the sac, which has also been tied. * Abdominal Hernia, p. i{ 74 OPERATIONS ON THE ABDOMEN. suture, the needle is withdrawn, carrying the suture, as before, with it. The two ends of the suture will now be seen entering the aponeuroses above the external ring, and forming below a loop over the cut edge of the proximal portion of the sac. The open end of the sac is next sewn up by a continuous stitch of catgut or silk, or occluded by a silk ligature placed around it as close as possible to the spot at which the invagination suture pierces its sides. The succeeding step is the invagination of the sac, which is effected by pushing wdth the finger the closed end through the canal into the abdomen, the invagination sutures passing through the aponeuroses being at the same time drawn tight. By this proceeding the sac is turned completely outside-in, and its fundus firmly attached to the peritonaeal surface of the anterior abdominal wall some distance above the internal ring. Fig. 25. Fig. 24 Testis Figs. 24, 25, aud 26 : Method of treating the sac in Bishop's method of radical cure of hernia. In Fig. 24 the sac is hemmed round with a silk suture. lu Fig. 25 the sac is puckered upon the outer side of the ring. In Fig. 26 the puckered sac is invaginated and forms a l)utton-like projection on the abdominal aspect of the ring. In each figure the suture carries a needle at each end. (Walsham.) (7.) Staninore Bishops MetJcod* (Figs. 24, 25, and 26). — This is a modification of Prof. Macewen's. The sac having been freed entirely up to but not beyond the internal ring, is carefully emptied, and kept so by the finger of an assistant pressing upon the ring. By means of a long, strong catgut suture, -which is passed through each side of the sac, this is hemmed round, aud thrown into a number of folds. The neck of the sac is then invaginated, and each end of the suture carried by a needle through the canal and through the pillar of the internal * Lanret, vol. i. i8go. p. 1237, RADICAL CUKE OF INGUINAL IIEIiXIA. 75 ring nearest to it. from within outwards. When both ends are pre- senting through the muscular structures they are pulled up, the sac being at the same time invaginated before the finger as the threads are drawn upon. The sac is then drawn inside-out in its passage, and becomes fixed at a rounded boss exactly over the inner ring, its peri- tongeal surface being turned to\\-ards the intestines, and its first fold on either side being firmly applied to the peritonseum immediately within Fig. 27. Halsted's operation. The iuguiual caual laid open ; the sac cut away after suture of the peritouseum ; elements of cord isolated and lifted up ; deep (|uilt sutures introduced. A, Aponeurosis of the external oblique. D, Yas deferens. F, Fascia transversalis. P, Remains of sac sutured. T, Conjoined tendon. Y, One of the spermatic veins. VV, Stumps of excised spermatic veins. the ring. The ends of the suture are then tied firmly, but not tightly. over the ring ; finally, this and the canal are sutured. (8.) Method of Halsted* — The following is Prof. Halsteds account of his operation (Figs. 27 and 28) : " Instead of trying to repair the old * Halsted. Bulletin of the Johns Hopkins Hosp., voL i. No. i ; Johm Iloj^hins Hasp. Jlep., voL ii. ; Surg. Fasciculus, No. i ; Ann. of Surg., 1893, voL i. p. 542. 16 OPERATIONS OX THE ABDOMEN. canal and the internal abdominal ring, I make a new canal and a new ring. The new ring should fit the cord as snugly as possible, and the- cord should be as small as possible. The skin incision extends from a point about 5 cm. above and external to the internal ring to the spine of the pubes. The subciitaneoiis tissues are divided, so as to expose- clearly the aponeurosis of the external oblique and the external ring. The aponeurosis of the external oblique, the internal oblique and trans-^ versalis and the transversalis fascia are cut throuo-h from the external Fig. 28. Halsted's operation. The deep quilt sutures wbich cross tlie canal are tied and cut short. The remains of the cord are seen to emerge between the upper two sutures, and to lie between the external oblique and the skin. abdominal ring to a point about 2 cm. above and external to the internal ring. The vas deferens and the blood-vessels of the cord are- isolated. Ail hut one or tiro of the veins of the cord are excised (Fig. 27),- The sac is carefully isolated and opened, and its contents replaced. A- piece of gauze is usually employed to replace and retain the intestines. With the division of the muscles and transversalis fascia, the so-called neck of the sac vanishes. There is no longer a constriction of the sac. The communication between the sac and the abdominal cavity is- RADICAL CURE OF IXGUIXAL HEUNIA. jy sometimes large enough to admit one's hand. The sac having been completely isolated and its contents replaced, the peritonseal cavity is closed by a few fine silk mattress sutures, sometimes by a continuous suture. The sac is cut away close to the sutures. The cord in its reduced form is raised on a hook out of the wound, to facilitate the introduction of the six or eight quilt sutures, which pass through the aponeurosis of the external oblique, and through the internal oblique and transversalis m\iscles and transversalis fascia on the one hand, and through the transversalis fascia and Poupart's ligament and fibres of the aponeurosis of the external oblique on the other (Fig. 27). The two outermost of the deep quilt sutures pass through muscular tissues, and the same tissues on both sides of the wound. The}" are the most important sutures, for the transplanted cord passes out between them. If placed too close together, the circulation of the cord might be im- 23erilled, and if too far apart the hernia might recur. They should, however, be near enough to each other to grip the cord (Fig. 28). The precise point to which the cord is transplanted depends upon the con- dition of the muscles at the internal abdominal ring. If in this situation thej' are thick and firm, and present broad raw surfaces, the cord may be brought out here. But if the muscles are attenuated at this point, and present their cut edges, the cord is transplanted further out. The skin wound is brought together by an uninterrupted suture, which is withdrawn after two or three weeks. The transplanted cord lies on the aponeurosis of the external oblique, and is covered b}' skin only." There are serious objections to this operation, and the results, though good, are not more favourable than those of Bassini's operation. The first objection is that the procedure is complicated, and more difficult to perform than Bassini's operation, and the length of time occupied by the operation thereby needlessly increased. The second and more serious objection is the efiect on the cord and the testis. O'Conor (Lancet, Aug. 26, 1899) says that in 80 per cent, of his cases treated by Halsted's method orchitis followed, and in 20 cases out of 129 atrophy of the testis resulted. This may be traced either to the superficial position of the cord, or to the free removal of spermatic veins. (9.) Method of Koclier* — This method is worth noting, as it is claimed that by it the sac is stretched in a direction opposite to that of the inguinal canal and the course of the hernia ; and that when the sac is fixed in situ, this is done more firmly and in a more permanent manner than by other methods. The skin and superficial fascia are divided over the canal. At the external ring the inter-columnar and cremasteric fasciae are divided, and the sac defined. This is then carefully isolated from adjacent structures, and strongly pulled down so that its pedicle may be exposed. The left index finger is now introduced into the inguinal canal, and to one side of the internal ring a small opening is made through the aponeurosis of the external oblique ; a slender pair of artery-forceps is passed through this opening and through the lower muscular fibres of the internal oblique and transversalis, following the left index as it is withdrawn, through the inguinal canal, and finally out of the external inguinal * A?m. of Siirrj., 1892, vol. ii. p. 524. 78 OPERATIONS OX THE ABDOMEN. opening. With these the isolated sac is grasped and drawn through the canal, and out at the small opening in the aponeurosis of the Fig. 29. Fig. 30. Koclier's operation. The for- ceps, introduced along the inguinal canal, are grasping the sac at the lower end. external oblique (Fig. 30). and energetically twisted. Fig. 31- Koclier's operation. The sac having been twisted, is laid down upon the aponeurosis of the external oblique. Eight deep sutures are also shown. (10.) McBnrnei/s Method. Koclier's operation. The sac is drawu out through a small opening in the external oblique aponeurosis. It is Ihen drawn out as much as possible. It is next strongly drawn down and laid over the outer surface of the ex- ternal oblique and outer ring, in the direction of the canal. By this tension of the sac the anterior wall of the unopened canal is pressed backwards into a gutter. Deep sutures are now applied, being passed above the twisted sac, through the aponeurosis of the external oblique and the in- ternal oblique and transversalis, through the sac itself, and taking- up Poupart's ligament below (Fig. 31). In the case of a long sac, all that extends below the outer ring is cut away. It is claimed that by this method the sac is firmlj^ drawn on the stretch, and securely pressed over the entire length of the canal, so as to form a solid pad or roll. The deep sutures would appear to be passed somewhat in the dark, as regards the cord. This is different from all others described, RADICAL CURE OF FEMORAL HERNIA. 79 in that, instead of trying for primary nnion, the wound is made to heal by granulation tissue. The sac having Ijeen reached by an incision exposing the whole canal and external ring, is separated and tied as high up as possible. The part below the ligature is then cut away. In order to keep the wound an open one, the superficial are then stitched to the deep parts ; next, skin and conjoined tendon above, skin and Poupart's ligament below, are sutured together. The wound is then packed with iodoform gauze. The wound is thus made to fill up by granulation tissue, producing a thick scar, which McBurney believes to be the best guard against relapse. RADICAL CURE OF FEMORAL HERNIA. There is less necessity for operative interfei'ence here — women, in whom the above variety is so much more frequent, finding a truss more efficient and less irksome, owing to their less active life and their mode of dress. In omental hernia, Avhere there is difficulty in fitting or un- willingness to wear a truss, in irreducible hernia, and in all cases of strangulated hernia, where the patient's condition and the surroundings of the operator admit of it, an attempt should be made to cure the hernia permanently. We are met here by a difficulty less present in inguinal hernia — i.e., that of closing the canal satisfactorily, owing to the scanti- ness of some of its immediate surroundings and the importance of others. Different methods : — i. The empty sac having been thoroughly separated from its sur- roundings — a step here usually carried out with ease — is twisted up tightly, transfixed, and tied with reliable catgut, and then thoroughh' invaginated within the femoral ring. ii. Kocher's method (p. yf) may be emploj^ed. The empty sac having been isolated and twisted as strongly as possible, is drawn through a small opening made above Poupart's ligament, and. much as described at p. y8. included in sutures which are passed through the pectineal fascia and Poupart's ligament with the hope of closing the femoral canal. iii. The sac may be treated much as in the methods of Barker and Bennett (pp. 72 and 73). Thus, after it has been isolated and emptied, the neck is thoroughly cleared with the finger passed up the femoral canal. The neck is now ligatured as high up as possible, the body of the sac cut away, and the ends of the ligature, which have been left long around the neck of the sac, are carried up the femoral canal by means of needles on handles alons' the index finoer. and made to emero'e in front of the peritonaeum through the external oblique aponeurosis just above Poupai't's ligament, about half an inch apart. When these are tied the sac will be invaginated. While the above ligatures are being passed one assistant should protect the femoral vein, while another draws up the upper angle of the skin incision so that the needles may emerge in the wovind. The above refers chiefly to treatment of the sac. The other cardinal step in the radical cure of femoral hernia — closui'e of the femoral canal and ring — is niucli more difficult here, for reasons above given, Fortu- 8o OPERATIONS ON THE ABDOMEN. nately trusses are much less of an infliction here, and thorough oblitera- tion of the sac on some of the lines I have described will, with the aid of a light-fitting truss, suffice amply. Where it is desired to go further and close the femoral ring and canal, one of the following methods may be made use of. ■ iv. Lochvood's Method* (Figs. 32, 33, and 34). — The stump of the sac is first drawn up and fixed as above described. The subsequent steps are described by the author as follows : " For this purpose the index finger of the left hand is pushed up the femoral canal so that it lies with its dorsum against the common femoral vein, and its tip upon and a little within the ilio-pectineal ridge. The finger is intended to Fig. 32. a, Poupart's ligament. &, Lacuna musfularis. c, Tiacuna vascularis. cZ, Cooper's ligament, e, Gimbernat's ligament, g, Ilio-pectineal ligament, h, Ilio-pectineal eminence, s, Sj)ermatic cord. (Lockwood.) protect the vein from the point of the herniotomy-needle, and to guide the latter as its point is thrust beneath Cooper's ligament (vide Fig. 32). In cases in which the femoral canal has been distended and stretched, the needle can be guided by vision. The herniotomy- needle is passed in the following manner : — Having been armed with about one and a half feet of No. 4 or 5 twisted silk, its point is guided up the femoral canal until it rests against the inside of the linea ilio- pectinea, opposite the outer edge of Gimbernat's ligament. The needle is then rotated so that its point scrapes over the linea ilio-pectinea and * Ilernin, Hydrocele, and Varicocele, p. 192. EADIOAL CURE OF FEMORAL HERNIA. picks up Cooper's ligament. Finally, the point emerges through the upper part of the pectineal fascia, where it is unthreaded and -with- drawn, leaving the suture beneath Cooper's ligament (vide Fig. 33). Additional sutures are passed in exactly the same way, but each a little farther outwards until the last lies at the inner edge of the common femoral vein. Two or three sutures generally suffice, but I have used as many as five. The next step is to again thread the upper end of each ligature in turn through the herniotomy-needle, and, by pushing the point of the needle half-way up the femoral canal and rotating it forwards, pass the thread from within outwards through Hey's ligament close to its junction with Poupart's ligament (yule Fio-. 33). Before knotting these threads the}' are pulled tight, to see whether enough have been passed to make a thorough and firm closure of the femoral canal, but without compressing the femoral Fig. 33. Lockwood's oi:)eration. Showing the mode of suturing the femoral caual. vein (vide Fig. 34)." The final results of Mr. Lockwood's cases are not fully given, owing to the difficulty in following them up. Ten cases, however, are mentioned. In nine of these the result was satis- factory after periods var^-ing from one to seven years ; the tenth case relapsed sviddenly at the end of six months. V. Bassini's Method. — After hioh lio-ation and removal of the sac, the canal is closed in the following manner : — Three sutures are passed through Poupart's ligament and the pectineal fascia. These are left untied while three or four more sutures are inserted and tied. These unite the falciform ligament to the pectineal fascia, the lowest being placed close to the saphenous vein. Bassini has published fifty-four cases operated upon by this method, without any recurrence in fortj'-one cases, traced from one to nine 3*ears. VOL. II. "^ 6 OPERATIONS OX THE ABDO.MEX. RADICAL CURE OF UMBILICAL HERNIA. This operation is rarely called for : in children the natural tendency to cure is very marked ; and in adults, the kind of patients usually met Avith — stout women of middle age with damaged viscera, bronchitis, &c. — are not suitable for operative interference, save after the operation for strangulation (p. 49). Treatment b}^ operation ma}' be considered under the following heads : — i. In Congenital Hernia of the New-born Child. — In these cases, either herniee into the root of the cord, or (from deficiency of the abdominal walls) partial eventrations, interference is often out of the question from the co-existence of other malformations. If the hernia be uncomplicated, and the child appear likely to survive otherwise, an attempt should be made by abdominal section to return the con- tents, refresh the edges of the opening, and unite them with sutures. Fig. 34. Lockwood's operation. Showing the closure of the femoral eaual comijleted. ii. In Infantile Hernia — the common form in children. — In those rare cases, where the wearing of a truss has not been sufficient, an operation may be performed with excellent prospects of success. A simple method is to explore the hernia, reduce the contents, and then, after cutting away superfluous sac and scar tissue, to unite the different layers — peritonasum, fibrous tissues, and skin — by separate layers of sutures. In cases where a pedicle can be made to the sac — not always, from my experience, an easy matter, owing to the directness and shortness of the opening — it may be twisted and invaginated as advised at p. yo, and the other structures sutured over it, or it may be invaginated after RADICAL CUEE OF UMEILICAL HEliNIA. 83 the method of Barker (p. 72) or Bennett (p. 73). Another method is that of Mr. Keetley (Ann. of Sut) a stricture may be pervious to fluid injection from below, though the intestinal contents may be unable to pass through it from above. Thus, in a case in which there was a mass of disease in the sigmoid flexure, just above the pelvis, four pints of water were injected per rectum ; of this a small portion only returned, the greater part passing through the stricture and adding to the accumulations above it. I would add one more caution with regard to these injections. Patients in much misery, and having sub- mitted to one or two rectal examinations, will sometimes ask for an anassthetic. Such an aid must be used with great caution if there is already abdominal distension. There is not only a danger of adding seriously to the distension, and thus further M-eakening or rupturing parts which may be already near the point at which they give way — e.g., a ca3cum with " distension ulcers" — but an anaesthetic, especially chloro- form, has additional dangers in such cases as these, where, in a patient probably no longer young, the action of the heart and lungs is interfered with by the upward pressure against the diaphragm. The vomiting, * Dr. Fagge, in drawing attention to this fact {Guy's IIosp. Beports, 1868, p. 314), quoted the following statistics from Dr. Brinton : — " Of 100 cases, 4 are in the caecum, 10 in the ascending colon, 11 in the transverse colon, 14 in the descending colon, 30 in the sigmoid flexure, and 30 in the rectum." The statistics of Dr. Fagge and M. Duchaussoy coutirm the above. LUMBAR COLOTOMY. 93 ■whicli the angestlietic may caiise, may also prove suddenly fatal, fjEcal matter beiiio- sucked down into the lungs. (3) The distance to irhicJo a lomj hoiKjic or rectal tuhe passes is of very little value, and needs only this briefest mention here, because the surgeon is still called to cases in which he is assured that the obstruc- tion cannot be in the rectum or low down in the sigmoid flexure, as a long bougie has l^een easily jiassed its full length. This fallacy, which is due to the bougie bending on itself, is more frequent than the other one in which the arrest of a bougie by one of Houston's folds misleads into the belief that a stricture exists low down. (4) 2Vie form of the abdomen may help to valuable conclusions. Thus, Dr. Fagge (loc. supra cit., p. 319) gives a case of cancer of the hepatic flexure in which it was ol)served during life that the caecum and ascending colon were distended, and not the descending colon. Again, he observes that when the rectum or the sigmoid flexure is the seat of obstruction, the lumbar regions and the epigastrium are no doubt generally prominent, and the course of the colon is more or less plainly marked out. That these conclusions are only valuable if not too im- plicitly relied upon is sho^^■n by the "fact that cancer of the rectum may be present, with vomiting, ^peristalsis, and borborygmi. and yet there may be no general distension of the abdomen, no filling out at all of its sides ; on the other hand, a prominent epigastrium, and the appear- ance of a large horizontal coil of intestine here, mskj lead to the conclusion that the transverse colon is distended, the disease being, nevertheless, in the ileum, a distended coil of which has rivalled the colon itself. (5) A symptom of some value, if verified by the medical man himself, is the fact that for some time the motions have been narroic, tape-Iil-e, iirolien up, ahnormal in hull; shape, andj length. Certain fallacies diminish, however, the value of the above — e.g., that in cases of stricture high up, as in the upper part of the sigmoid flexure, there is probably room for the faeces, after they have got through the stricture, to collect, till their characteristic form is s'iven them, thouo-h we do not know how far irritation of the intestine and formation of mucus at the seat of the gr©\\'th may interfere with this. (6) A few other points — e.;/.. constant arrest of horhwijgmi at one spot, fixedj pain ai one spot, as in the right hypochondrium — may give useful indications ; while others, such as a rectal examination, are so obvious as scai'cely to need mention. If, after weighing the above, the surgeon is still in doubt as to the exact site of the disease of the large intestine, he shoxild not hesitate to open the abdomen in the middle line and explore for the site of the disease, or perform a right-sided lumbar colotomy. He should not be deterred from this latter step by the anatomical difficulties (e.r/., a more complete peritonceal coat) supposed to exist on this side. Especially where the colon is at all thickened or distended, the operation on one side is no more difficult than on the other. LUMBAR OR POSTERIOR COLOTOMY. Though this operation has of late vears been verj- largeh' replaced by the iliac method, it deserves attention as the operation first largely employed, and as one that has still to be resorted to under circumstances 94 OPEPvATIOXS ON THE ABDOMEN. of difficulty. The indications for this operation have been ah-eady given at p. 91, and a comparison of the lumbar and iliac methods will be found below at p. loi. Landmarks (Figs. ^6 and 37). I. The lower border and tip of the last rib. 2. A point half an inch behind the centre of the crest of the ilium, this point being found by accurate measurement along the crest between the anterior and posterior superior spines (W. Allingham). 3. Aline drawn vertically up from the last-mentioned point to the last rib. This gives, with sufficient correct- ness, the line of the outer edge of the quadratus, and the position of a normal colon. Owing to the varying length of the last rib, the upper end of this line may meet this bone at its tip, or at a spot a varying distance in front of or behind this point. It is well to dot the ends of this vertical line with an aniline pencil. The dint of a finger-nail, made when the patient has been brought under the ana?sthetic, will mark these points sufficiently to begin with, but a little later, in a difficult case, the surgeon ma30je glad of having taken every possible precaution. Fig. 36. Auiussat's incision for lumbar colotomy. The vertical line between the last rib and the iliac crest is the guide described in the text. (Heath.) Incisions. I. Vertical, of Callisen. This at first sight is the best, as it follows the above line, and thus corresponds anatomically to the colon, but it has the disadvantage of giving but limited space, especially in a fat or deep- chested patient ; and, if prolonged upwards, so as to give all the space possible, it divides the intercostal vessels running with the last dorsal nerve, and gives rise to troublesome haemorrhage, 2, Transverse, of Amassat. 3. Oblique, of Brj^ant, modified from the above. One of the two latter is usually employed ; they have the great advantage of being readily prolonged when more room is required, and the oblique incision corresponds better with the course of the nerves and vessels.* It is the one given below. * The late Mr. Greig Smith {Abdom. Surg., p. 396) gave the following practical hint : — " lu thin patients, and particularly in women, whose iliac crests are more prominent than in men, there is a tendency for the upper lip of the wound to fall inwards, while the lower lip protrudes. This may be obviated by careful apposition, and by not bringing the line of the incision too close to the ilium," LUMBAR COLOTOMV. 95 Operation (Figs. 36-39). — The patient being turned on to his side (most usually the right), with a firm pillow imder the loin, the parts cleansed, the tip of the last rib and the point on the crest of the ilium, as given above, being dotted with an aniline pencil, an incision is made, beginning 2^ to 3 inches from the spine, according to the size of the erector spinse a little below the last rib, and running downwards and forwards for 3 -J- to 4 inches towards the anterior superior spine. The centre of this incision should bisect the line given above as the line of the colon. The first cut should expose the muscles, the skin in the posterior half being thick, and the subcutaneous fat often abundant. The next may go well into the muscles, the remainder of which should then be care- fully divided with the knife, so as to expose the fascia lumboruni ; any bleeding vessels being now secured, this fascia is pinched up, nicked, and slit up on a director. Two retractors being placed on the lips of the wound, the fat Avhich lies around the kidney and behind the fascia lamborum is next torn through and pulled away with the fingers. If the bowel is distended, it will bulge up into the wound, pushing before it the transversalis fascia, and the FiCx. 37. The surgeon, having opened the h;mbai- fascia, is dissecting through the transversalis fascia to the colon itself. The two crosses mark AUingham's line. operation can be readily completed. If, on the other hand, the bowel is emptj^, the real difficulties of the operation only begin at this stage. The wound being well opened, the kidney, if it come down below the rib (as it occasionally does, especially in a patient breathing heavil}^ under the influence of an anaesthetic), being kept out of the way by the finger of an assistant, the intestine is sought for by scratching with a director, or two pairs of forceps, through the transversalis fascia (Fig. 37), exactly in the line to which attention has been already drawn. Several layers of cellular tissue may be met with here, and it is now that most of the difficulty is usually met with, owing to the operator being afraid of the peritonfeum, and to his not opening the transversalis fascia with sufficient decision. Unless this point is attended to the colon cannot bulge satisfactorih' or be drawn up into the wound. When this has been done, scybala in the colon will in many cases be felt ; but if the large intestine is empty, much trouble may be met g6 OPEEATIONS ON THE ABDOMEN. with ill detecting it and getting it up into the wound, especially if, close by, the peritonaeum is bulging up. At this stage the following points may be useful!}^ remembered : — (a) The exact position of the line of the colon (p. 94). (/>) The lower end of the kidney, and its relation to the colon, (c) The outer edge of the quadratus lumborum (p. 94). {d) The sensation of thickness as given to the fingers in pinching u]) the colon, thus dis- tinguishing large from small intestine. (e) The feel of scybala if present. (/) Seeing one of the three longitudinal muscular bands which distinguish the colon.* (f/) Inflation with air or injection of fluid.f (A) Mr. Bryant has advised rolling the patient over on to his back at this stage, so that the colon ma}* be felt to fall on the finger inserted deep into the wound. The bowel having been found, its posterior surface is to be drawn well up into the wound. This is one of the weak points of the lumbar operation. Owing to the shortness of the meso-colon and the fixity of the bowel, especially when distended, it is very difficult to get the bowel out of the wound sufficient!}' to make a satisfactory " spur." Unless this is done there is a risk of the patient having a faecal fistula instead of an artificial anus. If the case is not an urgent one, the bowel, when well pulled up. may be retained there by means of a rod passed beneath it as described below (page 104). If the shortness of the meso-colon prevents the use of a straight rod, this must be suitably curved, so that the bowel may still be kinked, but without undue tension. The margins of the wound are then carefully closed with silver wire or salmon gut sutures, and a few fine ones may be passed between the bowel itself and the margins of the wound. The usual antiseptic dressings are then applied, iodoform being dusted over the bowel and wound. These dressings will probably not need changing till the fourth day, when the operation is completed by opening the bowel with a tenotomy-knife. This opening may be a small crucial one. Very little but flatus Avill pass at the time, but a director will show the presence of faeces, and mild aj^erients may be given as soon as the parts are firmly healed. ♦ Mr. H. AUinghani (Brit. Med. Journ.. April 28, 1888) seems to consider it very difficult to ensure finding one of these bands without opening the pcritonaeal cavity. "While I should be the last to make light of the difficulties which may beset this operation, I feel sure that few surgeons, who have had a large experience of colotomy, will agree that the above step is needful, especially if the line given by Mr. AUingham's father be strictly followed. Where the operation is done in two stages the peritonasum may be opened, if needful, without any drawback. But where the bowel must be opened at once — and this will be the rule in lumbar colotomy — any injury to the peritonaeum is to be avoided. The aphorism quoted at p. 53 is to be remembered here also. t Air is most readily made use of. It may be pumped in by a Higginson's syringe, a Lister's hand-spray, but, best of all, by the special apparatus described by Mr. Lvmd (^Lancet, 1883, vol. i. p. 588), which, by means of an clastic ring, secures air-tight contact with the anus while air is being pumped in, either as an aid in colotomy or as a means of reducing an intussusception. In some cases of cancerous disease of the rectum it Avill be very difficult to introduce any nozzle for inflation beyond the disease. In the summer of 1885, when performing colotomy at Guy's Hospital in a patient the lower part of whose rectum had been unsuccessfully excised at another hospital, I found it impossible to introduce any nozzle when desirous of inflating an empty colon. LUMBAR C0L0T03IY. 97 The method of performing colotomy by two stages was intro- duced at Guy's Hospital by some of my senior colleagaies, Mr. Bryant, Mr. Howse, and Mr. Davies-Colley, being based on that most im- portant modification of gastrostomy which Mr. Howse was the first to make use of in this country, Mr. Davies-Colley bringing before the Clinical Society, in 1885 {Trans., vol. xviii. p. 204), a paper on " Three Cases of Colotomy with Delayed Opening of the Intestine." The great advantages of this two-stage method are (i) that it defers the opening of the bowel till this is siifficiently adherent. (2) By this delayed escape of intestinal contents the gravity of any injury to the peritonaeum at the time of the oj)eration is very much diminished. (3) The second great trouble after colotomy — that of burrowing suppuration up and down the planes of cellular tissue, which have of necessity been freely opened — is done away with. The opening of the intestine being delayed, primaiy union, to a very large extent, can be secured, especially with the aid of deeply-passed sutures, or of chromic gut ones cut short and dropped in. and dry dressings. But, nowadays, under the conditions in which lumbar colotomy is usually resorted to — viz., obstruction and distended intestine — it will be necessary to complete the operation at one stage. Here the dis- tension, and the difficulties consequent upon it, are best met by tying in a Paul's tube. The wound having been closed as far as is possible, the intestine is drawn out, and the surrounding parts are shut off with sterile gauze ; a small opening is then made in the intestine, the tube inserted and tied in, and the patient turned on to his back while the chief of the accumulation in the intestine is allowed to run away safely. When sufficient relief has been given, the bowel maj' be additionally secured by some sutures between it and the lips of the wound. The wound having been carefully shut off with dressings, the faeces are collected by means of india-rubber tubing fitted on to the tube, soiling of the dressings, &c., being prevented by jaconet. If a Paul's tube is not at hand, the bowel must be well drawn out of the wound and carefully isolated by means of plenty of iodoform gauze. The patient being then turned on his back and brought over the edge of tlie table, the wound is carefully shut off with temporary dressings, and the bowel opened either by a trocar of calibre sufficient to admit a piece of drainage-tube if the contents are fluid, or by an incision into the gut, which is well pulled out and held over some appropriate receptacle for the escaping fasces. While these are coming away the wound should be carefully irrigated. As soon as the chief distension has been relieved, the opening should be temporarily closed, while the colon, now somewhat collapsed and easier to deal with, is carefully sutured, with silk that is not too fine, to the edges of the wound, which is well dusted with iodoform, or painted over with iodoform and collodion. If the distension be not sufficiently relieved, the means for temporarily closing the colon must be next removed, and the wound, which has been carefully closed and sealed around the opened colon, kept as clean as possible by frec[uent dressing. The parts around must be kept smeared with an ointment of eucalyptus and vaseline, while the dressings themselves are kept in position by a many-tailed bandage, by which means they are readily and painlessly'- renewed. VOL. II. 7 98 OPERATIONS ON THE ABDOMEN. Fic. 38. Lumbar oolotomy, showing the old method of opening and fixing the colon. (Heath.) The old operation of opening the bowel at once was easy but perilous (tide Fig. 38). A ligature having been passed first through one lip of the wound, then across the bowel and through the opposite lip, and another in the same way aliont half an inch from the first, an in- cision three-quarters of an inch long was then made into the gut, over these sutures, their centre hooked up into the woimd, and the four halves tied on either side, a few other sutures being put in between the cut lio\\'el and the wound. But in this case there was always some risk of fsecal matter or flatus being forced into the different planes of cellular tissue, especially if the bowel was much dis- tended, even if precautions were taken to keep the knuckle well up, and to close the wound thoroughly around it. If the bowel is full of scybala no attempt should be made to remove them ; they may be left until aperients can be safely given. At times the bowel seems so empty as to suggest a failed operation : there is no occasion to be troubled at this ; the contents will pass shortl3^ Difficulties in Lumbar Colotomy. I. An empty liowel.* This has been already alluded to (p. 95). 2. Mistaking bulging peritona3um for colon, and opening it. This may be due to the surgeon forgetting the line of the bowel, and working deeply too far forwards ; or it may take place from no fault of the surgeon, being due to the presence of a meso-colon, or to the extremely contracted condition of the colon.f It by no means always * It is noteworthy that the intestine may be found empty, even in obstructions of long continuance. Thus, Mr. Curling (^Diseases of the Rectvin, p. 182) writes: "In a case of carcinomatous stricture of the rectum, in which I performed colotomy after a month's obstruction, in a woman aged 40, not only was the colon contracted, but it was actually compressed against the spine and put out of the way by the distended small intestine, so that it was impossible to reach the bowel without opening the peritonaeum. No inflammation or unfavourable symptom resulted." It would have been interesting to know whether more than one obstruction did not exist in the large intestine in this case. t In a case in which, owing to the extreme pain during defaecation, the patient had dreaded any action of the ])owels, and had eaten very little, the colon was much contracted and lay far liack. In trying to find it, I opened the peritonsBum, and omentum protruded. A carbolised sponge was kept over the opening while the colon was found, the opening then tied up with chromic gut, and the colon not opened for four days. No ill result followed. As in supra-pubic lithotomy, the peritonaeum may give way during vomiting. Thus, Dr. Walters {Brit. Med. Journ., 1879, vol. i. p. 212) was stitching the colon to the wound when '-the patient retched violently, causing the pcritomeum to give way, and a coil of intestine to protrude from the anterior part of the wound. This was immediately covered with warm sponges, cleansed from the fieculent matter it had acquired by contact with the open colon, and returned." When, five weeks later, the patient sank from exhaustion, no trace of peritonitis was found at the necropsy. LUMBAE COLOTOMY. 99 causes peritonitis. When this accident has happened, as shown La- the escape of a Kttle serous fluid, the appearance of a coil of small intestine or of omentum, the opening should be at once taken up with dissecting-forceps and tied round with carbolised silk or chromic gut, and a little iodoform rubbed round the ligature. If the opening- be larger, it must be closed with catgut sutures. 3. A very fat loin. This is not a ver}' uncommon source of difficulty in elderly people who require colotomy. It must be met by a very free incision in which all the tissues are cut equally throughout (i.e.. not making a conical wound deep only in its very centre : this not only adds to the difficult}^ of finding the bowel, but also of retaining it in situ afterwards). To meet the additional tension and tendency of the gut to drag awa}' in these cases, it must be more carefully secured by close stitching, especially if it is necessary to do the operation in one stage, every care being taken to prevent extravasation of faeces into the surrounding cellular tissue.* In fat people the surgeon must be prepared not only for much subcutaneous but for abundant extra-peritonseal fat also, coarse, and difficult to dissect in. If. in such a case, the colon is contracted, there are few more difficult operations. 4. Presence of a meso-colon. This may be a cause of much difficulty and doubt, and render opening of the peritona3um necessary-. Where this is the case, the surgeon should always defer opening the colon if possible. Mr. Jessop (Brit. Med. Jonrn.. 1879, vol. ii. p. 614) mentions cases in which, owing to the presence of the above, he was obliged to open the peritoneal cavity and incise the gut through its peritonaeal coat. The cut edges of the bowel, brought through the opening in the peritonaeum, were stitched to the skin as in the ordinary operation. No bad effect followed. Mr. Bennett May (^Brit. Med. Joitrn., 1882, vol. i. p. 940). operating on the right side, found an empty colon, "and it was only by keeping strictly in AUingham's line, and patiently searching there between the layers of a great length of meso-colon. that the intestine was reached, collapsed and empty." 5. Abnormality of colon. Every surgeon must remember cases in which the descending colon, though present, was displaced, and came ■down in the middle line. Occasionally part of the large intestine is actually absent. Mr. Lockwood (St. Barthol. Hosj^. Reports, vol. xxix. p. 256) mentions three cases in which the colon could not be found ; in two its absence was verified at the necropsy, both on the right side. One of these cases is reported fully. The following are the main points : — Owing to obstruction of the large intestine, the site of which was doubtful, it was decided to cut down on the right colon. No colon could be found, and. relief being imperatively demanded, the peritonaeum was opened and a loop of small intestine drawn outside the wound. Death occurred four hours after the operation, and at the necropsy the right colon was quite absent.f the cagcum being found behind the liver in the right hypochondrium. the large intestine extending from this to the splenic flexure in the usual manner. * As much of the wound as is possible should be closed before the intestine is opened. t Mr. Lockwood {Brit. Med. Joxrn.. 1882, vol. ii. p. 574) explains the abnormalities of the large intestine by the fact that, during its development, it is very mobile : the caecum occupying first the umbilical, then the left, next the right hypochondrium. and. finally, the right iliac region, abnormalities may follow its arrest at any part of its .course. lOO OPERATIONS ON THE ABDOMEN. If the colon cannot be found, three courses are open to the surgeon — (a) To open the small intestine through the peritonseuni from the colo- tomy incision. The objections to this step are that it is very fatal, and that there is no telling what part of the small intestine is opened. (/S) To perform colotomy on the opposite side, and. if the colon is here distended, to open it, in two stages when practicable. This is the course that should alwa3'S be followed if possible, (y) If no colon can be found, or if the part found is below the obstruction, the linea alba should be opened to admit two fingers to explore for the displaced colon, and if no colon can be found, to draw up and attach a loop of small intestine, chosen as near the cEecum as possible. Or Nelaton's operation may be performed, this being the wiser step if the patient is exhausted by a previous prolonged operation. 6. Malignant disease at the site of colotomy. This is best met by performing colectomy in appropriate cases, or by perforniii:ig colotomy on the opposite side. 7. The kidney may be embarrassingly low. 8. The peritonaeum may be so pushed back by ascitic fluid that it is impossible to open the gut without injuring the peritoneum (Pepper, La/tce^, vol. i. 1888, p. 772). 9. Cases where the operation has to be completed at once, and the colon is much distended with feces, will give much trouble (p. 97). Troubles which may be met with after Colotomy. 1. Too large an opening in the bowel. This may lead to pro- lapse of the mucous membrane. If this take place to a large extent it is a great nuisance to the patient, owing to the moist, excoriated, bleeding surface which results, difficult to keep up by any apparatus. Even where the opening has been small, a good deal of prolapse may take place if there is much cough and a flaccid condition of the side. 2. Too small an opening in the bowel. This is of much less moment, as it can be readily dilated by tents. Of these, laminaria are much the most efficient ; two should be inserted at a time, to effect rapid dilata- tion. Then the opening is easily kept patent by the occasional insertion of the little finger, and by the wearing of a proper plug. (See also p. 108.) 3. Teasing descent of scybala into the bowel below the artificial anus. This, which often renders a colotomy disappointing, is best met by bringing the colon si^fficiently into the wound at first, and by keeping patent an adequate opening. If scybala still find their way down, the colon may be washed out from the anus or the wound. If these fail, the only course, and one not devoid of risk, is to open up the wound, to divide the bowel, and attach the upper end in the wound, and then tO' suture the lower end and drop it in. This last step can only be taken with safety if this part of the bowel is empty (p. 107). Causes of Death after Colotomy. These will vary somewhat according to the presence of obstruction or no. I. Exhaustion. Especially if the operation has been deferred too long. 2. Toxic conditions probably due to the continued distension of the intestines, and the resulting absorption by the patient of poisonous material. 3. Extravasation of faeces and burrowing suppuration. This is especially liable to happen in very fat patients, in whom there is a difficulty in getting the colon up into the wound, especially if the bowel must be opened at once. As the feces pump out under high pressure,. IXGUIXAL COLOTOMY. lOI a sufficiently* free opening should in these cases be made into the bowel after this has been secured as carefully as possible (p. 97). 4. Peritonitis. This may be due to the operation directly, or more indirectly from fa3cal or purulent retro-peritongeal extravasation, or from septicaemia. Often it is not due to the operation, but to the want of it a,t an earlier stage. Thus, the distended bowel may have given ■way just above the obstruction ; often it is that weak spot the caecum which is found perforated after the stress of distension, f 5. Septic cellulitis, erysipelas, &c. These are not always preventable in an exhausted patient where it has been necessarj- to open the bowel at once. 6. Vomiting. This has been noticed in a few cases to occur obstinately and fatally after colotomy. Mr. Couper [Brit. Med. Joiirn., 1869, vol. ii. p. 557) thinks that it is not an infrequent cause of death, and suspects that traction on the bowel, its proximity to the stomach, and the fact that both receive nerves from the solar plexus will account for this. 7. Broncho-pneumonia, pleuritic effusion, especiallj' if the wound has become septic in an exhausted patient. INGUINAL, ILIAC, OR ANTERIOR COLOTOMY. Of late 3-ears there has been an increasing tendency for this to replace the lumbar operation in the majority of cases which call for colotomy (vide supra, p. 91). The advantages claimed for the iliac operation are chiefly — (i.) It is easier. Thus, (a) the patient, being on his back, takes the ana3sthetic better than when rolled on his side ; (/3) In a stout patient, especially, the soft parts are easier to divide, and the resulting wound less deep and more readily dealt with than one in the loin : (7) The bowel is more easily reached, and with less disturbance of deep-lying soft parts ; (S) There is no risk of oj)ening small intestine, or of failing through abnormality of the colon, (ii.) The peritona?um being opened of set purpose, the surgeon can examine the site and extent of the disease, (iii.) The shallower wound makes it much easier to draw out the intes- tine, and make a satisfactory angle and spur, or to perform colectomy, (iv.) The position of the anus renders it more easily accessible for the needful attention. If the above advantages are considered separately, I think there is no doubt that the first (and this is the most important one) is correct. "Where the colon is distended, the lumbar operation is an easy one; but where the bowel is flaccid and lies deeply far away in a fat patient, the * Not needlessly large, for fear of troublesome prolapsus later. t The following reasons have been given in explanation of this well-known fact — viz.. the proneness of the cascum to give way under the stress of distension, and even when at some distance from the obstruction. Dr. Coupland and Mr. Morris (Brit. Med. Journ., 1878) attribute it to the cul-de-sac nature of this part of the intestine; its lixity and dependent position ; its being the place where two currents meet — viz.. from the ileum and, in case of regurgitation, from the colon; and the pressure to which it is subjected between the iliacus and the abdominal muscles. Mr. Lockwood {St. Bart. ]Io.) drawing down the intestine till the upper end is tight (Cripps). and then bringing it out through as small an opening as possible ; (c) closing this opening round the bowel, and the bowel to the edges of the wound, as securely as possible, whether a rod (p. 104) has been used or no; (d) keeping the patient at rest until the parts have had full time to consolidate ; (e) treating assiduously any such causes as constipation, coughing, straining in micturition, &c. ; (/) trying the effect, as early as may be, of a light spring truss and pad. The two following complications may occur during vomiting or coughing. 4. Small intestine or omentum may escape between the piece of sigmoid which has been drawn out and the edges of the wound. This accident may be known by the urgent vomiting, pain, collapse, and ,soakage of serum into the dressings. These should of course be removed at once, the small intestine cleansed and returned, and the wound made safe by additional sutures. This accident is most likely to occur when a large wound has been made, an insufficient number of sutures used, and the nurse has not made efficient pressure with her hand over the dressings (p. 104). Where omentum protrudes — a much rarer compli- cation — it may be left, as it will all shrivel away gradually, but additional sutures should be inserted at once. 5. A rarer accident, of u'hich Mr. Cripps has published an instance (Brit. Med. Journ., vol. ii. INGUINAL COLOTOMY. Ill 1895, P- 967), is where the bowel tears away from its attacliments and falls back into the peritoneal cavity. This happened on the seventh da}^ daring a violent fit of coughing. " The released bowel discharged a considerable motion into the peritonieal cavity. FortunatelT, I saw the case about an hour after the accident. The fjecal matter was thoroughly washed out from the abdomen, and the detached bowel restitched. The patient recovered."* 6. Strangulation of small intestine between the attached sigmoid and the parietes. An instance of this very rare accident will be found recorded by Mr. Cripps {loc sa[tra cit., p. 967). A patient on whom inguinal colotomy had been performed was about to leave the hospital when he was seized with symptoms of acute obstruction, the pain being referred to the colotomy opening. After vomiting three or four times the patient said he felt something slip in his inside ; the vomiting ceased, and the pain suddenly left him. A few days after, feeling quite well, he was discharged from the hospital, and was re-admitted ten days afterwards in a dying condition. The necropsy showed that a loop of small intestine had slipped down into a canal, about an inch long, between the attached portion of the gut and the reflection of the parietal peritonaeum, near the anterior superior spine. From this canal the intestine must have released itself at the first attack. Mr. Cripps adds that prompt abdominal section would have saved this patient. Causes of Death after Anterior Colotomy. — Many of these will be the same as those given in the account of the lumbar operation (p. lOO), and others, more peculiar to the anterior operation, have been so fully given in the pages just preceding that there is no need to repeat them here. RIGHT INGUINAL COLOTOMY. MAKING AN ARTIFICIAL ANUS IN THE C^CUM. This operation is but rarely made use of. One objection to it is that, owing to the proximit}' of the small intestines, the intestinal contents are likely to be more liquid, and thus to cause more trouble afterwards. It may be resorted to under such conditions as the following : 1 . When, in chronic obstruction of the large intestine, the site of the mischief is uncertain and the cgecum is much distended. Here, owing to the tendency of the caecum to slough from over-distension, a surgeon would be quite justified in cutting down upon the caecum instead of resorting to right lumbar colotomy, if he felt sure of being able to prevent contamination of the peritoneal cavity from the escaping faeces. 2. When, during the performance of a right lumbar colotomy, finding the colon is impossible. In the above instances the caecum would be reached by an incision made over it. And, personally, when the surgeon has been exploring the site of an obstruction through the linea alba and determines to open the cecum, I think it would be wise to do this through a second * Mr. C. Heath's remarks on this or a similar case QBrit. Med. Joitrn.. vol. i. 1892. p. 1243) are worth the attention of anyone inclined to think lightly of such an accident because the patient recovered. " Of course we hear of one case that did recover, but we do not hear of the ninety-and-niue cases which did not." The remarks which follow on the value of statistics are too bitter for me to insert them liere, but they contain a very large germ of truth. 112 OPERATIOXS OX TILE ABDOMEN. incision in the right iliac region, as I consider it risk}- to anchor intestine in the middle line. Sir F. Treves (Lancet, vol. ii. 1887, p. 853) published a very successful case, in which exploration in the middle line detected a stricture at the termination of the descending colon. As the Ciecum was enormously distended, its peritonjeal coat having given way at several spots, he brought the ca3cum into the Avound in the linea alba, bringing all the most damaged part out of the wound, which was united round it. A puncture of the caecum through one of the rents allowed an immense amount of gas to escape. Fortunately no feeces were seen. The hole in the bowel was clamped, and the wound dressed with iodoform. When the bowel was opened on the fifth da}- a large quantity of frecal matter escaped. Six months later the patient was in excellent health. On the other hand, the case of Mr. Cripps, which I quoted at p. in, shows how very small a space between anchored bowel and the parietes may be sufficient to bring about a fatal strangulation. Operation. This differs so slightly from a left-sided iliac colotomy that very little more need be said. The incision should be about three inches long over the distended intestine, or parallel with the outer part of Poupart's ligament and the iliac crest. There may be no meso-cascum ; in such a case the surgeon may experience considerable difficulty in getting the ceecum satisfactorily into the wound. MAKING AN ARTIFICIAL ANUS IN THE TRANSVERSE COLON. This is the most rarely performed of all the colotomies. Mr. H. Allingham gives three cases in his book on Colotomy, p. 170 — one of his own, and two performed at St. George's Hospital. lu oue, chronic obstruction was present, and a median incision showed a growth in the descending colon. The lower part of the exploring incision having been closed, in the upper two inches the parietal peritoneum was stitched to the skin ; the transverse colon was brought out here and stitched in the iisual way. The bowel was opened the next day. In another case, opening the transverse colon was preferred to lumbar colotomy, on account of the diflBculty of making a satisfactory spur in the latter position. CHAPTER IV. OPERATIONS ON THE KIDNEY AND URETER. NEPHROTOMY— NEPHRO-LITHOTOMY— NEPHRECTOMY— NEPHRORRAPHY— OPERATIONS ON THE URETER. NEPHROTOMY. Indications. — The following are the principal conditions which demand this operation : — i. Pyonephrosis and Abscess of the Kidney. — When due to tuber- culous disease, and the tumour is large, or the patient is not in a condition to stand primary nephrectomy, nephrotomy should be per- formed as a preliminary measure ; when, however, there is evidence of disease of the opposite kidnej" or of other viscera, nephrotomy alone is available. The results, however, when a secondary nephrec- tomy cannot be performed are, as might be expected, extremely unsatisfactory. Otto Ramsay, of Baltimore (Annals of Surgery, vol. ii. 1900, p. 461 et seq.), gives the results of fifty-five cases. Of these, four at the most, and probably two only, can be considered as cured. When the abscess is due to calculi, these will be removed and the cavity drained, except in special cases where nephrectom}'' is indicated (vide infra, p. 1 30). In a few rare instances pyonephrosis may be due to a sti'icture of the ureter. An example of this condition is referred to below under the Surgery of the Ureter (vide p. 170). ii. Hydronephrosis. — If the kidney has been entirely destroj^ed, and the size of the tumour prevents removal, incision and drainage should be employed either as a method of cure or as a preliminary to a secondary nephrectom3^ iii. As an exploratory operation for diagnostic purposes for certain obscure renal symptoms. Some of the conditions that have been found are mentioned below under Nephro-lithotomy (vide p. 1 18); in others a calculus will be found. In others again, particularly where the only symptom is hsematuria, the exploration may have a negative result. Hurry Fenwick (Brit. Med. Journ., vol. i. 1900. p. 248), however, records two striking cases of operation for unilateral painless renal haematuria. In the first case, a young lady, aged 18. had suffered from attacks of heematuria for five years, causing marked anaemia. With the cystoscope the blood was seen to come from the left ureter. At the operation the left kidney was brought out on to the loin, the VOL. II. 8 114 OPERATIONS ON THE ABDO^IEN. pelvis incised and illuminated with electric light. It was then seen that one of the renal papillae was of a bright red colour, and appeared to be villous on the surface. The papilla and half the pyramid were removed with a Volkmann's spoon. No hjematuria has occurred since the operation. In the second case there had been alarming hematuria for a fort- night, producing profound antemia. The blood was seen to come from the left ureter. The operation was similar to that performed in the first case, as was also the condition found. This case was like- wise completely cured. iv. Anuria. — This will be dealt with later (ride p. 137). Operation, — As this is identical with the first stages of a nephro- lithotomy the reader is referred to the description of that operation (vide p. 123). NEPHRO-LITHOTOMY. The following are the chief symptoms and conditions justifying nephro-lithotomy : — I. Continued Hcemahtria, or Passcuje of Blood and Pus. — I may at once be criticised for putting this first; and, indeed, it is somewhat difficult to decide which symptom of renal calculus is clinically the most important.* On the whole, I am inclined to agree with an old friend, G. A. Wright, of Manchester (Med. Ghron., March 1887, p. 463), who considers "renal hsematuria as the only single symptom of anything like cardinal importance," if without evidence of nephritis. A few words as to the character of the haematuria of renal calculus and the fallacies which must be borne in mind. It is a hsematuria of long standing, often repeated, frequently increased by exercise or jolting, rarely profuse, and never producing anaemia, as in growth of the kidney. Always intimately mixed with the urine, the tint varies from a bright or deep red (which I think are rare) to a smoky or porter-like colour. Fallacies : (a) Haematuria ma}' be absent from first to last. This, an undoubted fact, is one veiy difficult of explanation. It was the case with the smaller calculus (Fig. 40). And this is the more extraordinary as the stone is covered \\'ith minute crystalline spicules, a condition which would have appeared certain to lead to oozing from the inflamed mucous membrane of the pelvis in which the stone lay. The only explanation that I can give is that at the operation I found the abdominal muscles extremely rigid ; even when the patient was fully ansesthetised, they gave the impression to the scalpel of cutting through tissues frozen by ether. Now, if it is fair to suppose that on the other side of the kidney the quadratus and psoas were as firmly contracted, the kidney and the stone in its pelvis may have been so firmly held that no irritation by the calculus could take place, and thus no haematuria. (h) Another fallacy is that the haematuria of calculus ma}- be only temporar}- , present for a while * Being convinced of the frequency of errors of diagnosis in renal calculus, I have dealt with these fully. I may also refer my readers to my paper, Brit. Med. Journ., 1890, vol. i. p. 117. NEPHRO-LITIIOTOMY. 1 1 5 and then ceasing altogether. This occurs, though rarely, when a small renal calculus becomes encysted, (c) The value of heematuria, though only occasional, is shown by a case of Dr. Owen Rees', to which Mr. Morris has drawn attention. It was that of a youug lady with lumbar pains and frequent micturition, which were both put down to the hysteria that was markedly present. After a while, haematuria was found to be present ou several occasions, and eventually, after death, a mulberry calculus was found in one kidney. Other fallacies are presented by the host of kidney conditions which may give rise to hasmaturia — namely, (i) the passage of uric acid crystals ; (2) tubercular kidney ; (3) granular kidney ; (4) gro\vths ; (5) increased intra-renal pressure, &c. To these I shall refer later. 2. Pain and Tenderness, Licmhar ami elsewhere. — (a) Fixed Lumbar Paix. — Characters : Generally diill. gnawing, pricking, or aching, in- creased iisually by exercise, twisting from side to side, or flexing the body.* Sometimes it is relieved by pressure of the hand, leading to thickening and vascularity of the parts when they are incised at the operation, (b) Radiating Pain, for example, in the testis, f region of the small sciatic nerve, calf, foot, or in the intestine simulating colic. It is easy to see how readily the pain of a renal calculus, if limited to distant parts, and if occurring without hismaturia, may mislead. Another point ^\•ith regard to the pain of renal calculus is the frequency of nocturnal exacerbations. The explanation of this is doubtful, whether, as Mr. Morris has suggested, from the passage of flatus in the colon, at this time over a stone in the pelvis, or, as I venture to think more probable, as accounting for stone whether in the pelvis or in one of the calyces, to the concentration of the iirine, and consequent deposit of crystals, which takes place at night, is unsettled. The fact, however, is undoubted. In the case of a patient, aged 58. who had suffered from symptoms of renal calculus for thirty years, and from whose left kidney I removed the huge calculus (Fig. 40), the pain at night was often so severe as to drive him from his bed into his garden or the streets of the town in which he lived. (c) Renal Colic. — Very acute in character, radiating from the loin, usually downwards, and accompanied often by rigors, nausea, vomiting, and profuse perspiration. The attacks are usually recurrent, and vary greatly in severity. On the other hand, pain is, much more rarely, absent. With regard to tenderness, Mr. Jordan Lloyd (Praci., vol. xxxix. p. 178), in a paper to which I shall have again to refer, writes thus : "I attach great importance to the evidence to be obtained * As in going upstairs ; probably from the pressure on the kidney by the contract- ing psoas. But the relation of the pain to movement, and the kind of movement which most induces pain, vary greatly. Thus Mr. Butliu's patient is said to have suffered greatest pain when driving, least when riding. Prolonged walking seems the most frequent cause. t In a case of Mr. Butliu's (^Clhi. Soc. Trans., vol. xv. p. 113) the patient sought relief from severe neuralgia of the right testis, which was generally retracted and extremely tender. Later ou it was noticed that these neuralgic attacks were associated with some lumbar pain and tenderness. Complete recovery followed after the removal of a small, prickly, calcium-oxalate calculus from the pelvis of the right kidney. Il6 OPEEATIOXS ON THE ABDOMEN. by immediate percussion over the suspected organ, a method of investigation which has not received that amount of attention to which it is entitled. It is best practised from the loin, just beneath the space between the tips of the last two ribs, and should be made in a direction upwards, forwards, and slightly inwards. It is best for the patient to stand upright before you. The blow should be sharp and decisive, and of force sufficient to affect a structure situated several inches below the surface. It may also be practised from the front, at a point midway between the umbilicus and ninth rib. When a calculus is present, the patient will complain of sharp, stabbing pain at the moment of percussion. Other conditions doubt- less give rise to percussion pain, but not of the characteristic stabbing of calculus." I have tried the percussion test of Mr. Lloyd in many of the cases which have come under my hands for nephro-lithotomy (table, p. 138) since his paper was published. In three the tenderness was increased, but in one only was there any " characteristic stabbing." In this, where a small and very spiculated oxalate of lime calculus occupied the top of the left ureter, the patient at once said, " You stab me there." This patient. No. 5 in the table, was thin and spare. Tenderness more or less marked will, however, be usually elicited by making firm pressure upon the kidney between the two hands, one placed in front and one behind the kidney. 3. Points in the Previous Ilistort/. — Space will only allow of my noticing a few of those given above, namely, lithiasis and oxaluria, history of previous passage of a stone, history of previous colic. The history of long-standing lithiasis and oxaluria is of obvious importance, from the fact that the habitual passage of crystals or gravel and the formation of a calculus lie not far apart. But there is another point which has not, I think, received sufficient attention, and that is, that in patients who have habitually, for many years, passed uric acid and oxalate of lime, there is a most serious risk that the minute anatomy of their kidneys will have become seriously damaged by the constant presence of the above crystals. We should all be agreed as to the damaging effect of multiple calculi on the secreting tissue of the kidney. I would suggest that in the future the results on the kidney of the daily passage of crystals of uric acid and lime oxalate must receive sufficient attention before patients at all advanced in life are submitted to nephro-lithotomy. Further- more, it is obvious that long-continued lithiasis and oxaluria will very likely have led to the formation of bilateral stones. Under the heading of Renal Colic, I would point out that the vomiting and nausea which are thought to be characteristic of the agony of a descending calculus may also be caused by a stone which is distending the renal pelvis, bi^t has not yet begun to make its way down. 4. Frequency of Micturition. — The co-existence of irritability of the bladder ^^■ith renal calculus is well known, and may be explained either by nerve disturbance, or by the blood and pus, or the over-acid urine which often accompanies stone in the kidney. A point with regard to bladder irritability is that it may be of value in making that most difficult diagnosis between a calculous and a XEPHRO-LITHOTOM Y. 1 1 7 tubercular kidnej'. Thus, if a patient with h^ematuria, lumbar pain, &c., has irritability of the bladder which is not relieved by rest in bed, but which continues bv nio-ht as well as bv dav, it is probable that this is due not to trouble in the kidney alone, but to co-existmg ulceration of the bladder, and this will probably be confirmed by examination of the prostate and vesicul^e seminales in the male, and by digital exploration of the bladder in the female. 5. Sliagrajyhic Evidence. — So mam* obscure cases of renal and ureteral calculi have now been made clear by means of radiography that, wherever the means are at hand, cases that are at all doubtful should be submitted to this test. If a distinct shadow is seen in the skiagram of the affected side, it may be taken to be indicative of the presence of a calculus. On the other hand, the absence of a shadow cannot be said, in the present state of our knowledge, to prove the absence of a calculus. 6. Failure of Previous Treatment to ijive Belief. — I can only touch on one point here — i.e.. the question of the advisability of trying to exert any solvent action on a calculus in the kidney. Whilst, for myseli. 1 attach the greatest importance to the use of large quantities of water, it is rather because this, by washing out the kidne3's, removes collections of crystals, and gets the patient into a better state for operation, than because I believe in its jDOSsessing any actively solvent action upon the calculus. I do not forget that Sir W. Roberts has proved by experi- ments on calculi, both those without the body and those in the bladder, that urine rendered alkaline by fixed alkali has a distinctly solvent action. Dr. Ralfe has reported {Path. Soc. Trans., vol. xxxiii. p. 206) a case of a i)atient, aged 37, who. after sufferiug from uric acid gravel for some years, had a violent attack of renal colic, with profuse haematuria, no calculus or gravel being discharged. Alkaline treatment was at once resorted to, and for a time afforded relief, but the patient could not be persuaded to continue it systematically. He was then ordered to drink copiously of soft water — filtered rain-water. Two years later he began to pass grit and scales of calculous matter with his urine ; and shortly afterwards, after a severe attack of colic, he passed the sheU. of what had evidently been a solid calculus.* But it must be remembered that, as my late colleague Dr. Hilton Fagge pointed out {Medicine, vol. ii. pp. 373. 383). such solvent treat- ment is only worth trying in the case of uric acid calculi. He at the same time showed that the greater relative frequency of lime oxalate calculi over those of uric acid, especially in patients after early adult life, is nmch more marked than is generally believed. ^loreover, * Dr. Ralfe (^Dheascs of the Kidmys. p. 523) points out that the solvent action of distilled water is due to several influences. In the first place, by causing a low specific gravity of the urine, it induces disintegration, since Kainey has shown, experimentally, that bodies placed in solutions of different density to those in which they were formed undergo molecular disintegration. Again, chemical analysis has shown that those calculi that undergo spontaneous disintegration are always poor in inorganic con- stituents: the use of soft water diminishes the supply of these, even if it does not actually act as a solvent on those forming the outer crust of the calculus, and so increases the tendency to disintegration. Lastly, soft water probably diminishes the catarrh of the urinary passages, and by diminishing the swelling of the mucous mem- brane allows a small stone to pass which was before obstructed. Il8 OPERATIONS ON THE ABDOMEN. as Morris {Hunterian Lectures, 1898) points out, it cannot be too strongly urged that, in the presence of definite symptoms of calculus, any prolonged course of palliative treatment is to be deprecated, for during this time the stone may be steadily but slowly destroying the kidney, and so valuable time will be lost. 7. Calculous AmLTia. — Exploration of the kidney in this extreme condition is urgently called for, although in a few cases recovery has taken place without operation. Morris Qoc. sujfra cit.) gives two collec- tions of cases, those operated on and those not operated on. Of forty- eight cases not operated on, ten, or 20"8 per cent., recovered ; of forty- nine cases operated on, twenty-five, or 51 per cent., recovered. These figures speak for themselves. The most important and difficult point to decide is the question as to which kidney should be explored. If it can be determined which kidney has become the more recently affected, this should be chosen for operation, because this kidney will be the one that is least destroyed by disease. Apart from history, abdominal pain, rigidity, and tenderness may help to clear up this point. This subject is again referred to later, p. 137. Conditions which may simulate Renal Calculus. — Before deciding to operate on a given case, it must be borne in mind, in addition to what has been already said, that many other diseases may give rise to the same symptoms as renal calculus. So closely do some of these conditions simulate renal calculus that a correct diagnosis can only be arrived at by means of an exploratory operation. Morris (Joe. supra cit.) gives a list of no less than forty-four cases occurring in his own practice in which the kidney was explored for stone, and no stone found. In a few of the cases a calculus was passed soon afterwards, so may have been lodged in the ureter at the time of the operation. In the majority of the cases, however, some other morbid condition of the kidney or ureter was found and remedied. So that, although no stone was found as the result of these operations, no harm was done in any (for none were fatal), and good was done in the majority. Morris says : "It is certain that the diagnosis of calculus, though incorrect, was advantageous to the patients, for the very reason that it led to the exploration, and in this way to the discovery of the true cause of the disease." These conditions simulating calculus must now be severally con- sidered. They may be usefully divided into two groups — affections of the kidney and ureter, and diseases of other organs. A. Affections of the kidney and ureter which simulate renal calculus. 1. Lithiasis. — I have already alluded to this condition as one which simulates renal calculus by the hfematuria which crystals of uric acid may cause. Lumbar and testicular pains are also points which mere lithiasis shares with renal calculus. The diagnosis will not be difficult by watching the result of treatment, which only gives relief in the one, but clears up the other. Exercise, again, is a test. 2. Tubercular Kidneij. — Lumbar pain and tenderness, frequent mic- turition, haomaturia, are all common to tubercular kidney and renal calculus. The chief aids in the diagnosis appear to me to be : (a) the pyuria; (6) careful examination of the urine ; (c) early pyrexia; ((Z) early exploration of the kidney. NEPHRO-LITIIOTOMY. II9 {a) Pyuria. — This is usually present early in the case with a pro- portionate amount of albumen, without much hgematuria, the blood often occurring only as a thin layer over the pus at the bottom of the itrine-glass, or as small, thready clots. With all the pus the urine is strongly acid at first, then more feebly so, but often remains slightly acid to the last, (ft) Careful examinations of the urine. — The sediment contains caseous matter, and sometimes debris of connective tissue can be made out, a point of much importance. Finally, there is the bacillus tuberculosis. While I am well aware of the frequent want of success in demonstrating the presence of the bacillus in urine as in bone, I may add that it was found in six out of the thirteen cases in which I have been asked to explore tubercular kidneys.* (c) Pyrexia. — I do not here speak of the hectic which accompanies the advanced stage, but of the pyrexia which may be an important factor in the diagnosis much earlier in the case. Often intermittent at first, and liable to be overlooked in the anorexia, nausea, and debility which accompany it, later on, and too late, it becomes only too evident and confirmed, {d) Early exploration of the kidney. — Morris mentions three cases in which tuberculous foci were found in the kidney and excised. In one case three separate wedges of kidney substance Avere removed, and the resulting gaps in the kidney closed by sutures. This matter is referred to later, p. 158. 3. Hydrmiephrosis due to stricture of the ureter, or a vahmlar obstruction at the commencement of the ureter. Several remarkable cases of this nature have been described, notably those of Morris and Fenger. These will be referred to later, p. 169. Mr. Bruce Clarke has also published {Lancet, vol. ii. 1891, p. 984) two cases of this kind in which the cause was not found. The first was perhaps an early stage of hydronephrosis, and the pain a very prominent feature, dull and aching, with severer attacks ; but, as it was found at the operation that "'the kidney pelvis was very slighth^ dilated," the case is not decisive. The second is more convincing. The kidney here was dilated and a mere shell, no cause being found. There was a definite history of several attacks of renal colic, and Mr. Bruce Clarke thought that these had probably been caused by kinking of the ureter. 4. Slight Pyelitis, not Tid>ercular. — This condition may. by hsematuria, pus in the urine, lumbar and testicular pain, simulate renal calculus closely. It may follow a gonorrhoea, perhaps a previous stone, or occur in women after pregnancy ; perhaps, as Dr. ^I. Duncan thinks, from some parametritis extending up the psoas to the peri-renal fat and kidney. * I may point out here that bacteriology will help the surgeon iu difBcult cases. My colleague, Dr. Washbourne, has thus cleared up two obscure cases for me. One, a delicate woman of 32, with a tubercular history, was sent to me by Dr. Forty, of Wotton, in Gloucestershire, with obstinate cystitis and irritable bladder. The endoscope and digital exploration showed swollen and hyper-vascular mucous mem- brane, but detected no ulceration. AViping over the mucous membrane with a solution of silver nitrate (gr. xl. — 5j) was followed by very great relief lasting over two months on two occasions. At my request Dr. Washbourne injected some of the pus containing urine (in which no bacilli could be found) under the skin of a guinea-pig. No result apparently followed, but, when the animal had been killed, oiw of the nearest chain of glands was enlarged and caseating. A few undoubted bacilli tuberculosis were found in it. This and the other case will be found in the Gtafs Hasp. Bcp.-, 1890. I20 OPERATIONS ON THE ABDOMEN. 5. Movable Kidney, especially if associated with neuralgia, pyelitis, or if recurring with some of the reflex causes of nephralgia to be mentioned below. The following case under Mr. Watson Cheyne (Brit. Med. Journ., vol. i. 1899, p. 17), in which there was severe hematuria, caused probabl}^ by congestion due to kinking of the renal vessels, is Avorthy of note in this connection. A woman, aged 40, had a fall, hurting her back, in 1885. This caused great pain and hsematuria, the urine being bright red in colour. This continued for five weeks, during which time the patient was confined to bed. and then ceased. There was no further hsematuria for ten years, although pain was present during most of the time, Severe hsematuria then occurred again, and again stopped after a time. In June 1897, severe hsematuria and pain came on again, and continued till November, when the operation was performed. No stone was jDresent, but the kidney was found to be freely movable. The kidney was fixed, with the result that hsematuria ceased immediately and did not recur. 6. Ureteritis. — The following is a very striking instance of this rare disease, described by Israel {Berl. Klin. Woch., xxvii., 1893) : A young man. aged 28. had for eight years suffered from a urinary affection which began with frequency of micturition. Soon acute attacks of pain in the bladder and left renal colic of extraordinary severity began. The clinical examination in corroboration of the patient's account left no doubt as to the presence of renal calculus : there were frequently blood and mucus, but no tubercle bacilli, present in the urine; there was also tenderness in the left flank, and pain was caused by pressure on the ureter through its abdominal course. The kidney was explored, and found to be small and soft, but no calculus was present. The wound healed rapidly, but the symptoms continued as bad as ever. Two months and a week later the kidney was again explored, and then it was dis- covered that the ureter througliout its length was extraordinarily hard, of nearly three times its normal diameter, and presented at intervals enlargements of quite carti- laginous consistence. The ureter was permeable from kidney to bladder, but at three points slight obstructions were present, due to folds of thickened mucous membrane, the result of ureteritis. Nephrectomy was performed, and resulted in a complete cure, 7. Aching Kidney. — Under this title Dr. M. Duncan has described a condition, especially common in women, which ma}'' simulate renal calculus. Its chief features are a heav}', wearying pain, deep in the side, usually accompanied b}" tenderness, often great ; the pain may run in the course of the great sciatic or anterior crural, and is frequently accompanied by irritability of the bladder, and by pain in the course of the ureter. The disease is liable to be aggravated by exercise. The chief points in the diagnosis of this condition are, Dr, Duncan points out, the absence of blood and pus, the fact that the " aching " often occurs onl}' at the menstrual periods and is always worse then, from the intimate connection between the kidneys and the generative organs, not only developmental but pathological, A definite nephralgia is also caused sometimes by malaria, as pointed out by Morris, and ma}' be relieved by the administration of quinine. 8. Interstitial 8hrviildn(j Nephritis. — This condition may simulate renal calculus both by hsematuria and pain. Dr. S, West {Lancrt, 1885. vol. ii. p. 104) drew attention to the htematuria which may accompany granular kidney, and published three cases, aged 21, 19, and 24 ; in the first the haemorrhage was profuse. Mr. Bowlby {Clin. Soc. Trans., vol. xx. p. 14) also published three cases, aged 73, 49, and 64 ; two of these died, and the kidneys were NEPHRO-LITHOTOM Y. 121 found markedly granular. He points out the following as distinguishing this condition from renal calculus : The specific gravity of the urine, after the blood has cleared up, only 1008 to 1015; tortuous arteries, cardiac hyperti'ophy, and high arterial tension; blurred, ill-defined discs, some retinitis and effusion amongst the blood-vessels. The paper concludes with the following warning : •• Unless it be recognised that blood may emanate from a kidney which is simply granular, operations may be undertaken for the removal of renal calculus." With regard to renal pain in granular kidney, this is of two kinds. There is the dull aching generally found, if the case be watched, to be felt across both loins, as well as in one side. Occasionally, though this is rarer, the pain occurs in violent paroxysms, simulating renal colic. This was so in the case to which I have alluded, and to a more marked degree in one brought by Mr. Mansell Moullin before the Clinical Societj^ (TraMS., vol. xxv. p. 60). If now, in addition to the hgematuria and paroxysmal pain, there be nausea, passage of uric acid, and frequent micturition, the mistaken diagnosis of calculus maj' easily be made. Where granular kidne}- is possible, such a case should be carefully watched, and if the specific gravity of the urine never rises above 1015, the question of operation must be entertained with the greatest caution, and the very great risks most clearly put before the patient. Other conditions mentioned b}^ ^lorris as having been found in some of the above-mentioned forty-four cases are — small abscesses, or sup- purating c^'sts, solid renal or peri-renal tumours, tense cysts, blood extravasated either under the capsule or within the substance of the kidney, dense adhesions. B. Diseases of other organs which may simulate renal calculus. 1. Gastric and Duodenal Ulcer. — Morris has seen a case of gastric ulcer which sinnilated renal calculus, and Ralfe (Brit. Med. Joiirn., 1888, vol. i. p. 183) gives one which he thinks was due to duodenal ulcer. Thus, a patient had many symptoms of renal colic, and three attacks of paroxysmal pain accompanied by vomiting, great tenderness in the right renal region, urine loaded with uric acid, but no pus or blood. The patient, who was losing flesh, recovered with treatment directed to duodenal ulcer. 2. Litest inal Adhesions. — A case is given by Dr. Tirard (Lancet, vol. i. 1892, p. 16). Though (as the kidney' was only punctured) the presence of a calculus cannot be excluded in this case, it is very possible that the exi3lanation given below may meet other nephralgias. A schoolboy, aged 12, gave a history of ha^maturia with severe pain, after another boy had jumped suddenly and roughly on his back. There was only this one attack of hematuria, but from this time occurred frequent attacks of severe pain, which seemed to return with any sudden jolting movements, a railway journey or a ride in a hansom often proving sufficient exciting cause. It was also noticed that the pain was worse with constipation or diarrhoea. Although no certainty was felt about the presence of a renal calculus, it was generally thought that the sj'mptoms might be due to this. At the operation no stone could be found, though the pelvis and the substance of the kidney were carefully explored with a needle. A firm cicatrix was, however, discovered, circling the capsule of the kidney and the descending colon, and this was so tough and so extensive that it was thought expedient not to divide it. 122 OPERATIONS OX THE ABDOMEN. The lad recovered, and is now able to keep fairly free from pain so long- as he attends closely to the action of the bowels. 3. Gall Stones retained in the Gall Bladder may be taken for right renal calculus. Dr. Murchison pointed out long ago that they not infrequently coexist. My old friend. G. A. Wright, of Manchester, has recorded {Lancet, 1885, vol. i. p. 563) a case in which the right kidney was explored for a calculus believed to be in the ureter. On exploring this tube a hard spot was felt near the brim of the pelvis, and taken for a stone in the ureter. A calculus the size of a pigeon's egg was removed and found to be a gall-stone. Acute peritonitis carried off the patient, and a stone was found to exist in the pelvis of the right kidney, with its apex in the ureter. While on this subject of nephralgias due to conditions of viscera near the kidney, I may refer to some remarks of Mr. Godlee (Pract., vol. xxxix. p. 246). in which he insists that repeated attacks of intestinal colic, especially if accompanied by nausea, may be the only symptoms of the presence of either a renal or biliary calculus, and that this fact should lead the practitioner to investigate the state of the kidney and urine, bearing in mind the possibility of the symptoms being due to renal or biliary calculi. 4. Sjjinal Disease. — The great difficulty which may arise in diagnos- ing between certain cases of spinal caries and renal calculus is not yet sufficiently recognised. A writer already quoted from (G. A. Wright, Med. Chron., No. vi. p. 642) thus alludes to this matter : " Where a local patch of caries of a vertebral body exists, and especially where deep suppuration occurs and presses upon the kidney, as in a case of my own and one or two others which I have seen, nearly all the symptoms of a calculus have been present. In my own case, without any deformity or tenderness of the spine, there was unilateral rigidity, testicular pain, intermission of symptoms, increased frequency of micturition, nausea during attacks, and oxaluria, with local pain and tenderness. Subsequently an abscess developed, and on exploration a small patch of caries was found, and the kidney was felt exposed in the anterior wall of the abscess cavity. Probably, as in floating kidney, obstruction of the vessels and ureter may arise and cause symptoms, so that pressure of the spinal abscess may disturb the kidney, and quite possibly give rise to hEematuria." In addition to the above, Morris alludes to having known cases of each of the following conditions give rise to symptoms simulating renal calculus : — malignant and tuberculous growths in the intestines, aortic, or coeliac aneurysm stretching the ureter or renal vessels, vesical calculus, abscess and calculus in the prostate, growths in the bladder, ovaritis, and tuberculous disease of the Fallopian tube. Finally, I must mention the following exceptional case of malignant disease inrolvinrj the last dorsal nerve, that came under my care seventeen years ago : The patient, aged 44, came with hsematuria, wearing pain, tenderness in the right loin and thigh, and oxaluria. His childhood had been passed in Norfolk, and as a lad he had been cut by Mr. Birkett for stone in the bladder. I sounded him twice, and finding no stone, I swept the sound in contact with the bladder in different directions, in the hope of detaching fragments of growth if one were present. No relief being given by drugs, I explored the right kidney, and could find nothing abnormal. Four days after the operation, when all seemed to be doing well, the patient died very suddenly. At the necropsy we found (a) a primary carcinomatous growth of the bladder of a somewhat unusual kind ; it involved the apex as a flocculeut, superficially ulcerated area ; (i) a ring of secondary deposit surrounding NEPHEO-LITHOTOM Y. 1 2 3 the right last dorsal nerve, just at its exit from th'e spine ; (c) a mass of enlarged glands around the inferior vena cava, and at one spot sprouting into it ; (■ a ^t . „ , , ^ ., in the text. It weighed 473 gr., and consisted of sixth dav a change for the worse ,..,. ., ^ i-i.i „<.„„ ti^o ,.io;„ ,-,io== la-ir I'n ' ° lithie acid and lithates. the mam mass lay m set in, first much flatulence and nausea, ^j^^ ^^j^^^^ p^l^ig^ tl^e processes fitted into the then constant restlessness, followed by ealyces. The smaller calculus, composed chiefly «oma, ending in death on the morn- ^f oxalates, was successfully removed from a ing of the eighth day. I cannot patient aged 24. It weighed 42 grs. The two doubt that the opposite kidney was are good instances of what nephro-lithotomy here also the seat of stone, and its can, and what it cannot do, without grave tissue too much impaired to admit risks, of recovery, though I was unable to obtain a post-mortem examination to verify this. I should add that the urine in this patient before the operation was acid, of sp. gr. 1018, and without sugar or albumen. The quantity passed was natural, and the urea sometimes normal, some- times slightly deficient. Dr. Whipham and Mr. Haward {Clin. Soc. Trans., vol. xv. p. 123) have recorded a case which, with my own just given, points urgently to the importance of surgeons being permitted to explore earlier : The patient, aged 56, had for " several years " been troubled with " graveL" The symptoms here were chiefly indicative of calculous mischief in the left kidney, but there was some tenderness on the right side as well. The urine here was 1006 sp. gr., alkaline, and contained pus. The left kidney was explored, and found in a state of pyo-nephrosis ; no calculus was found, but a copious discharge of pus took place soon afterwards, giving great relief. The patient a little later again lost ground, and the wound was thoroughly explored a second time, but the patient sank a few hours after this, a month after the first operation. The left kidney-pelvis was much dilated in its upper part, and communicated with a large peri-nephritic abscess. The right kidney contained a large branching calculus. 4, Septicaemia. This condition may be induced by the wound becoming foul, a complication which can always be prevented after removal of small stones from healthy kidneys. But where pyo- nephrosis exists, it may be impossible to keep the wound sweet from the first. This was so in Case 6 of the subjoined table. Here, after removal of nine calculi, I was obliged to remove the kidney a year later, owing to the persistence of a foetid sinus. 134 OPERATIONS ON THE ABDOMEN. And it is to be noted that septicaemia may occur after a nephro' lithotomy, successful as far as the removal of the stone goes, after a considerable interval, where pyo-nephrosis coexists. This is an additional reason for carefully considering the advisability of perform- ing nephrectomy in such cases. Dr. Shepherd, of Montreal, has published* a very interesting instance of this kind : Nephro-lithotomy was performed in a patient aged 26, who had suffered from symptoms of stone for seven years, with no tumour, and pus in the urine. An enormous, unbreakable stone of triple phosphate was removed with much difficulty from the left kidney. It weighed 4 oz. 7 dr., and measured 3^ inches in length and 9 inches in circumference. The tissue of the lower part of the kidney exposed seemed healthy, and no pus being evacuated it was thought best not to remove the organ. The wound continued to discharge pus, and the temperature varied corre- spondingly for three months and a half after the operation, when septicEemia set in and proved fatal. The necropsy showed that the upper part of the kidney, which was not exposed, consisted of large communicating sacs, containing over 10 oz, of fetid pus, and a number of irregular branched calculi. Dr. Shepherd points out that the fatal septicfemia was undoubtedly due to these abscesses, showing the need of thorough exploration in all cases where a large stone has set up grave changes, and of extirpation in most of them. I have described lumbar nephro-lithotomy fully because I believe that, on the whole, it is much the safer operation for the great majority of operators. But, to make the account complete, reference must be made to the proposal that abdominal should replace lumbar nephro-lithotomy. As might be expected, this proposal lias come from a specialist in abdominal surgery. Mr. K. Thornton (Harveian Lectures, " Surgery of the Kidneys," p. 34) gives the following reasons for preferring his combined method: "Recognising the difficulty in the diagnosis of a stone, and the still further complication introduced by the transference of pain in some cases to the opposite side, and the importance of being able to examine the other kidney and both ureters thoroughly, throughout their whole course, I proposed to open the abdomen by Langenbiich's incision over the suspected kidney, examine carefully both kidneys and ureters, and, having found a stone, to employ one hand in the peritonaeum to fix the kidney and stone, and guard the colon, while with the other I could cut down upon the stone directly from the loin, merely making an opening through the loin tissues large enough to introduce the finger and necessary forceps for the extraction of the stone." And again, at p. 36 : " We are certain that the patient has the usual allowance of kidnej^s. The chances of overlooking the stone, if there is one present in either kidney, is reduced to a minimum. I do not say that the abdominal handling is absolutely infallible, but in fourteen operations I have only once failed to find a stone, and the recovery and present health of this one patient make it highly improbable that there was, or is, a stone in her kidney. This result compares very favourably with the large number of unsuccessful lumbar explorations already recorded." • Philadelphia JVews, April 23, 1887 ; Annals of Surgery, vol. vi. August 1887, p. 185, The right kidney is stated to have been perfectly healthy, but double its normal size. NEPHRO-LITHOTOMY. 135 No one who has seen much of lumbar nephro-lithotomy would allow the above remarks to pass uncriticised. While I am fully aware of the difficulties in determining whether a stone is present, and in what part of the kidney it lies, I am convinced that every year that goes by will perfect our power of diagnosis, by making clearer to us the conditions that simulate stone. "The large number of unsuccessful lumbar explorations" of which Mr. Thornton makes a strong point is not quite correctly referred to by him. He implies that a stone was there, but that operators making use of lumbar nephro-lithotomy failed to find it. Now this is not quite the case. In the great majority of cases no stone was present. They were cases in which the diagnosis was at fault. It has always been so with every new operation, and is one of those faults which time alone puts straight. In reality, these failures to find a stone are rather creditable to the lumbar operation. The operators have been of the most vaiying degrees of experience, and the great majority of their cases* have recovered. Would this have been the case if the explorations had been through the peritoneal cavity with " the necessary manipulations to examine the kidneys and ureters " ? Now, on this hangs one of my chief points. No one who knows anything of what Mr. Thornton has done for abdominal surgery will doubt for a moment that operations on the kidney through the peritonaeum are certain to be as safe in his hands as any such operation can be. But what this book has to try and teach is what operation is the safest for the largest number of operators. I cannot agree with Mr. Thornton that the increased risk due to the opening of the peritona3um is practically nil— i.e., if the surgeon Avill take the pains to perform a thoroughly aseptic operation. I should agree that the risk of peritonitis is now much smaller than it was, but there are other risks which are inseparable from this mode of exploring the kidney.f 1 refer to the shock which the necessary manipulations of certain very vital parts must entail. Mr. Thornton will be able to go straight to the kidneys with a minimum of disturbance of the overlying parts. But is it to be believed for a moment that this would be the case with the majority of opera- tors? And this brings me to another point. Others who haAe tried this method have not found it so easy to detect the presence ()f a renal calculus or to determine the condition of the kidneys. "With regard to the latter point, I may mention the following : A woman was seat to me with long-standing pyuria of renal origin. She was clearly very near her end from kidney failure, and during the five days she lived * I have pointed out (p. 131) that there is reason to fear that fatal cases have not been published. But this would not apply to the lumbar operation only. t Every one who has seen much of renal surgery will know that grave shocks may readily be met with in some of these explorations of the kidney. Thus, in the case of nephro-lithotomy (No. 12 in the table, p. 138) in a lady of 40, with fifteen years' history, from whom I removed three cystine calculi, the patient was so ansemic and unhealthy from her long-continued pain and marred life, that she nearly succumbed during the operation. Yet this was of the simplest, the loin thin, the calculi (3S7 gr.) found at once and extracted easily, the operation itself not exceeding twelve minutes. A.C.E. followed by ether had been given, but the pulse, always weak, became almost; imperceptible after the first incision. 136 OPERATIONS OX THE ABDOMEN. no operation was admissible. After lier death I thought it a good opportunity to investigate the condition of the kidneys by an abdominal incision. I was able to feel that there was a right kidney, which felt so hard that I thought it contained a stone. About the condition of the left kidney I was quite unable to satisfy myself. The necropsy showed that the right kidney was in a condition of fibroid atrophy ; no stone was present. The left was a thin-walled sac containing pus. Owing to the great tenderness on this side, I had looked on this kidney as the source of the pyuria. It would have been readily reached from the loin. I have onl}^ once tried to detect a renal calculus through an abdominal incision. The case was No. 21 in the table at p. 139. As, in addition to the renal symptoms, there was trouble indicating oophorectomy, I took the occasion, after Dr. Galabin had removed the ovaries, to explore the left kidney, where the presence of a stone was suspected. The existence of a calculus, which felt a large one — in reality, three were present — and of a small hydro-uephrosis could be made out, conditions which were verified at the time of the nephro-lithotomy a little later. In this case the kidney was not enlarged, of the ordinary firm consistence, save near the pelvis, and free from the results of past inflammation. In such cases as these it will always be easy to detect the presence of the stone, but it will be very different in those cases where the stone lies in an enlarged kidney, the seat of a collection of fluid, or in one matted down with much thickening of surrounding tissues from long-standing inflammation. But I would rather quote the opinions of others. Mr. T. Smith (Discussion at the Clinical Society, By-it. Med. Journ., 1887, vol. i. p. 393) said that Mr. Thornton had seemed to represent that by open- ing the abdomen from the front one could ascertain with certainty whether there was a stone in the one or other kidney. But one could not always tell this even if one felt the kidnej^ out of the body. In three different cases in which he had handled kidneys so removed no stone could be detected therein until the kidneys were cut open.* Another very interesting case, brought by Mr. Page before the Medico- Chirurgical Society {Brit. Med. Journ., 1888, vol. i. p. 795) shows what care is needed when abdominal exploration for the examination of the kidneys is made use of. Mr. Page thought that in this case abdominal exploration, had he made it, would probably have led him astray, as the left kidney, which, though small, was the working one, would have been removed, while the right viscus, which was really the seat of pyelitis and contained some small stones, would have been looked upon as merely enlarged to do the work of two, this increase in size being really due to its diseased condition. Mr. K. Thornton (p. 37) mentions a case in which it took an hour to find the kidne}^ by the lumbar incision, and which ended fatally, and another in Avhich the surgeon failed entirely to find the kidney by the same method. Such cases, as shown by their number, are quite exceptional. When the large number of explorations of the kidney by the lumbar method is considered, it will be acknowledged that the lumbar method is characterised by the ease with which the kidney is found, and the well-doing of the cases afterwards, especially when the great number and the diversity of operators are considered. With regard to pain in one loin due to mischief in the opposite * On this point see Mr. Morris's case, p. 129, NEPHRO-LITHOTOMY. 1 37 Ividney, we have very little knowledge as to sympathy between the kidneys. But this condition is certainly rare. As a rule, in renal calculus, pain is alone complained of on the side in which the stone lies. Pain in both loins means usualh' stones or disease on both sides, a far graver thing than " sympathy." Mr. Thornton, in his combined method, which I have described at p. 134, lays stress upon the small clean cut which is made upon the stone by the loin, only large enough to introduce the finger and forceps. It is difficult to see how such an opening would suffice to remove a small stone lying in a calyx on the anterior surface of the kidney, one •of the most difficult of all cases. By the lumbar operation the surgeon would be able, after freeing the kidney, as is nearly always feasible, to luring it out of the wound on to the loin, and carefully handle the anterior as well as the posterior surface. With regard to the risk of the hernia which Mr. Thornton states (loc. supra cit.) to be "a not Tincommon result of the lumbar operation," the experience of most surgeons will be quite the opposite. As already stated (p. 103), the tissues in the lumbar region are so strong and unjaelding, compared with those in the anterior abdominal wall, that a protrusion does not readily talve place here. Exploration of Kidney in Suppression of Urine. — The above •condition is so grave when a mechanical cause which medicine can •avail nothing is present, the history may be so obscure or perplexing, the call for help so urgent, that some allusion must be made to the subject here. One of the most brilliant examples of what nephro- lithotomy can do in some cases of suppression of ui'ine is shown by a case brought by Mr. R. C. Lucas before the Medico-Chu-urgical Society (Trans., vol. Ixxiv. p. 129) : The patient, aged 37, had had her right kidney, a " mere shell, containing masses of stone weighing twenty-one ounces" successfully removed. Three months later she was seized with agonising pain in the back and left loin. Suppression of urine quickly set in, and ou the fifth day a calculus was remored which was exactly of the shape to act as a ball-valve to the top of the left ureter. The patient made an excellent recovery. But in many cases of suppression the indications are less clear, and there is often much difficulty in deciding which ureter is blocked, owing to the deficient history. An excellent instance of such cases, in which the surrounding difficulties wex'e most successfully met, is recorded by Dr. Fraser and Mr. Parkin, of Hull (Lancet, vol. ii. 1893, p. 688) : The patient here suffering from suppression of urine was 74 years of age. Beyond the evidence pointing to obstructive anuria, there was very little to throw light on the condition of the kidneys, or which organ should be explored. As the patient liad been observed by her friends to support the left side in walking, and as there was deep-seated tenderness in this loin, Mr. Parkin explored the left kidney from the loin. The organ was enlarged, distended, and hypertrophied. About six ounces of urine escaped when the kidnej' was incised along its convex border, the last portion to come away being mixed with some pus. No stone was found, and the cause of the suppression must remain obscure, as tlie patient, though 74, made a good recover}', with a sinus from which most of the urine passed. The above cases show the importance of knowing the history of the case, and, where this is deficient, making a most minute examination, no point being considered too trivial to be pieced in with others, before 138 OPERATIONS ON THE ABDOMEN. ^ e ■o ,a s"-S S . V -t^ to J-"" O ^ 3 1^ ^ eg «Ph eg S ID ►» U >» >, "*^ iH -^ S ^-^2 •■a 1 Jh a 1* CO ■3 ID a OS 2 rH a C0«H ? "-^5 .s-S •Sa^'a^ u S o c3 8 Ph a 2 4) OJ ^:S2'St^ ^ fl CC 03 '^ St t^'^a ? a hfi -g*^ eg tc-P Oi (D ^ .=. a 0)^:2 -^ eg ^-^ >3 to ^-0 ® :J3 > a > a o p< o OS 03 i >. ■ c3 >» a o o 2 -a S) r! m eg |i o 2 •mQ « 4> js i; ID eg

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Any operative interference should be undertaken, if possible, before the stage of constant hiccough and vomiting, twitching or convulsions, and drowsiness deepening into coma, has been reached. Before alluding to the operative steps to be resorted to it will be well to remember that the causes of suppression of urine which it is thought may be benefited by surgical interference are various in their nature. The first and the one most likelj' to be permanently relieved is a calculus impacted in the pelvis or the ureter of the only working kidney. Another and much less favourable class is that where the only remaining functional kidney is the site of acute inflammation dating to old calculous or tubercular pyelitis. Another class is the traumatic one. Such cases are the following : Mr. Cock recorded (JPatli. Soc. Trans., vol. i. p. 293) the case of a youug man who died comatose on the eleventh day after an accident. All the symptoms of the original injury and the subsequent peritonitis subsided in a few days, save that the catheter withdrew nothing but blood. The autopsy showed a ruptured single kidney. In Mr, Poland's case (_Guy's Hasp. Reps., vol. xiv.) the complete suppression of urine which followed an injury was due to thrombosis of the renal vessels of one kidney, and rupture of the pelvis on the other side. It will be seen that obstruction by a calculus* is the only one which promises much success to the efforts of the surgeon. With regard to the operation in cases of suppression, if the patient's condition is good, and if no sufficient history is forthcoming, the surgeon will be justified in examining the condition of the kidneys by an incision in the linea alba, being mindful of the fallacies to which I have alluded at p. 135. If he finds a stone in one ureter he must either push it up to a part where he can cut down upon it by the safer lumbar operation, or remove it from the abdomen by the steps given below, p. 167. If no stone is found, and it is decided to d^-ain the kidney which seems to be the working one, this should be done by a lumbar incision. It is not only safer for the great majority of operators, but it must always be remembered that in these cases of suppression the working kidney is usually a damaged one, and pyelitis may be present with more or less pus in the kidney. NEPHRECTOMY. , . Indications. I i. Cases of renal tuberculosis, preferably as the primary operation and also cases of tuberculous pyo-nephrosis explored previousl}^ and drained by nepju-otomy, but in which a discharging sinus persists. Here the kidney should be removed when the following conditions are favourable , * In very rare cases the ureter may be obstructed by a body, perhaps capable of removal, and not a calculus. Mr. Butler, of Guildford, records (^Lancet, vol. i. 1890, p. 79), a case of suppression of urine lasting thirteen days. The necropsy showed that the ureter of the only working kidney (the left one) was greatly distended with urine and plugged by a solid hard body in about its centre. This proved to be a venous thrombus which, formed in one of the veins in the kidney, had passed through a rent in the kidney tissue into the pelvis and ureter. Here the suppression came on four days after a blow on the abdomen. No symptoms had pointed to renal disease, and, save that the blow was on the left side, there was nothing to tell on which side the obstruction was. NEPHRECTOMY. 141 — viz., the age and strength of the patient, the absence of visceral infection, tubeixular or lardaceons, and, if possible, a date not too long deferred, for the additional reason that the kidney will be increasingly matted down and difficult of removal, while its fellow maj' have become involved in the disease. On this point I may quote again from my paper on the conditions which simulate renal calculus (Brit. Med. Journ., 1890, vol. i. p. 117) : " I would most strongly urge this course (early exploration of the kidney) with a twofold object: (i) to clear up the case, and (2) to perform nephrectomy if the kidney is found to be the site of so fatal a disease. If I am told of the unwisdom of this step, owing to the proba- bility of both kidneys being affected, I would reply that, as a rule, both kidneys are not affected at an early stage. Thus Dr. Fagge (Medicine, vol. ii. p. 488) gives a list of thirteen cases which show 'the characters of tuberculous disease of the kidney at its commencement.' In only three of these were both kidneys affected, and in all these tubercular mischief was present in the bladder also. If during this early explora- tion one or two pyelitic dilatations are found, extirpation of the kidney should be performed while the organ is still small and movable, and before the rest of the genito-urinary tract becomes involved. " I need not remind my hearers of the miseries which lie before a patient with established tubercular kidney, the results of ulceration of his bladder, with, perhaps, vomicae in his prostate, and the inevitable course downhill — arrested, it may be, for a little while by nephrotomy and drainage." My own experience of drainage alone in established tubercular kidney is most unfavourable, the relief being slight and short-lived, and not arresting long the hectic and increasing debility. On the other hand, in four cases in which I have been able to perform nephrectomy early (cases Nos. 8, 12, 13, 16, p. 159) the result has been most satisfactory. In four others (3, 4, ii, 17, ibid.), the recovery, though less complete, was very satisfactory. Finalh', in two (cases 15 and 22, ibid.), the eleventh and twelfth cases in which I have removed a tubercular kidney, the disease was too advanced in both for the result to be satisfactory. Ramsa}' (loc. cit., p. 113) gives the results of 191 cases of primary nephrectomy for renal tuberculosis. Of these 106 were noted as cured, 31 were improved. 37 died within one month of the operation, and 17 died at a later period. Forty-nine cases of secondary nephrectomy after a pi'evious nephro- tomy are also given. Of these 18 died shorth' after the operation, and 23, or 46 per cent., were cured. Of the 37 deaths resulting from primary nephrectomy, 9 were due to uraemia, 3 to tuberculosis of the other kidney, and 2 to amyloid degeneration of the other kidney. These 14 deaths serve to emphasise the importance of thorough investigation of the capacity of the other kidney before nephrectomy is decided upon. For although the second kidney, as mentioned above, is not often affected in early cases, yet when the case only comes under observation in the more advanced stages, it will very possibly be diseased. Should the condition of the other kidney still remain doubtful after the ordinary methods of investigation have been exhausted, then it becomes necessar}' to examine it by means of an exploratory incision. Edebohls {Annals of Swgery, April 1898) advises a lumbar exploration, 142 OPERATIONS OX THE ABDOMEN. and this is doubtless the safer and more certain method. The disturb- ance caused will be comparatively slight, and is more than balanced by the additional security that the surgeon will feel when proceeding to perform nephrectomy a week later. The doubtful utility of examination of the other kidney through an abdominal incision has been referred to above (p. 135). These remarks apply equally to the two following conditions, calculous disease and hydro-nephrosis. ii. Calculous pyelitis or pyo-nephrosis where the kidne}' is destroyed by long formation of calculi and consequent suppuration, where numerous calculi exist with sacculation of the kidney, or where a large and Ijranching calculus is so embedded as to resist removal. These indications for nephrectomy have been already considered under the heading Xephro-lithotomy (p. 130), as it is during the performance of this operation that the question of removing the kidney for the above conditions will arise. iii. A kidney the site of hydro-nephrosis. The tji-eatment here will vary according to the degree to which the disease has advanced. Aspiration, lumbar nephrotonw, and drainage, the edges of the cyst being stitched in the wound, and nephrectomy have, each, been advo- cated here. Occasionally repeated aspirations are sufficient, as in Mr. Croft's case (Clin. Soc. Trans., vol. xiv. p. 107), in which eight aspirations (through the lumbar region) within four months, between three and four pints being withdrawn each time, sufficed to cure a hydro-nephrosis in a boy aged 12. It is noteworthy that the case was distinctly traumatic in origin, and that the last fluid withdrawn contained a very large amount of albumen. It is for such cases, especially if the interval between the aspirations lengthens each time, that aspiration should be reserved. This method is, however, so rarely successful that the surgeon will, in advanced cases, have to decide between nephrotomy and drainage, and nephrectomy. It is now acknowledged by the advocates of the former step that it has given less favourable results than were expected. The time taken is usually very great, the frequent change of dressing necessitated by the constant soakage is most irksome, and, later, the wearing of a lumbar urinal is most inconvenient, leading as it often does to an eczematous, raw area around the sinus. The sinus, moreover, is liable to become foul and to contain phosphatic material. The tube also, A\'hich leads into the urinal from the sinus, easily becomes blocked, and causes much discomfort from redistension of the cyst. In future, nephrectomy will be oftener performed for hydro-nephrosis where the kidney is much altered, either as a primary operation or after allowing a sufficient interval to elapse for shrinking of a large cyst, but no prolonged delay. Where, therefore, the patients are young, with every prospect of a long and active life before them, where a month's drainage has failed to bring about any considerable diminution in the amount escaping, and where the fluid thus coming away contains but a small amount of urine, and where there is evidence that the other kidney is competent, the cyst and remaining kidney tissue should be extirpated from the loin befoi*e it has become more firmly matted to the surround- ino- parts.* * If in hydro-nephrosis, after an exploratory nephrotomy, bloody urine descends into the bladder, the indication for leaving the kidney will be greater, especially if the viscus show a cortex of fair thickness, and is not a mere sac with little if any secret- ing tissue. NEPHRECTOMY 143 In cases where the hydro-nephrosis is early and due to movable kidnev, nephi'orraphy will often suffice (p. 162). In a few other cases the lu'dro- nephrosis may be due to valve or stricture of the ureter. For an account of the different operations performed for the relief of these conditions, I may refer my reader to the surgery of the ureter (p. 167). iv. Certain cases of malignant disease. These fall into two groups, which must be looked at separately from an operative point of view. One group, the sarcomata, occurs in children before ten, usuallv much earlier, before five. In such cases the risks of immediate death from shock, aided often by peritonitis, of early recurrence, or of death from secondary deposits elsewhere, should be put clearly before the parents, together with the certainty of an early death if the groT\i:h is left. The other group, the ca/rcinomata, occurs usually in patients past middle age. In either case, an operation should only be performed in an early stage, while the growth is still internal to the capsule, and while the strength, health, and condition of the viscera are satisfactory. On the other hand, where the history makes it probable that the growth has got beyond the earlier stage, when there is any extension to the lumbar glands or other \'iscera. when there is nausea, emaciation, or a tempera- ture inclined to fall, the time for operation has gone by. So, too, anv ascites or oedema of the lower limb are absolute contra-indications. With regard to the frequency of secondary deposits, the fact that Dr. Dickinson* iound these to be present in no fewer than 15 out of 19 cases strengthens, very decisively, the argument in favour of early operations while these growths are small, at which time, moreover, they can be successfully attacked through a lumbar incision sufficiently enlarged by the steps given at p. 148, or by one made anteriorly. Much information may be gained from a very complete studv of sarcoma of the kidney in children by Mr. George Walker, of Baltimore {Annals of Surijer;/, vol. ii. 1897, P- 529 et seq.). In all, 74 cases in which nephrectomy was performed are here collected. Of these 27 died from the effects of the operation, 28 died from recurrence, 14 passed out of sight, and 4 remained well from three to five years after the operation. The immediate mortality is therefore 36"4 per cent. Thouo-h still very high, this is a vast improvement on the earlier published figures ; for instance, Butlin {Oper. Surg, of Mali) by one in the linea alba. C. Through the Abdominal Wall, without opening the Peritonseum. These methods are compared at p. 156. D. A Combination of the Abdominal and Lumbar Incisions. E. Knowsley Thornton's Com- bined Method. NEPHRECTOMY. 1 47 A. Lumbar Nephrectomy. Operation. The position * of the patient and the earlier steps are much as those already given in the account of Nephro-lithotomy, p. 123. When the lumbar fascia has been slit up and the fat around the kidne}" torn through, this organ should be ^^'ell thrust up by an assistant making careful, steady pressure with his fist against the abdominal wall ; the wound being now widely dilated with retractors, the surgeon examines the kidney, and has next to decide on three points : (i) Is removal required ?t (2) Will more room be wanted ? If so, the incision already made, slightly oblicpie and aboiit half an inch below the twelfth rib, should either be converted into a T-shaped one by another made downwards from its centre, or at its posterior extremity, along the outer edge of the quadratus lumborum, or continued downwards and forwards, as described under Nephro-lithotomy (rw?e p. 124). Additional room may also be gained bj^ an assistant slipping his fingers under the lower ribs and drawing them forcibly upwards. (3) Is the kidney firmly matted down or no ? If there has been no surrounding inflam- mation, the extra-peritonfeal fat, the peritonaeum, and colon will be readily separated by the finger working close to the kidne}^ until the pelvis and vessels are reached. But if inflammation has caused firm adhesion and matting down of the kidney to adjacent parts, the altered fat and thickened and adherent capsule must be divided down to the kidney itself, and this gradually enucleated (partly with the finger, partly with a probe-pointed bistourj^) from out of its capsule, which is left behind. The only guide in such a case is the tissue of the kidney itself, close to which the finger and knife must be kept. A case of Mr. H. Marsh's well shows this difficulty : Eemoval of the kidney could not here be effected, owing to its size and the firmness with which it was embedded in the surrounding condensed areolar tissue. That part of the kidney which had been exposed was accordingly transfixed with a strong double ligature, and cut away. Complete suppression of urine followed the operation, and the patient died in about thirty hours. At the post-mortem examination the remaining part of the right kidney and its ureter were found to be so firmly embedded in dense cicatricial material that they were dissected out only with diflSculty. The kidney itself was converted into numerous sacculi, in the walls of which, however, some remains of renal structure could still be traced. The opposite kidney weighed 6 oz. Its capsule was adherent, and there were two or three cysts on its surface. On section, its structure looked somewhat confused and cloudj'-, but its condition was not such as to indicate advanced disease. Mr. Greig Smith stated {Ahdom. Surtj., p. 508) that, in cases of old- standing suppuration with great enlargement, the vena cava and the aorta may be intimately adherent to the capsule. " One such case was met with in the post-mortem room of the Bristol Infirmar}- ; here it was simply impossible, after death, to dissect apart the venous wall and * Additional care should be taken to open out the space between the last rib and the crest of the ilium by the arrangement of pillows underneath the loin ; the precautions given to avoid shock (p. 144) must also be taken here. t This question has already been alluded to in the case of a strumous kidney incised and drained (p. 140) ; in that of a kidney much damaged by one or more calculi, under the subject of Nephro-lithotomy (p. 130) ; and in the case of hydroucphrosis (p. 142). 148 OPERATIONS ON THE ABDOMEN. the renal capsule. In another case, for similar reasons, the organ conld not have been removed by any proceeding claiming to be recognised as surgical."* If further room is still required, this may be easily and effectually gained by making use of additional incisions as recommended by Prof. Konig, of Gottingen {Gent. f. Ghir., 1886, Hft. 35 ; A7171. of Surg., Nov. 1886, p. 445). This surgeon, having found great difficulty in getting free access to the kidney by the ordinary lumbar incision, cuts through the soft parts vertically downwards along the border of the erector spinaB to just above the iliac crest. He then curves the incision towards the navel, and ends at about the outer border of the rectus, if necessary going through this muscle to the umbilicus. It may be often advisable to make the perpendicular cut oblique, running in a flat curve into the umbilical part. All the muscles are incised quite down to the perito- neum. This method gives a surprisingly free entrance, but it can be much improved by introducing the hand through the perpendicular part of the cut, separating the peritonasum in front and pushing it forwards. Prof. Konig proposes to call this the retro-peritoneal lumbo-abdominal incision. If sufficient space is not thus affijrded, or if, for diagnostic or operative purposes, it is desirable to approach the tumour from the abdominal cavity, the peritoneum can be divided in the transverse cut. If infective material is to be removed, this peritoneal opening must be carefully looked after. Very large kidneys and renal tumours can be got out through very free lumbar incisions. I may state here that I twice, in 1890, removed kidneys eight inches long through the ver}^ limited ilio-costal space of little children aged respectively 3 and 3^. One was a case of sarcoma, the other of cystic kidney. Both made excellent recoveries ; but as, in the former, the renal vein was thrombosed with growth, it was clear that a few months would see the end. In each case the lumbar incision was carried forward ver}^ freely, and the long axis of the tumour brought out in that of the wound. In both Abbe's successful cases of sarcoma (vide supra, p. 143) long transverse lumbar incisions were found to give ample room, in the second case the tumour weighing yh lb. in a child only 14 months old. Many other cases might be quoted. The danger of ventral hernia is guarded against by using deep sutures, by allowing only gentle movements at first when the patient gets up, and by the use of a support. By these means the risk of hernia may be reduced to a minimum. f When the kidney has been sufficiently enucleated either out of its capsule, or, together with this, out of the peri-renal fat, the vessels * As will be seen from Case 22 in the table at p. 161, in which I injured the vena cava in the case of a large tubercular kidney, very adherent ; the most diificult case 1 have met with. In a case of attempted nephrectomy (^Amer, Journ. Med. Sci., 1882, vol. ii. p. 116) the removal of the organ was rendered impossible, not only by its adhesions to the tissues around, but also, as was proved post mortem, to the colon and pancreas as well. t It is noteworthy that Prof. Bergmann, of Berlin, whose name is well known in connection with the surgery of the urinary organs, advocated the lumbar operation for the removal of malignant growths of the kidney (^Aiinals of Surgery, Sept. 1886, p. 256). NEPHRECTOMY. 1 49 and ureter must be dealt with. The latter should be taken first, as this step, especially if the ureter be enlarged, will facilitate dealing with the vessels. If the ureter is dilated, and contains foul pus or tubercular matter, it should be divided as low down as possible, and the stump carefully cleaned out with a sharp spoon and dusted with iodoform, or fixed in the wound with a suture, for fear of its caiising infection. Tlie vessels are then tied in at least two bundles with sufficiently stout carbolised silk, or chromic gut. This is passed, with an aneurysm-needle of sufficient length and suitable curve, through the centre of the bundle, each half of which is tied separately, and finally one of the ligatures is thrown round both halves together. In passing the ligatures, they should be pushed well in towards the spine, so as to leave ample room between them and the kidney to prevent all risk of their slipping. If the kidney can be raised out of the wound, passing the ligature is much simplified. If this is impossible, the surgeon may find help by having the lower ribs well pulled up by an assistant, while another keeps the kidney well up by pressure against the abdominal walls, light being also thrown in, in case of need, by a forehead mirror or electric lamp. While the ligatures are being tied and the pedicle divided, no tension should be put upon the vessels. As soon as the ligatures are secured in position, the pedicle is snipped through at a safe distance from them with blunt-pointed scissors. If the pelvis of the kidney contains foul or tubercular pus, and if there is room, a large pair of .Spencer Wells's forceps should be put on the ureter, and the pedicle cut through between this and the ligatures, so as to prevent the escape of septic material. If any heemoiThage now takes place, it is probably due to some vessel* not being included, or to an artery having slipped through the knot owing to the parts being stretched at the moment of ligature. The bleeding point, to which the ligatures will act as guides, is now secured with forceps and ligatured. The ligatures are then cut short When a pedicle presents especial difficulties from its shortness, thick- ness, and the way in which it is overlapped b}^ the kidney, a preliminary ligature should be applied and the kidney cut away well in front of it,t a step which will give access to the vessels and ureter ; a double ligature is then applied behind the temporary ligature, which is now removed. Again, where the pedicle is very short, a portion of kidney may be left to * The late Mr. Greig Smith (loc. supra cit.') gave the following practical hints as to the vessels : — The veins are a good deal larger than the arteries and overlap them. At the hilum the veins branch quite as much as the arteries — i.e., four or five times — and the subdivision extends farther towards the middle line. It is very frequent for two or more trunks to represent the renal vein, and sometimes surround the artery. The want of uniformity in the renal vessels is against the possibility of ligaturing the artery and vein separately. In many cases this will be found impossible ; in none is it necessary. Indeed, the walls of the veins, by acting as a sort of padding, may add to the safety of ligatures, preventing the thread from slipping. Mr. Greig Smith further states that the only deaths as yet recorded from secondary hiemorrhage were in two cases where the vessels were separately tied. t Dr. Lange (New York Surg. Soc, Nov. 22, 1886; Aimals of Surgery, April 1887) has shown that in a case in which he adopted this course no sloughing took place, as I50 OPERATIONS ON THE ABDOMEN. ensure the ligature retaining a safe hold. I was obliged to adopt this course in a case of nephrectomy for calculous pyelitis in which I had removed twelve stones a year before (case No. 7, Table, p. 159). A sinus persisted, which became abominably septic. As the stump of the kidney was foetid, I inserted no sutures, and packed the wound with strips of sal alembroth gauze wrung out of turpentine. The patient made a good recovery. A modification of the method of leaving a portion of the kidney to form the pedicle may be made use of in cases of kidneys of large size which cannot be brought through the wound. In such cases, the vessels having been secured by a temporary ligature or by Spencer Wells's forceps, the kidney should be cut away in separate portions, thus doing away with the struggle required in bringing out a large kidney and the risks of producing serious shock by pulling on the vessels.* Another means of treating the pedicle, where this is short and matted doM^n, is to cut it through piece by piece, securing each bleeding point with compression forceps, and tying them off one by one. Or the vessels may be under-run, as in excision of the knee, but on a larger scale and more en masse. By such methods as the above the risk of wounding the cava or aorta is avoided. If the amount of kidney left is small, it will no doubt atrophy and give no further trouble, but, if large, some sloughing will probably take place ; in such a case, iodoform or glutei should be dusted on to the stump and free drainage provided. Another difficulty which may be present now is caused by the kidney having contracted adhesions to the peritonaeum and some of its contents. I have three times opened the peritonasum, when using the lumbar incision. To one case, a nephro-lithotom^y, I have alluded at p. 128; the other two were cases of growth and tubercular pyelitis, for which I was removing the kidney. All three cases recovered. The opening, in the two latter cases a small one, was at once covered by an aseptic sponge, and sutured with fine chromic gut. Where it is certain that septic fluid from the kidney has entered a wound in the peritongeum, the surgeon shoiild, after the operation is completed, make a small opening in the lower part of the linea alba, wash out the jieritongeal cavitj' with boiled water, and place a drainage- tube in Douglas's pouch, this being regularly emptied as often as is the thick, fleshy part of the pedicle beyond the ligatures was gradually absorbed by the healthy granulations of the wound, which remained aseptic. Dr. Leopold (^Areh. filr Gyndk., xix. i), in a case of nephrectomy, tied the pedicle in three, and left a triangular portion of the kidney parenchyma, in order to prevent haemorrhage. The patient made a good recovery. * The question of how far serious shock may be induced by tightening ligatures on parts in such intimate relation with the abdominal sympathetic centres is one of great importance and needs further investigation. According to Mr. Barker QDict. of Surg., vol. ii. p. 49), who has taken the trouble to have the pulse watched carefully at this stage of the operation, it is not much affected to the touch, but a sphygmographic tracing taken in one case showed some irregularity during the necessary handling of the kidney, and increased arterial tension when the pedicle was ligatured. In my own experience, any alterations in the pulse are occasional only, and quite inconstant. Dragging on the pedicle is much more likely to produce shock. NEPHRECTOMY. 1 5 1 requisite. Mr. Page, of Newcastle, adopted this plan in two cases, with entire success (Lancet, vol. i. 1893, p. 999). The question may arise as to what is to be done if hjfimorrhage still persists after the kidney is got out and its pedicle tied. Ver}- few cases will occur in Avhich ligatures cannot be applied to each bleeding point if the wound be well opened up, carefully dried, and if light be thrown down to the bottom. But when bleeding still goes on, Spencer Wells's forceps must be applied to the bleeding point and left in situ for two or three days, during which time they will also help to drain the wound. I have used this method twice with good results. If the forceps will not hold, careful plugging must be resorted to, strips of iodoform or sal alembroth gauze wrung out of carbolic acid lotion i in 20, the deepest attached to silk, and systematically packed into the bottom of the wound around a large drainage-tube till the wound is thorough^ filled; an external gauze dressing is then applied, and over this a firm but elastic padding of sal alembroth wool, which is kept in situ by firm bandaging. Mr. Clement Lucas (Trans. Intern. Med. Congr., vol. ii. p. 271) nearly lost, from secondaiy haemorrhage, a case in which nephrectomy had been suc- cessfully performed for suppurating strumous pyelitis. The bleeding came on about the fifteenth day, probablj^ from the ligatures, which had been left long, being dragged upon. The haemorrhage again occurred on the sixteenth day, when an attempt was made, after opening up the wound, to slip a ligature along the old ones, and thus to re-tie the pedicle. Haemorrhage again occurring on the seventeenth da}", and the patient being in a most precarious state, the wound was tightly and forcibl}" plugged with two large sponges steeped in perchloride of iron, and the abdomen bound firml}^ round with a flannel bandage. Morphia Avas given subcutaneously. About a week later the removal of the sponges, b}'- cutting away the protruding part, was commenced, and this Avas completed by the end of another week. No bleeding recurred after the plugging, and the patient made a good recovery. When all bleeding is stopped, a large drainage-tube should be inserted, vdtli one end carried down to the very bottom of the wound, and the other cut almost flush with the surface. The wound is then partially closed with salmon gut and carbolised-silk sutures, some iodoform dusted in, and aseptic dressings applied. If there has been much difficulty in getting out the kidney — and in cases of old inflammation it has to be dug out by touch, with very little help from sight — as in case No. 2, Table, p. 159 — no sutures should be used, the wound being merely lightly plugged with iodoform gauze wrung out of carbolic acid lotion I in 20. Dr. Weir, of New York (Ann. of Surg., April 1885, p. 311), during a nephrectomy in a young woman the subject of pyonephrosis, met with very severe hi^morrhage after ligature of the pedicle. This had apparently been effected with a single ligature. After removing the kidney, a gush of venous blood ensued, which was only partly arrested after repeated seizures with long pressure-forceps, but was finally controlled by stuffing the wound full of sponges and turning the patient on her back. The shock was profound, and all the measures to produce reaction were resorted to. Transfusion performed twice to a total amount of 22 oz. gave rise at first to great improvement, but the patient died ten hours after the operation. The necropsy showed that the haemor- rhage came from a vein of considerable size, 1-5 centimetre above those secured by the ligature and forceps. 152 OPEEATIONS ON THE ABDOxMEX. B. Nephrectomy by Abdominal Incision through the Peritonaeum. a. By Langenbiich's Incision at the Outer Edge of the Rectus. h. By an Incision in the Linea Alba. These two methods may be taken together. The former is the one most usually employed, as it has the following great advantages : — I. The incision is nearer the vessels and ureter. 2. There is much less general exposure of the peritoneal sac (Knowsley Thornton). 3. The kidney is reached through the outer or posterior layer of the meso-colon, a step which avoids (a) htemorrhage and (h) the risk of sloughing of the colon, as it is the inner or anterior layer — that between the colon and the middle line — which contains most of the vessels to the colon, and is especially rich in veins. It is this layer which is divided in the incision through the linea alba. 4. The operation can be rendered largely extra-peritonseal by having the inner edge of the cut meso-colon and that of the parietal peritonasum held in apposition or sutured with catgut. Both operations give good room for necessar}' manipulations, both afford an opportunit}' for examining with the hand the condition of the opposite kidne}".* After both, the wound can be drained posteriori}' from the loin, but more easily after Langenbiich's incision. a. Langenbiich's Incision. — The abdominal wall having been cleansed, an incision is made, at least four inches long at first, com- mencing just below the ribs, in the line of the linea semilunaris on the side of the disease, the centre of the incision being usuall}^ opposite to the umbilicus. The skin, subcutaneous tissue, and the aponeuroses at the outer edge of the rectus having been divided down to the transver- salis fascia, and all ha3morrhaget having been carefully arrested, the trans- versalis fascia and the peritonaeum are pinched up together, punctured, and slit up on a finger used as a director, the hand is introduced, and the size of the growth and the condition of the opposite kidne}' investigated. In the case of a large growth the incision will now be enlarged, and any further lijemorrhage arrested. The growth, if large, is usually now seen in part. Any presenting intestine is turned over to the opposite side, and kept out of the way with a pad of aseptic gauze. The outer or posterior layer of the meso-colon will now probably present itself, pushed forward by the growth, which is often bluish-white in appearance and covered by large veins. The above-mentioned layer of the meso- colon is next torn through, either in a vertical or transverse direction, as will best avoid the vessels exposed. Any bleeding should be at once * I cannot but think that this advantage of the incisions through the peritonaeum has been made too much of. In Mr. Barker's words QDict. of Surg., vol. ii. p. 48), " Though the hand may reach the kidney opposite to the one it is proposed to excise, its soundness or the reverse cannot be ascertained by mere palpation. Great enlargement, or, on the other hand, great reduction, in size, or complete absence, might be detected ; but the organ might be tubercular, or fibroid, or contain a moderate-sized calculus, and yet the hand be unable to detect the condition." I have also referred to this matter, p. 135. f The amount of this, as will be familiar to all surgeons who have opened the peritonaeal sac by this incision for intestinal obstruction, &c., varies a good deal. In the case of growth, large vessels are often present in the peritonaeum over the kidney. NEPHRECTOMY. 1 53 arrested by Spencer Wells's forceps and ligatures of fine silk. The intestines are then packed away with sterile gauze. A sufficient opening having been made in the outer layer of the nieso-colon, the fingers are introduced to examine into and further separate the connections of the kidney. During all the necessary manipulations in the case of a growth, the greatest possible gentleness must be used so as not to rupture the capsule. In rapidly growing sarcomata, especially in children, the consistency may be jelly- or glue-like, and thus, if the capsule is opened, portions of the gro^^i:h may readily be left behind. Again, hsemor- rhage may easily follow this accident, and prove most embarrassing.* If the bleeding is of the nature of troublesome oozing it may be met by packing the cavity with iodoform gauze, the ends of which are brought out through a counter-incision in the loin. The wound in the peritona?um is next carefully sutured over the gauze, thus shutting off the abdominal cavity. The gauze may be removed in forty-eight hours (F. Page, Lancet, vol. ii. 1893, p. 11 88). If the bleeding is from one or two points which cannot be tied, Spencer Wells's forceps may be left in situ, and removed in forty-eight hours. The same precautions as to not damaging the capsule should be taken in the case of a kidney full of fiuid. Where there is any risk of such fluid or of soft growth escaping into the peritonteal sac, sterile gauze should be carefully packed around, or the cut edges of the meso-colon and the parietal peritonjBum united. If the parts about the pedicle are free from adhesions, the vessels may be tied before the kidney is enucleated, which will render this latter step bloodless. Wherever it is possible, forcejis should be placed on the vessels close to the kidney before they are divided, to save spilling of blood from the kidne}^ ; and where tliis contains pus, the same pre- caution should be taken with the ureter. The vessels should be tied \\i\h. the precautions given above (p. 149). All dragging on the pedicle should be scrupulously avoided. The kidney being removed, the site of the operation is most carefully cleansed and dried. If troublesome oozing has occurred and is at all likely to persist, a large drainage-tube had best be passed out through the loin by pushing a short j^air of dressing-forceps from the site of the kidney so that it bulges in the loin, where it is cut down upon, and used to seize the tube. Another way of draining is by Keith's tube through the abdominal incision, sucked out regularly. Both this and lumbar drainage should be employed in complicated cases. It has been suggested that the divided edges of the meso-colon may be united with a few points of catgut suture, but this precaution does not seem to be absolutely needful, as the edges usually fall readily into apposition. Mr. Knowsley Thornton laj^s stress upon his method of treating the ureter. This tube is taken last in the enucleation of the kidney, '"and, * Thus it has even happened to Prof. Czerny, whose experience in nephrectomy is almost unrivalled, to be driven to tic the abdominal aorta. The profuse hsemorrhage met with in removing a large growth of the left kidney could only be stopped by pressure on the abdominal aorta. This vessel was accordingly tied. Death took place ten hours later. It was found that the renal artery had been torn through at its entrance into the tumour. The ligature on the aorta had been so placed that, while the blood-supply through the left was cut off, the right vessel was pervious. 154 OPEEATIOXS OX THE ABDOMEX. before separation, its renal end should be secured by pressure-forceps, then a ligature tied a little way from the forceps, and a sponge placed under it before it is divided. Whenever it is possible, I enucleate it for some distance from the kidney before dividing it, so that its cut end, "with the sponge under it, may be at once di'awn outside the abdomen ; and afterwards fix it in the lower angle, or most convenient part of the abdominal incision, with a cleansed safety-pin. I regard this fixing out of the stump of the ureter as the most important detail in the operation, and in every case in which I have been obliged to cut it off" deep in the wound I have had distinct evidence of suppuration and trouble around it." Mr. Thornton considers the objection that this method risks the occurrence of future intestinal obstruction an entirely fanciful one. At the worst, a ureter so treated is onlv a slight ridge over a small surface of the abdominal wall, quickly disappearing by atrophy. Other surgeons, who have treated the ureter b_v ligature and dropping it in, have not met with the results of suppuration and sloughing which Mr. Thornton thinks are very likely to follow on this course. The onl}' after-trouble which I have known the ureter to give is in cases of removal of tuber- cular kidney. Unless this operation is performed at a very early stage, there must always be a great risk that, owing to the ureter having become involved, the mischief will spread to the bladder. Ramsay (loc. siqrra cit.) discusses the mode of dealing with the ureter in tuberculous cases at some length, and quotes Eegnier as having removed a tuberculous ureter some months after the nephrectomy^ Kelly, in the Johns Hopldns Bulletin, March 1896, reports three cases in which he removed the whole of the tuberculous ureter with success at the time of the nephrectomy. On the other hand, there is evidence to show that tuberculous disease of the ureter tends to undergo a process of cure after nephrectomy. One case in point is that of Tilden Brown {Annals of Surgert/, 1899, vol. i. p. 755). Here the kidney was removed and the ureter left behind. At the necropsy, some months later, the ureter, previously as thick as the thumb, had diminished to one-fourth its size. Ramsay's conclusions on this point are as follows : " It is safest to remove the ureter with the kidney, as a persistent fistula may give trouble if it is allowed to remain in the body;" and again, "that a certain proportion of these fistulse will finally disappear, either after the removal of a deep suture, or because of the slow disappearance of the tubercular disease in the ureter, which, in these cases, gradually changes into a fibrous cord." h. Nephrectoniy by an Incision in the Linea Alba. — For reasons already given, ]). 152, this method is not recommended, that of Langen- biicli, alread}^ fully described, being preferable. The incision in the linea alba will not materially differ from that for ovariotomy or abdominal exploration, and the same precautions are called for in removing a kidney by this method as in that through the linea semilunaris, of which the chief only need be recapitulated here — viz.: I. Keeping the intestines well over to the opposite side by carefully applied gauze. 2. By the same means keeping the general perito- nieal cavity shut off as much as possible ; as pointed out already', this method has the grave objection of more readily causing infection of the NEPHRECTOMY. 1 55 peritonaeum. 3. Avoiding all large vessels which are met with over the kidney, and securing these carefully with chromic gut or fine carbolised silk ligatures before dividing them. 4. Securing as full access as pos- sible to the kidney pedicle. 5. Dealing as gently as possible with the kidney when distended with fluid, and still more when it is the seat of a soft vascular growth. 6. Separating adhesions, especially any situated posteriorly, with the utmost carefulness. 7. Avoiding all ten- sion on the pedicle. 8. Scrupulously cleansing the site of the wound. 9. If fluids or portions of the growth have escaped into the general peritonEeal sac, ensuring cleansing of this with sponges, or, perhaps better, b}* irrigation with a warm solution of normal saline. 10. Taking care that the cut edges of the peritonaeum over the kidney are in exact apposition, either by natural adaptation or by the aid of catgut sutures. II. Providing suflicient drainage (p. 153) if the operation has been a difficult one and the parts much disturbed, and especialh' if septic fluids have escajDed into the periton^eal cavity. In this latter case irrigation with boiled water or a 2 per cent, solution of hot boracic acid must be made use of. 12. Conducting the difi*erent steps of the operation, especially the earlier ones, with as much expedition as possible, and, in addition, providing against shock by taking' those precautions recom- mended for this purpose in any grave operation, as at p. 144. C. Nephrectomy through the Abdominal Wall, but without opening the Peritonaeum. — Having made use of the method in one case nine years ago, and being much struck by the room afforded, I may make brief mention of it : The patient was a woman, aged 54, the subject of a movable kidney on the right side, the kidncv being also the seat of malignant disease. As the abdominal walls were thin, and as the kidney could easily be made to project in the anterior part of the right lumbar region, I made a longitudinal incision from the anterior superior spine up to the eighth rib. The different layers were cut through, very little hiemor- rhage being met with ; when the peritonaeum was reached, this was then stripped up out of the iliac fossa, upwards and inwards, then upwards off the anterior surface of the kidney until its vessels came in view. Xo difficulty was experienced in dealing with the pedicle — first the ureter, and then the vessels. The vena cava was seen for about i^ inch receiving pulsation from the aorta. The patient never rallied thoroughly from the operation,* and sank about twenty-four hours after. The necropsy showed ligatures tirmly tied; one of those on the renal vein had slightly puckered in the inner surface of the vena cava. A clot the size of the little finger constituted aU the bleeding that had taken place. The kidney was, save for one small patch at the lower part, entirely converted into encephaloid carcinoma. Two or three of the aortic glands were enlarged ; there were no other secondary deposits. D. Combination of Lumbar and Abdominal Nephrec- tomy. — Dr. Hume, of Newcastle, made use of this method in a case of sarcoma (Lancet, vol. i. 1893, p. 196) ; An incision about six inches long was first made in the linea semilunaris, and the swelling found to be in the left kidney. A lumbar incision was then made from the middle of the first cut, dividing aU the structures forming the abdominal waU, including the peritonaeum. The intestines were pushed to the right aud protected with sponges. The peritonaeum covering the kidney was then separated until the whole growth was exposed. The large cavity left was plugged with sublimate gauze * I think that the thinness of the abdominal walls prolonged the operation, owing to my anxiety not to wound the peritonaeum. As has been said above, the haemorrhage was very slight, and I was careful not to pull upon the pedicle. 156 OPERATIONS ON THE ABDOMEN. dusted with iodoform, the ends of the strips being brought oiit through an opening in the most dependent part of the loin. The strips were removed in thirty-six hours. The patient recovered. E. Mr. Knowsley Thornton's Combined Method. — TJiis is given at p. 134. a. Choice between Lumbar and Abdominal Nephrectomy. — While it is certain that all kidneys of small or moderately large size can be easily removed by a lumbar incision sufficiently enlarged (p. 147), time alone will show whether I am right in my opinion that before the lumbar method is abandoned a trial should be made of such a free incision as Konig's (p. 148) when large kidneys have to be attacked. And this leads to the question of chief importance: How far is the danger really increased by going through the })eritonfeum to get at the kidne}' ? I am strongly of opinion that, in spite of all the recent improvements in abdominal surger}^ and their success in preventing peritonitis, interference with and handling the contents of the perito- neum, save in the shortest and simplest instances, remains, on the score of sJiocJi, as grave a thing as ever it was. I am quite aware that, in the hands of a few operators, such as the late Sir S. Wells, Mr. K. Thornton, and Mr. ]\Ialcolm, removal of kidneys, even in difficult cases, through an abdominal wound involving the peritona3um, has given excellent results — results perhaps as good as, or better than, those by the lumbar method. But, while allowing this, it cannot, I think, be lost sight of that the kidney is an extra-peritonteal organ, not one, like the uterus and ovary, within the peritona?al sac. It will assuredly never come about that removal of the kidney will pass, like oophoi'ectomy and removal of the uterus or its appendages, into the hands of a few operators, however specially skilled in abdominal surgery. This being so, and the organ in question being one behind and outside the peritonaeum, while each man will decide for himself and according to his special experience and line of work, the majority of surgeons will, I think, prefer to make their attacks from behind whenever this is possible. This question is also dealt with above (p. 134). Lumbar Nephrectomy — Advantages: — i. The peritonogum, save in cases of exceptional difficulty, is not opened or contaminated. 2. Efficient drainage is easily provided. 3. The structures interfered with are much less important. 4. As pointed out by the late Mr. C4reig Smith, " in the case of its being unwise, as in abscess, or in tumour affecting the sur- rounding tissues, to proceed to removal, it is less serious to the patient." 5. If the kidney is firmly matted down, as in the cases given at p. 147, such dense posterior adhesions are most readily dealt with by the lum- bar method. 6. The lumbar incision, if converted into a T-shaped one, or prolonged forwards by Konig's method, will give sufficient room for meeting most of the conditions which call for nephrectomy. Thus modified, it will suffice for new growths. Lumbar Nephrectomy — Disadvantages: — i. It is thought by some that too little room is given by this method for the removal of large kidneys. It has already been shown (p. 148) how extensively this inci- sion can be enlarged. It is doubtful, therefore, if this objection holds good for an}- cases, even those of unusually- long-chested patients, or those with spinal deformity. 2. In a fat subject the organ may be difficult to reach, even when well pushed up from the front, owing to NEPHRECTOMY. 157 the great depth of the wound. 3. The pedicle is less easily reached,* and thus, in cases of difficultj^, bleeding at a very important stage of the operation is less easily dealt with. 4. If the kidney be very adherent, important structures — e.;/., the peritona?um and colon — may be opened, unless great care is taken. 5. The condition of the opposite kidney cannot be examined into. Possible fallacies here have been pointed out. pp. 135, 152. Nephrectomy by Abdominal Incisions in the Linea Alba, or at THE Edge of the Kectus, the Peritoneal Cavity being opened — Advantages: — i. Additional room in case of large kidneys. 2. More eas}' access to the pedicle. 3. The possibility of examining the condi- tion of the other kidney. It has already been pointed out (pp. 135, 152) that this advantage is probably overrated. Nephrectomy by Abdominal Incisions through the Peritoneum — DiSADVANTA(iES : — I. The peritoneeal sac is opened. 2. The same sac may be seriously contaminated if a kidnej' containing septic matter, or one largely converted into soft growth, is ruptured during the needful manipulations. ' 3. The intestines may be difficult to deal with, and ma}-, b}^ crowding into the field of operation and the incision in the abdominal wall, prove most embarrassing. 4. The handling and interference with the contents of the peritoneum may cause considerable shock. 5. The vitality of the colon may, b}^ interference Avith its blood-supply, be endangered, 6. It is more difficult, by this method, to deal with any dense adhesions which may exist behind the kidney. 7. If bleeding follow the operation, reopening an abdominal wound, finding the bleeding points and securing them, or plugging the wound, will be attended by more shock than the adoption of the same course by the lumbar method. A case supporting this view is candidly reported by Mr. Page, of Newcastle {Lancet, vol. ii. 1893, P- i^S/)- 8. Efficient drainage is less easily provided in cases of any contamination of the peritonasal cavity, or of oozing after the kidney is removed. 9. The after- complication of a ventral hernia is much more probable by this method, though it must be allowed that the free lumbar incision already alluded to may he followed by the same result. Causes of Death after Nephrectomy. — i. Shock. — This may be induced by hemorrhage, much traction on the pedicle, and thus, probably, interference with the solar plexus, injuiy to the colon, and, where the peritonasal sac is opened, by much disturbance of its contents. 2. Hajmorrhage. — This is especially to be dreaded where the pedicle is deep and difficult to command ; where there are aber- rant renal vessels ; where these vessels are enlarged and perhaps softened ; where, owing to too much tension on the pedicle, a vessel retracts from within its loop of ligature ; where the kidney capsule and tissue are broken into. In the intra-peritona3al method there is the additional danger of enlarged veins within the meso-colon. Second- ary hasmorrhage has been alluded to above, pp. 131, 151. 3. Uremia and Anuria. — These are onh" likely to occur when it has been impossible to form a correct estimate of the condition of the opposite kidney, or where, to give a patient a chance, the surgeon operates in what he knows * This objection and the next can be met by a very free incision (p. 14S). 158 OPERATIONS OX THE ABDOMEX. to be a doubtful case. "Where there is reason to believe that the sup- pression of urine may be clue to a calculus in the opposite kidney, this should at once be cut down upon in the hope of finding a calculus that can be removed. Mr. Lucas's brilliant example of what nephro- lithotomy may do, when such peril sets in at a later date, has been referred to at p. 137. 4. Peritonitis. — This, if septic, is due either to mischief introduced at the operation or from the kidney. While it is certainly more likely to follow the intra-peritona^al operation, it may occur after that through the loin, especially M-hen much difficulty is met with here, owing to numerous adhesions, or to Avorking in a wound of insufficient size.* 5. Septic trouble — Cellulitis — Erysipelas — Pvtemia. — These are especially likely when the kidney contains septic matter, when the soft parts are much bruised, or when many fingers enter the wound. Other, rarer, causes of death are— 6. Pul- monary Embolism. 7. Empyema. — This may be brought abovit by an extension of septic cellulitis, or by removing, during the operation, a portion of rib in order to get more rQom — a step the danger of which cannot be too strongly enforced Cp. 123). An anatomical pre- disposition favouring the passage of inflammation from the kidney to the pleura has been pointed out by Dr. Lange, of Xew York. This authority on renal surgery found, in one subject, an enormous gap in the diaphragm, the muscle fibres being absent from the ligamentum arcuatiim internum as far as the outermost part of the eleventh rib. Between these two points the fibres of the diaphragm communicated in a high arch, bounding an area in which the fatt}' tissue about the kidney was in direct contact with the pleura. 8. Intestinal Obstruction. — This occurred fatally in one of Mr. Thornton's cases. He thought it was brought about by his suturing the two edges of the peritonaeum over the kidney together, and thus producing kinking of the large intestine. Partial Nephrectomy. — This has been rendered justifiable by the results of experiments on animals. Morris (loc. siqrra cit.) says, '•Tuffier's experiments on animals, in 1888, and Earth's histological researches supply ample proofs of the healing power of the kidney, and the process by which healing is accomplished, even after extirpa- tion of considerable portions. Paoli, of Perugia, performed extra-peri- tonseal operations for resection of the kidney upon twenty-five dogs, cats, and rabbits, with perfect recovery." Morris also gives a resume of eleven operations, three for cysts, three for calculous pyonephritis, two for new growths, and one each for puerperal pyonephritis, renal fistula, and a patch of interstitial nephritis mistaken for malignant disease. None of these cases died ; nine made good recoveries, one required nephrectomy, and in one fistula resulted. Ramsay (loc. supra cit.) mentions nine cases of partial nephrectomy for tuberculous disease; in only two of these, however, was the result * During a uephrectomy for pyonephrosis the peritonaeum vras injured owing to the adhesions of the renal capsule. As it was thought certain that some septic fluid had escaped into the peritonseal cavity, this was opened by a small incision above the pubes after the lumbar wound had been closed. Some ounces of bloody fluid escaped, the cavity was washed out, and a drainage-tube placed in Douglas's pouch. The patient recovered. (F. Page, Lancet, vol. i, 1893, p. 999.) NEPHRECTOMY. 159 i :S s i; 1; — .= =*; s "i s S bi ^ =3 S ■;£ ^ g ;5 ^ r^ ^^ S 2 r X Q > >f^ ^ sill's 3 ? >"' = SPx g-2 OS lis ■2^ ^ "^ -k3 a > ^ c ii"= b i 2 >> ■- = ?= ^' 3'S 5 ? ^ cJ 6 3 3 '~ > 'a ~ [i^=3 • 1 "x ^ ^ = 'S ? 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J -f >..f :;^ 1 1 £ X >■■- -^1 T i2 I ? ^■"" ^ "i i 1 /■va ^^ .-^ ^ 1 ^ "* "• ~^ — X c3 XX -iS t4 l^ i. X § -11 1:|| ?l 1:1 ;q e3 £ ~^ c >>■- — c- ^ 'j.z " r = "3 ^ VOL. II. I I 1 62 OPERATIONS OX THE ABDOMEN. satisfactory- One, reported by Israel, was well one year later; the other, by Morris, was well two years later. This operation may also be performed in cases of laceration of the kidney by injury, where the greater part of the organ is uninjured. Here the organ will very likely be healtlw, and removal of an almost detached part ma}^ be sufficient to arrest the haemorrhage. Mr. Keetley has recorded a case of this kind (Lancet, vol. i. 1890, p. 134) : A young man bad been crusbed by a waggon-wbeel. Tbere was laceration. Five or six bours after tbe accident he showed signs of serious recurrent bEemorrhage. Through an incision a mass of blood-clot was scooped out, also tbe separated lower end of the kidney, a deep bleeding point being compressed with sponges, which were removed in twelve hours. Convalescence was rapid. No urinary fistula or bydro- nepbrosis resulted. It may be said, therefore, that where, on examination of the kidney, a suitable opportunitj" presents itself, partial nephrectomy may be performed, and the greater part of the kidney in this way saved. The w^ound in the kidney may be sutured or the heemorrhage may be arrested by means of plugging with iodoform gauze, suturing being the preferable method where possible; for in this way both hsemorrhage and escape of urine will be prevented, and rapid healing of the whole wound thus secured. In view of the imsatisfactory results that have attended this method of treating tuberculous disease, and of the great difficulty there must be in making certain that all disease has been removed, it would seem wiser to remove the entire kidney in such cases. Results of Nephrectomy. The foregoing list shows twenty-three cases with four* deaths. Tuber- cular cases, where the mischief is advanced and the adhesions extensive, as in case 22 ; malignant growths ; and cases of calculous pyelitis where both kidneys are affected, though one onl}^ at the time of operation may contain stones, will alwaj's keep up the mortality of nephrectomy. Mr. H. Morris (iSurgery of the Kidney and Ureter, vol. ii. p. 275) gives the following statistics of his cases : («) In twenty-nine nephrectomies for calculous disease, there were five deaths ; [h) in twenty-four nephrec- tomies for hydro- and pyonephrosis there were three deaths ; (c) in twenty-two nephrectomies for tuberculosis there were five deaths ; (d) in seventeen nephrectomies for tumour there were four deaths ; (e) in three nephrectomies for fistula there were no deaths. Thus, there were seventeen deaths out of ninety-five cases. NEPHRORRAPHY. It is well known that nephrorraphy has not always been followed by the relief expected. This, I think, is due to one or more of the following causes : I. The operation has been performed in unsuitable cases. (A.) Cases ■ where the mobility of the kidney is only, in reality, a small part of the * I have included No. 20. as I performed the nephrectomy. Tbe case was, however, i admitted under tbe care of another surgeon, and I was only called to it at tbe very end. On the other band, case 15 ought, perhaps, to be accounted a fatal case of nephrectomy. NEPHRORRAPHY. 1 63 trouble. Well-marked instances of this group avouIcI be those cases where mobility of the kidney co-exists with a markedly neurotic ten- dency, a group in which, were it not for the above tendency, the mobility of the kidney would be little complained of; a gi'oup in which operation has been resorted to far too often, thus bringing much discredit upon it ; a group, finally, in which nephrorraphy is rarely to be resorted to, and then only with the greatest caution.* In dyspeptic, neurotic women approaching the menopause the operation should be avoided altogether. In the neurotic tendenc}^ lies one of the chief difficulties with regard to making a decision on the question of operation. The frequency with which a highly nervous temperament is present suggests the obvious question. Would these symptoms have arisen were it not for the neurotic tendency ? Any honest medical man would answer that in the majority they would not. In a certain nvimber the mobility of the kidney deter- mines the region and distribution of the neurotic trouble; in a very few it originates and causes the neurotic tendenc3\t Again, where the mobility of the kidney is associated with a general proptosis of the viscera, especially of the liver, with long-standing dyspepsia or constipa- tion, or with uterine or ovarian trouble, it will be useless to perform nephrorraphy, unless the other ailments can be corrected^ — a matter of no little doubt and difficulty in some of those patients in whom we meet with this disorder. (B.) In a certain proportion of movable kidneys — and this, perhaps, a larger one than is usuall}^ allowed — organic disease coexists as well. I have met with three such cases. In one (Case i. Table, p. 159) the kidney was the site of carcinoma; in a second (Case 8, loc. siipra cit.), earl}^ tubercular disease must have, been present. About two months after the nephrorraphy, pain having returned, further examination showed that the urine, which had before been found normal, contained pus. At a second operation two early foci of tubercular suppuration ^ were found and the kidney was removed. Six years later the patient was alive and well. The third case was one associated with hydronephrosis. At this time, when performing nephrorraphy, I was passing my sutures through the tissue of the kidney itself, a method which I now consider quite unreliable, and I am doubtful if the relief given in this case of hydronephrosis was permanent. The question of nephrorraphy in hydronephrosis is referred to below. 2. Another frequent cause of nephrorraphy failing to give perma- nent relief is the way in which the operation is performed. Too often the peri-renal fatty tissue has been thoroughly pulled out, some of it * In an interesting paper by Dr. Drummond (loc. infra cU.'), thirty cases of movable kidney are given, two of which were treated by nephrorraphy. Both relapsed. In a third case, the details of which were supplied to Dr. Drummond, " excision of the movable kidney was practised without any relief." f As in the rare cases where a man, previously active and healthy, has his life spoilt and becomes hypochondriacal after one kidney has become movable. X My silk sutures, with which the kidney had been fixed, were found f/i silii, but as the collections of pus were on the inner aspect of the kidney, I do not think they dated to the stitching, in which the kidney substance had been boldly taken up. The early appearance of pus after the nephrorraphy is, however, suspicious, and it is quite possible that in delicate patients the injury inflicted by suturing might be the starting-point of tubercular disease of the kidney. 1 64 OPERATIONS ON THE ABDOMEN. removed, and its edges sutured to the lips of the wound. Frequently the kidney is already movable Avithin this capsule, and no good results, and where no such mobility has existed, the loose fatty tissue, how- ever carefully pulled out, tightened and stitched, gradually stretches and ceases to fix the organ. In other cases the operator tries to pass his sutures so as to take up the capsule of the kidney without regarding more than the surface of the cortex. Such a hold is insufficient. In other cases — and this is very frequent — the kidney tissue itself is deeply traversed by the needle. Now, the friability of the kidney is well known. Eveiy operator who has passed sutures in this way is familiar Avith their tendency to cut through before or just as they are finally tightened and tied. So soft is the tissue of the kidney, especially when injured and inflamed — as around a suture — that I believe that, even when silk sutures thus passed have been left in situ, their cutting through is only a matter of time. When catgut, however stout, has been employed the result is still worse. Like silk, it is ver}' liable to cut its way through the easily lacerable kidney tissue as it is tied ; if it does not do so then its softening- takes place so quickl}' in the vascular kidney tissue that any permanent anchoring by the blending of this material with other tissues is impos- sible.* Moreover, there is another danger, not altogether a fanciful one, which ma}^ follow on deeply puncturing the kidney. A German surgeon, Barth, has seen a necrotic centre caused in the kidney owing to the occlusion of one of the arterial centres b}^ the anchoring suture. A similar condition has been noted as the result of puncture. One of the large arteries was obstructed, hgemorrhagic infarction took place, and ultimateh" necrosis (M'Ardle. Brit. Med. Journ., vol. i. 1894, p. 526). A fourth step that has been advised, scarifying the surface of the kidney and scraping the adjacent muscles andfasciaB does not commend itself to me as satisfactory at the time or likely to be of permanent utilit}^ later. To speak of the indications more exactly. Where an otherwise health)^ kidney is verj^ movable, especially where this dates in sensible people to an injury, if the surgeon is in doubt as to an operation, he should try and satisfy himself that other treatment, including a sufficient trial of a well-fitting belt, has failed, that the pain, whether constant or paroxysmal, is hand fide, and that it really cripples and spoils the patient's life. Constipation and dyspepsia will of course have been treated, tight lacing given up, and a trial made of a well-fitting belt, or a corset coming low down in front and so fitted as to gather up the lower part of the abdomen and its contents. Thus, conditions of movable kidne}' which call for operation are : When it is accompanied by undoubted vomiting, or when, on the patient's stooping, the viscus comes down so far as to be jammed between the ribs and the crista ilii. Another strong indication for nephrorraphy is early hydronephrosis. Here the operation is resorted to not only to save the patient from * Dr. Newman drew attention to this fact several years ago QLerts. on the Surg, Sis. of the Kidney, p. 69) : " The sutures passed into the kidney became destroyed more rapidly than elsewhere ; the living renal tissue seems to have an iinusual power of absorption." NEPHRORRAPH Y. 1 6 5 the pain caused b}- the movable kidney, but to " prevent the organ from bringing about its own destruction " (Lucas). Mr. Lucas (Brit. Med. Joarn., vol. ii. 1891, p. 1344) relates four cases in which mobility of the kidney allowed of displacement of the organ on its transverse axis, causing bending of the ureter,* and thus distension of the pelvis with urine. Two of the cases were treated by nephrorraphy, and when last seen remained cured. One of the cases, in which the hydronephrosis was undoubtedl}' due to the displacement, seemed to show that the destruction of the kidney may occasionally go on without any severe attacks of pain. The following questions arise as to the sutures, (i) What is the best material ? (2) What tissues are to be taken up ? The answer to each of these questions is, in my opinion, a simple one. (i) Silk, which is easily obtained and readily sterilised, with a little care will be quite eiHcient. It should not be of the plaited kind, it should be of medium size and carefully prepared. Buried as it is deeply, the use of silk here is not open to the objections to wdiich I have alluded in the account of Radical Cure of Hernia. Kangaroo-tail tendon is another excellent material. (2) In answer to this question I am strongly of opinion that to ensure a permament cure in nephrorraphy, the sutures should take hold of the proper capsule of the kidney itself, after this has oeen careful peeled off in two flaps. I have tried other methods, e.g., inserting them through the substance of the kidney itself, either fastening them to each side of the wound and dropping them in, or passing them from one lip of the wound through the kidney and finally through the other lip of the wound. The longer I watched my cases the less reason had I to be satisfied, though the earlier results had been excellent. I have used the following method in fifteen cases, four of which were bilateral. One case, a patient of Dr. Brogden's, of Ipswich, was operated on eleven years ago. She remains well, having married and had a child since the operation. Of the others, in one only do I kno^^- of the organ becoming loose again, a patient sent to me by Dr. W. A. Davies, D.S.O.,-of Johannesburg. In two others, owing to the patients being moved too soon, the wounds reopened. This caused considerable trouble. Operation. — The kidney is first thoroughly exposed by the steps given at p. 123, an assistant keeping the organ well pushed up into the loin while the surgeon cuts down on it. I may here say that in some of these cases of very movable kidney the tissues around are so loose from the dragging and shifting to and fro of the kidney that they wrap round the organ very closely, and thus it is easy to injure the peritoneum. Thus, in one of the patients mentioned above the right kidney was mobile through an extremely wide range, and so loose that when lying on her left side the patient could make it project as a * This same displacement of the kidney, which occludes for a time the ureter, will also, by twisting the pedicle, affect its vessels. As Mr. Lucas points out, the vein will suffer more from pressure than the artery, thus causing turgcscence of the organ generally as well as distension of its pelvis. Thus are brought about the nausea, pain, vomiting, &c., which have been described as strangulation or acute dislocation of the kidiioy. (Bruce Clarke, Trans. Mcd.-Chir. Soc vol. Ixxvi. p. 263; Brit. Meri. Joiirn., vol. i. 1895, p. 575). 1 66 OPERATIONS OX THE ABDOMEN. convex lump in the left iliac fossa. When I was operating on this side I found the kidney easily reached, but not easy to define, owing to the extreme looseness of the folds of the perinephritic tissue and perito- naeum.* This latter structure I opened in two places, the thin edge of the liver appearing at one, and some omentum in the other. The first opening was clamped and tied up with a catgut ligature, the second closed with a continuous suture of the same. Strict aseptic precautions were taken, and not the slightest ill result followed. The kidney itself having been exposed, it is gently withdrawn through the wound, surrounded with aseptic gauze while an incision is made with a very light hand all along the convex border from end to end. Unless the utmost gentleness is taken in the last step the tissue of the organ itself will certainly be incised, causing free oozing. With the handle of a scalpel or a blunt dissector, flaps of capsule are then deli- berately but gently stripped oif the kidney up to a point about halfway along its lateral surfaces, so as to raise sufiicient flaps for the sutures to find a holding in. The flaps having been raised the}" are sutured with medium-sized sterilised silk to the aponeurotic and subcutaneous edges of the wound. To get a firm and permanent holding, each suture should take up plenty of capsule on the one side and a sufiicient grip of the lumbar fascia on the other. I generally use upwards of twenty- sutures, perhaps twelve in one flap and eight in the other. One word of caution should be added. This method of anchoring is so eflacient that, iinless care is taken, it is joossible to fix the kidney, which has been drawn out, actually between and not beneath the lips of the wound. After one row of sutures, say the upper, has been inserted, tied and cut short, and the second merely inserted, care should be taken gently to push the kidney into its proper place in the loin, just under the wound : the lower sutures are then also tied, cut short, and dropped in. Any oozing met with after stripping off* the flaps of capsule will 3'ield to firm sponge- pressure kept up by an assistant while the surgeon is putting in his sutures. It is well also to keep a sponge in the lower part of the wound, to be removed before the last sutures are tightened. If when all bleed- ing is arrested the wound is very carefully dried out and dusted with sterile iodoform, no drainage-tube will be required. In closing the wound I unite the edges of the cut lumbar fascia with buried sutures of chromic gut, and the skin with salmon gut. I recommend this method most strongh* : it is both easy and efiicient, and sufiicient time has now elapsed in several of my cases for me to be able to say that no injury is inflicted on the kidney by the stripping off" of its capsule. So convinced am I of the superiority of this method that I shall not occupy my space or my readers' time in describing any other. * This was not a mesonephron, an exceedingly rare condition. I find that Dr. Drummoiid, of Newcastle, described a similar condition several years ago (" Clinical Aspects of Movable Kidney," Lancet, vol. i. 1890, p. 121) : " In almost every instance in which the kidney has been found to be freely movable, the other abdominal organs have been correspondingly loose in their attachments — the spleen, liver, caecum, stomach, &c. More than once a distinct mesonephron was present, but much more often the peritonaeal covering was simply loose, so that the organ could be easily placed in various novel positions. At times the kidney had dragged the relaxed peritonaeum so far from the abdominal wall as to bring into close conjunction the upper and lower layers, so as to form a false mesonephron." OPEEATIONS OX THE URETER. 167 OPERATIONS ON THE URETER. There are two main conditions in which operations on the ureter are necessary : A. Ureteral Obstruction. B. Injuries to the Ureter. A. Ureteral Obstruction. — This in the great majority of cases is due to the impaction of" a calcuhis in the ureter; in others, however, it has been found to be due to a valvular formation at the opening of the ureter into the renal pelvis or to a stricture of the ureter. These condi- tions will be considered separately. I. Ureteral Calculus. — Impaction of a calculus may take place at almost any point in the course of the ureter, although in most cases impaction occurs either at the upper extremity of the ureter close to the kidne}', opposite the brim of the pelvis, or at the vesical orifice. There can be no doubt whatever that in many cases, where a renal calculus has been diagnosed and no calculus found, the stone has really been in the ureter. With more thorough exploration of the ureter, however, in every case where no stone is found in the kidney, failure of the operation from this cause will doubtless be prevented. The methods of dealing with these cases will now be considered under different headings, ac- cording to the site of impaction of the calculus. I. Impactio'ii of a Calculus at or above the Brim of the Pelvis. — In these cases the ureter can be sufficiently exposed by prolonging the incision already made for exploring the kidney as above described (vide p. 126). In some cases the dilatation of the ureter above the site of impac- tion will allow of the calculus being pushed gently along the ureter, either up to the kidney or, at any rate, to some more accessible part of the ureter. Tuffier (Duplay and Reclus, Traite de Chirurgie, t. vii. 1892), during a lumbar nephro-lithotomy, in which examination of the kidney revealed no stone, detected a hard oval body about three centimetres long, where the ureter crossed the pelvis brim. The stone was movable and was pushed up into the pelvis of the kidney, and removed by an incision into the convex border. The patient recovered. If the stone cannot be pushed up as far as the kidney, or is so tightly impacted that it cannot be moved, it should be removed through a longitudinal incision in the ureter. The incision in the ureter may be sutured with fine silk or catgut, passing through the outer coats, or it may be left without sutures. Should inflammatory thickening or ulceration of the ureter be present, it would seem wiser not to insert sutures. A number of successful cases, both \yiih. and without sutures, have been recorded. The following case, described by Dr. Kirkham (Lancet, March 16, 1899). is an illustrative one. and is, I believe, the first case in which a patient has been saved from death from suppression of urine by the removal of a calculus low down in the ureter: The patient was 58. He had twice suffered from right renal colic, and had passed a small calculus. May 24, left renal colic came on. No urine was passed from this date till after the operation. May 30, the patient was drowsy, with prostration and muscular twitchings. Dr. Kirkham then explored the kidney in the hope that if no calculus wa.s 1 68 OPEEATIONS ON THE ABDOMEN. removed life might be saved by affording an outlet to the urine by an incision into the jjelvis of the kidney. An incision was made from the tip of the last rib towards the anterior superior spine. No stone being found in the kidney, the exploration was con- tinued along the ureter, in which a stone was distinctly felt about half an inch above where the ureter crosses the external iliac. There was a little difficulty in reaching the iireter in this part of its course, but after enlargement of the wound a calculus about the size of a date-stone was removed. A little urine escaped from the incision into the ureter. No sutures were placed in this. Half an hour after the operation an ounce and a half of urine was passed naturally. Very little escaped from the wound in the ureter, and the patient made an excellent recovery. 2. I'mpadion oj a Calculus in the Pelvic Portion of the Ureter. — In the male, the greater part of the pelvic ureter can be exposed by a prolonga- tion of the lumbar incision already made for exploring the kidney as recommended by Morris (^cide p. 126). Should the patient, however, be fat, and the lumbar incision already very deep, this method will be found to be extremely difficult. In such cases, and also in the female, the abdomen should be opened by an incision in the semilunar line or through the rectus sheath. In most cases it will then be found possible to push the calculus along the dilated ureter up to or near the kidney, when its removal can be accomplished through the lumbar incision, and the abdominal wound closed. This plan was first carried out by Lane in the following case (Lancet, 1890, vol. ii. p. 967) : A woman, aged 23, had had symptoms of renal stone for twenty j'cars, but there was nothing to point to the fact that the stone was in the ureter and not in the kidney, except that, associated with her renal pain, she complained at times of pain in the lower part of the abdomen on the same side, which did not appear to be reflected. The kidney was explored by the lumbar incision, and nothing found either in this organ or in those parts of the ureter which could be reached from above or per Tectum. The pain having returned with its original severity, the abdomen was opened along the left liuea semilunaris, and in the portion of the ureter which had not been explored at the previous operation a small stone was felt. This was forced upwards along the ureter to the crest of the ilium, and by means of a small incision in the side the ureter was exposed and the stone removed. The aperture in the ureter was sewn up by a fine con- tinuous silk suture. No leakage took place from the ureter, and the woman recovered completely, losing all her pain and discomfort. It may, however, be found impossible to push the calculus u]-) the iireter, owing to firm impaction or to insufficient dilatation of the ureter above the calculus. In this case the calculus must be removed through the peritonaeum, and the ureter, if possible, sutured,, drainage in case of leakage being provided for by means of a tampon of iodoform gauze. In a case recenth" operated upon by one of us (F. J. Steward, Clin. Soc. Trans., vol. xxxiv.) this was done, and the ureter and peritonteum sutured : The patient was admitted for hematuria and painful micturition, which, in the absence of pain or tenderness over either kidney or ureter, were thought to be due to a vesical calculus. As the sound detected nothing, the bladder, after being distended with air, was opened above the pubes. Nothing was found in the bladder, but through its walls a stone could be felt in the lower part of the right ureter. As the stone could not be worked down towards the bladder the wound was closed. Eight days later an incision about five inches long was made in the lower part of the right linea semilunaris and the peritonseal sac opened. The stone was easily felt, and was gently manipulated up the ureter as far as a point a little above the iliac vessels. As it would go no further, the peritonEeum and then the ureter were incised and the stone, weigh- ing nine grains, removed. The ureter was then closed with a fine silk suture, taking OPERATIONS ON THE URETER. 169 up the outer coats only; the peritouEeura was then sutured in like manner, and the wound closed with the exception of a small part through which a gauze drain was brought. No leakage occurred, and the patient made a satisfactory recovery. Other methods have, however, been adopted. Enimett and Cabot have both successfullj' removed ureteral calculi through the vagina, while Ceci records a successful case in which he removed the stone through the rectum. The latter method cannot, however, be con- sidered safe. 3. Impaction at the Vesical Orifice. — A number of successful cases of removal of calculi in this position have been recorded. This has been done, in the female, after dilatation of the urethra, by Emmett, Berg, Eichmond, Czernjr, Sanger, and Thornton. Tuffier has also removed stones in this position twice by supra-pubic cystotomy. ^ II. Valvular Obstruction. — Simon, in 1876, gave theoretical direc- tions for the relief of this condition ; the first successful operation was. Fig. 41. SiQE Tlhistratiug Fenger's operation for stricture of the ureter. (Morris.) however, performed by Fenger, of Chicago, in 1892. The method of dealing with the condition ma}^ be gathered from the following ?'esMHt6' of Fenger's case (Ann. of Sun/., vol. xx. 1894). The patient was a woman, aged 28, with intermittent hydronephrosis due to a movable kidney. The pelvis and calyces were first explored and no stone found. As the ureter could not be catheterised, a small opening was made in the posterior wall of the infundibulum, wlien a valvular obstruction was found at the upper end of the ureter where it joined the renal pelvis. The valve was divided vertically, and the ends of the longitudinal incision united by sutures, so as to convert the incision into a transverse one. The incision in the infundibulum was then closed with sutures, and the kidney fixed in the loin, a bougie being passed through the wound in the renal parenchyma and retained in position in the ureter for two days. The I/O OPERATIOXS OX THE ABDOMEN. patient recovered witliout a fistula, and subsequent!}' liad no return of the hydronephrosis. III. Stkictuke of the Ureter. — Various plans have been adopted by different surgeons to remedy strictures of the ureter, the chief being the plastic method of Fenger (loc. supra cit.), dilatation by bougies (Alsberg), and resection of the strictured portion (Kuster). The first of these plans only will be here described, as it a^t.11 probably be found applicable to the greatest number of cases. Moreover, this method has been successfully carried out at least three times b}' Fenger, Morris, and Mynter. The details of the operation can be very well made out b}' reference to the three illustrations in Fig. 41. The strictured portion of the ureter is first divided longitudinalh' ; sutures of fine silk are then passed on either side of this in order to draw the two extremities of the incision together and thus convert it into a transverse one, after the manner of the Heineke-Mickulicz operation for stenosis of the pylorus. Further sutures, passing through the outer coats only, now bring the edges of the rest of the incision together, thus folding the ureter on itself to some extent. The following short account of Fenger's case well illustrates the brilliant success of the operation : " Traumatic stricture of ureter close to entrance into pelvis of kidney; intermittent pyonephrosis for twenty-four years ; increased frequency of attacks. Nephrotomy ; no stone in sacculated kidney, ureteral entrance could not be found ; longitudinal ureterotomy revealed stricture at upper end of ureter ; longitudinal division of stricture and plastic operation on ureter. Recovery without fistula." B. Injuries to the Ureter. — These may be met with either in the form of traumatic ruptures, or of accidental division or removal of a piece of the ureter during the course of certain abdominal operations, such as hj'sterectoni}' or the removal of a pelvic tumour. Traumatic rupture of the ureter has not yet been treated by direct suture. This is owing doubtless to the extreme difficulty in the diagnosis of tliis condition in the earl}' stages, for most of the cases have not been recognised until an accumulation of urine, blood, or pus has formed and has been opened. The tumour due to the accumulation may not be noticed for some time, two to three weeks (Stanley, Page, Barker, Hicks), thirty-nine days (Croft), and in one case (Stanley's) not until seven weeks after the injury. For accidental di\'ision or removal of a piece of the ureter during the course of an abdominal operation, a very large number of different operations have been performed. It is impossible here to mention or describe all these operations. An attempt will, however, be made to indicate the methods which are likely to be found most suitable to the various conditions that may be met with. In the great majorit}^ of instances it will be found possible to directly unite the divided ends of the ureter. The results that have so far attended the various methods of bringing this about clearly show that it should be done wherever possible. Bovee (Ann. of Surg., Aug. 1900) mentions twenty-seven published cases with only two deaths, and not in one was thei*e failure to unite. If the ureter has been simph* divided without loss of substance, and if both the ends are accessible and the OPERATIONS OX THE URETER. 171 upper end A\-ill not reach the bladder, then, because it is the most simple method to carry out, and because it is the least likely to be followed by stricture, the following operation, devised by Van Hook (vide Fig. 42), should be performed. The following are the steps of the operation as given by Fenger (Joe. supra cit.) : " (i) Ligate the lower portion of the tube one-eighth or one-fourth of an inch from the free end. Silk or catgut may be used. Make ^vith fine sharp-pointed scissors a longitudinal incision, twice as long as the diameter of the ureter, in the wall of the lower end, one-fourth of an inch below the ligature. " (2) Make an incision with the scissors in the upper portion of the ureter, beginning at the open end of the duct and carrying it up one- fourth of an inch. This incision ensures the patency of the tube. Fig. 42. Uretero-ureterostomy. Van Hook's method. (Morris.) " (3) Pass two very small cambric sewing needles armed with one thread of sterilised catgut through the wall of the uj^per end of tha ureter, one-eighth of an inch from the extremity, from within outward, the needles being from one-sixteenth to one-eighth of an inch apart, and equidistant from the end of the duct. It will be seen that the loop of catgut between the needles firmly grasj)S the upper end of the ureter. " (4) These needles are now carried through the slit in the side of the lower end of the ureter into and down the tube for one-half an inch, Avhere they are pushed through the wall of the duct side by side. " (5) It will now be seen that traction upon this catgut loop passing through the wall of the ureter will draw the upper fragment of the duct into the lower portion. This being done, the ends of the loop are tied together securely, and as the catgut will be absorbed in a few days, calculi do not form to obstruct the passage of the urine. 172 OPERATIONS OX THE ABDOMEN. '• (6) The ureter' is now enveloped carefully with peritonaeum." If, however, a portion of the ureter has been accidentally removed, and the upper end will not reach the bladder, it will probably be found that there will not be sufficient length of ureter available for performing- Van Hook's operation. In this case the ends must be united by end-to- end suture, or by the oblique method of Bovee {vide Fig. 43). Should it be found that the upper end of the divided ureter will reach the bladder, implantation into this organ is preferable to all other procedures. This may be carried out by the method of Paoli and Busachi (Anncdes cles Maladies des Organes Genito-urinaires, 1888), which consists in splitting the distal end of the in-eter and uniting it by sutures to an incision in the bladder, or by a modification of the operation of Van Hook for uretero-ureterostomy, the cut end of the Fig. 43. Uretero-ureterostomj-. To illustrate the oblique ir.etliocl of Bovee. (Morris.) ureter being invaginated into the bladder. This method has been adopted by Penrose and others {Med. Ne^is, vol. Ixiv., 1894, p. 470). Finally, should such a length of ureter have been removed as to render both direct union of the two ends and implantation into the bladder impossible, the proximal end must be either implanted into the bowel or on the skin. The results of both these plans have so far been on the whole extremely unsatisfactor}', owing to infection of the ureter and kidney in the case of implantation into the bowel, and to discomfort and constant irritation of the skin when the implantation is made on the skin. For these reasons a secondary nephrectomy will nearly alwaj^s be necessary in such cases. CHAPTER V. OPERATIONS ON THE INTESTINES. ACUTE INTESTINAL OBSTRUCTION. — APPENDICITIS. — PERFORATING ULCER OF STOMACH— OF DUODENUM —OF INTESTINE AFTER TYPHOID FEVER.— SUPPURA- TIVE PERITONITIS. ~ TUBERCULAR PERITONITIS. — ENTEROSTOMY.— FORMATION OF ARTIFICIAL ANUS.— SUTURE OF INTESTINE.— RESECTION OF INTESTINE. —ENTERECTOMY.— COLECTOMY. — INTESTINAL ANAS- TOMOSIS AND SHORT CIRCUITING.— ENTEROPLASTY.— CLOSURE OF ARTIFICIAL ANUS AND FJECAL FISTULA. ACUTE INTESTINAL OBSTRUCTION. Considered generally, without reference to the causation of the obstruction, the successful treatment of acute intestinal obstruction depends largeh" on two points : («) The Question of Operation, and (h ) The Question of the Extent of Interference that is indicated in any given Case. (a) The Question of Operation. — Although cases of so-called " spon- taneous cure " have from time to time been recorded, the number of these is so small, and the correctness of the diagnosis in many of them so doubtful, that for all practical purposes it is wiser to leave them entirel}^ out of consideration. For, apart from these and the small number of cases of intussusception that have survived the sloughing of the intussusceptum, as Sir F. Treves saj^s, " there is no avoiding the fact that acute intestinal obstruction, if unrelieved, ends in death " (Intestinal Ohstruction, p. 475). This being so, it clearly becomes the dutj- of the surgeon to operate on ever^' case of acute intestinal obstruction. The operation, moreover, should be performed at the earliest possible moment after the diagnosis has been made, for, serious as the operation is in itself, it is not nearly so serious as delay, since the mortality rises extremely rapidly as the period between the onset of the sj'mptoms and the time of operation increases. Neither should uncertainty of dia- gnosis be allowed to delay the operation, for of the many conditions that 174 OPERATIONS OX THE ABDOMEN. simulate acute intestinal obstruction — e.g., typhlitis and appendicitis, peritonitis from different causes, thrombosis of mesenteric veins, acute pancreatitis, enteritis, &c. — in some an operation may be beneficial, while as to the others it would be better that an exploratory operation, as long as it is done by skilled hands, took place needlessly than that a remediable condition should be left untouched. Here, again, the valuable opinion of Sir F. Treves may be quoted. He says : " Operation in these cases is too often regarded as a last resource. It should be the first- resource, as it certainh* is the oiilij resource." The mortality of all cases of acute intestinal obstruction at the present time, as shown by Gibson {Ann. of Surg., Oct. 1900) in a collection of cases operated upon between 1888 and 1898, is about 47 per cent., his list including 646 cases with 312 deaths; and although this is without doubt a vast improvement upon former times, it is still to be hoped that in the near future earlier recognition and more immediate operation will do much to bring about still further improvement. Even then the mortality will probably always be high, and this owing to the frequently complicated nature of the cause of the obstruction, the peculiar vitalitj' of the parts which have to be handled, and the readiness with which these pass into a condition beyond recovery. Bearing in mind, however, the essentialh' fatal character of the condition, apart from relief by operation, every successful operation should be looked upon rather as a life saved, than every fatal one as a life lost. (/>) The Extent of Interference that is indicated in a given Case. — The operation must be according to the state of the patient. These cases of acute intestinal obstruction are not to be grouped together as all equally fit for operation, or as all certain to be relieved by operation as long as this is undertaken earh^. In some the condition of the patient is good, the abdomen is undistended and a prolonged search may be made. In others a precisel}' opposite condition is present, any prolonged exploration is out of the question, and all that can be done, if the cause is not found at once, is to open one of the most distended coils, as low down as possible, and drain the intestines {vide infra). I propose to describe the operation generally first, and then to allude to its application to the chief forms of acute intestinal obstruction. Operation. — The bladder is first emptied, and the abdominal wall shaved and cleansed, A water-bed should be filled with hot water, and if the patient's condition is bad, a hot port wine enema should be given. The question of anaesthetics in these cases is a very important one, and should be well considered. The impeded respiration due to the abdominal distension is liable to make the administration of a general anassthetic difficult and dangerous. The tendency to vomit is another grave danger, a sudden attack during the administration having fre- quently caused immediate death from choking. Apart from these two considerations, the administration of a general anaesthetic seems to have special dangers of its own in cases of acute intestinal obstruction, for it undoubtedly often produces a complete and sudden change in the Avhole aspect of a case, a patient thought to be in good condition and well able to bear an operation becoming suddenly moribund within a few minutes of the commencement of [the adminis- tration. ACUTE INTESTINAL OBSTRUCTION. 175 For all these reasons it is achasable, wherever possible, and espe- cially in very bad cases, to make use of local anajsthesia only, the infiltration method of Schleich with cocaine, or y3 eucaine, being the most suitable. Should it, however, be deemed inadvisable to operate without general anesthesia, the stomach should be previously washed out if vomiting has been severe, and saline infusions, either intra- venous or into the cellular tissue of the axilla, should be made as soon as possible after the adminis- tration of the ana3sthetic has been begun. The operation to be performed ^^^ll necessarily vary according to the general condition of the patient, and the mode of procedure will be described under two heads : (A) Early Cases, or where the condition of the patient is good ; and (B) Late Cases, or where the condition of the patient is very serious. (A) The surgeon makes a central incision,* beginning two inches above the umbilicus, and passing to the left of this he gains the middle line to descend, going quickly down to the peritonseum, but arresting all haemorrhage before this is opened. If the linea alba is not hit off exactly, and is not qiiickly found, any muscular fibres are torn straight through with a steel director, and the transversalis fascia and peritoneum thus reached. I strongly advise the sm-geon to give himself plenty of room, so as to quickly get his hand in and explore efiiciently. A short median incision below the umbilicus, and the introduction of a couple of fingers, is usually futile. The abdominal wall in these cases is not thinned and overstretched as in ovariotomy ; hence, if inadequately opened, it grips the hand most embarrassingly. If the case has been allowed to go on until the intestines are distended, the search for the cause of the mischief will be rendered all the more difiicult, and there must be sufficient room to introduce the hand freely. If an assistant skilfully keeps the edges of the wound together where this is not occupied by the inserted Avrist, the intestines will not escape. The peritonaeum should alwaj'S be well lifted up before it is opened, especially if there is distended bowel beneath. The opening is then enlarged with a blunt-pointed bistoury or scissors, two fingers with the palmar aspect turned upwards serving now as the best director. The late Mr. Greig Smith advised, where the peritoneum is thin, that it be pinched up between the finger and thumb, and rolled about to see that no bowel is included. f The surgeon should now decide Avhicli mode of exploration he will make use of. The following is as useful as any: If the parts are not much distended, three possible sites of strangulation should be first looked to. (i) The c£ecum,:J: which will give twofold evidence, first, its * Tn those extremely rare cases where the obstruction can be localised to one or other side of the abdomen, a lateral incision may be made use of, either over the swelling, if auj' be present, or in the linea semilunaris. t If much fluid is present, it now often shows itself through the peritoneum. X If the cecum can be made out to be empty, tracing up empty coils from this will very likely lead to the obstruction. The more marked the evidence of collapsed small intestine, the greater the probability of the obstruction being high up, and the less fit the case for enterostomy (p. 221) (R. Jones. Urit. Med. Journ., vol. i. 1894, p. 1123). In this case a baud was found and successfully dealt with. Here the obstruction had 176 OPERATIONS ON THE ABU03IEN. distension or emptiness telling whether the obstruction is above or below it ; and secondly, the state of its appendix, whether normal or adherent, whether empty or containing some concretion. (2) Next, the internal inguinal, the femoral, and obtui'ator rings are explored, to make sure that no tiny hernia exists, imperceptible from the outside. The fingers are next swept upwards towards the (3) umbilicus, in the hope of finding one of the diverticular bands mentioned at p. 179. If, up to this, the search has been fruitless, the brim of the pelvis is next examined, as bands of omenta are often fixed hereabouts, and also because, in women, local peritonitis, originating about the uterus or its appendages, and, in either sex, about the appendix cteci, is, not infrequently, the cause of the obstruction. If the search fail — and it often will when distension is present, embar- rassing the fingers in their movements, and obscuring the relation of parts — one or two of the loops which lie nearest to the wound should be carefully scrutinised.* These should be followed in the direction of increasing congestion and distension, thus leading to the obstruction. Fixity of a coil may be another aid. Where there is ground to believe that the case may be one of acute supervening upon chronic obstruction, the sigmoid and colon should be first investigated. If this prove fruitless in cases where there is not much distension, the plan adopted b}^ Mr. Cripps {Clin. Soc. Trans., vol. xi. p. 225) is the simplest — i.e., to draw out some inches of intestine at a time, bit by bit, from the upper part of the wound, passing it in again into the belly through the lower part, in such a way that at no time are more than five or six inches of intestine exposed. After drawing out and replacing some feet of intestine in this way, it is probable that, owing to the increasing congestion or I'esistance, the surgeon will reach the obstruc- tion.! This is, however, a tedious method, and one only to be adopted when the condition of the patient is good. An assistant should hold the coil from which the surgeon starts in the lower angle of the wound under a hot sponge, so as to save the surgeon going over the ground a second time. If a search for ten minutes has failed ;J: to find the cause of obstruction the following courses remain open : (a) Kummell's plan of allowing the small intestines to prolapse under hot aseptic towels ; {j3) empt3ang the most distended coil, and either closing the opening later, or (7) inserting in it a Paul's tube ; (S) " short-circuiting." (a) The objection to this method is, of course, that it is often exceed- been incomplete at first, one of incarceration followed by strangulation. I have men- tioned a similar successful case at p. 278. * The late Mr. Greig Smith said that as the most distended coils will rise nearest the surface, and the greater amount of bowel is within three inches of the umbilicus, there is a probability that the most dilated coils will be in sight. f If he find that the bowel is getting healthier and emptier, the surgeon must reverse the direction of his search. J " The difficulty of finding the obstruction in some cases is well shown by Madelung, who, in several cases where the seat of obstruction could not be located during life, requested the pathologist, when he made the post-mortems, to locate the obstruction hy introducing his hand through an incision, allowing him from ten to twenty minutes for the exploration ; in every instance he failed to find the obstruction within the specified time " (Senn, loc. svpra cit.'). ACUTE INTESTINAL OBSTRUCTION. 1 77 ingly difSciilt to get the distended coils back into their home, and that the necessaiy manipulations and exposure must produce shock, and may inflict serious damage. If, however, the condition of the patient is satis- factory and the amount of distension not great, it is, if done properly, and with care to prevent undue exposure of. and damage to, the intes- tines, perhaps the wisest course to pursue. This practice is. moreover, recommended by no less an authority than Sir F. Treves, who considers that the damage done to the intestines, by the amount of exposure necessary, is probably less than that caused by prolonged manipulations within the abdominal cavity. The abdominal incision should be made very free, and the intestines then allowed to escape between smooth-surfaced sterile towels, wrung out of salt solution at a temperature of 110° F. In this wa}* the intestines can be immediately covered with the towels. and the farther search for the cause of obstruction conducted with ver}' little exposure or interference. Usually the seat of obstruction will be quickly indicated by fixity of some loop of intestine, which thus will not leave the abdomen. (/S) Should, however, the amount of distension be considerable, it is wiser to relieve this condition before proceeding further. To this end a different method must be adopted according to the seat of greatest dis- tension. Should this be the large intestine, for instance, in a case of volvulus, the distended loop may be emptied, either by multiple puncture with a very fine h}"drocele trocar if, which is rare, they contain only gas, or by incision if liquid ffeces are present as well. Both these steps are often disappointing. Two conditions must be present to allow multiple punctures "with the finest hydrocele trocar to be safe. The coats of the intestine must be sufficiently healthy, neither infiltrated nor paralysed, to allow the peritonteal and muscular coats to close the opening in the mucous by gliding over it, otherwise a fatal leakage will take place iiaUatira imless every puncture is closed by a fine parietal suture. The second condition is, that gas only must be present ; liquid faeces being almost invariably present as well. A wiser course is to incise and evacuate the most distended coils. The patient being turned on to one side, the most distended loop is drawn out over a basin, incised parallel to its long axis at a point most distant from the mesentery, the rest of the coils being kept within the abdomen, and the one withdrawn carefully isolated by tampons of iodoform gauze or hot aseptic towels. As the escape of gas and fluids, owing to the paralysis of the intestine, will probably be very slow, it will be wise to follow Dr. Senn, and ^' resort to pouring out the contents, as it were, by seizing the gut several feet above and below the incision, and elevating it," a large quantity of fluid fieces being thus poured out. This emptying of dis- tended coils will not only facilitate reduction, but. as first urged by the late Mr. Greig Smith (Abdom. Siirg., p. 436), it will diminish the harmful effects of a greatly distended abdomen, viz., dyspnoea, palpitation, and abdominal shock, and, as regards the bowels themselves, the danger of continued distension, paralysis, and absorption of toxic products. When the evacuation has been made as complete as possible, the next step will depend upon the condition of the patient. If this be good, and the relief of the distension has been sufficient to justify further exploration, the surgeon closes his incision in the intestine by Lembert's sutures, taking care to efiect real inversion of the edges, and, leaving one or two VOL. II. 12 178 OPERATIONS ON THE ABDOMEN. of the sutures long, keeps this bit of intestine outside, entrusted to an assistant, while he continues his search for the cause of the obstruction. If this be found and removed, the opened and sutured part of the intestine must again be inspected, and its exact closure made sure of before it is returned ; any sutures left long having been first cut short. Before finally closing the wound the question of cleansing the peritonteal cavity, irrigation, and the insertion of a Keith's tube into Douglas's pouch may arise. If, on the other hand, it is found that the small intestine is the seat of most distension, then very little advantage will be gained by either puncture or incision, for the acute flexures caused by the distension will prevent more than a very small portion of the gut being emptied by each incision. In this case it is wiser to drain the intestine for a time by performing enterotomy, as described below (p. 222), and to search for and, if possible, remove the cause of obstruction after the worst of the distension has been relieved. (7 and S) Where the patient's condition makes any further search impossible, or where there is great distension, a temporary or permanent artificial anus must be made, or else "short-circuiting" must be performed. As the last can very rarely help us in acute intestinal obstruction, I will first dispose of this subject. It will be remembered that I am speaking of short-circuiting as one of the courses open to a surgeon when he fails to find the cause of an acute intestinal obstruction, or rather, of an acute supervening upon a chronic obstruction. It is evident that it is only to a few cases that this method is suitable — e.g., cases of matting together of coils of small intestine, as after previous mischief set up by a mesenteric gland, or appendicitis. In such cases if there is inextricable matting but no recent inflammatory changes and nothing like gangrene, a coil of the distended small intestine may be short-circuited to the most conveniently placed piece of large intestine. This is effected by the use of a Mayo-Robson's bobbin. Murphy's button, or Senn's plates (q.r.), according to the surgeon's familiarity with each, and the time at his disposal. In the majority of cases where the surgeon cannot find the cause, some part of the small intestine will be suffering not from chronic matting as above, but from the pressure effects of some band, orifice in the omentum, &c., and softening, or even gangrene, may be impending ; then a better plan to relieve the distended intestine will be by performing enterotomy as described below, by tying in a Paul's tube,* or puncturing with a large trocar and cannula (p. 223) one of the most distended coils, this being first withdrawn and com- pletely isolated with sterilised towels or iodoform gauze. While the distension is being relieved the parietal wound may be sutured, and the knuckle of projecting bowel attached by a few points to the edges of the wound. The peritonasal sac must be next cleansed of any fluids, and above all of any discharges, either b_y sponges introduced on large Spencer Wells's forceps down into the pelvis and along the costo-vertebral furrows, or by * I have recorded, pp. 226, 278, a case in which this treatment saved the life of a, patient suffering from strangulation of the small intestine (localised gangrene having set in) by a band. ACUTE INTESTINAL OBSTRUCTION. 1 79 flushing with a hot solution of boracic acid (2 per cent.) or ^ per cent, of salicylic acid, in boiled water ; pints of this being introduced by an irrigating tube. After the flushing, sponges are again used, and a Keith's tube inserted. Drainage is always to be emploj^ed when the peri- tonaeal sac has been contaminated. Further details are given at p. 215. The opening in the abdominal walls is then closed with sutvires of wire, or silk or fishing gut. material of sufficient stoutness being pro- vided if any tension is present. Care should be taken to include the parietal peritongeum, and, as the sutures are inserted, to prevent any blood entering the cavity of the peritonaeum. B. Late Cases. — Here the condition of the patient will not allow of any but the briefest operation. A small incision, two inches long, is made in the median line below the umbilicus. On opening the perito- ngeum. two fingers are introduced and carefully feel for the most distended coil within reach, and bring this up into the incision. This must now be opened and an artificial anus formed as described below at p. 224. It may happen that this plan will result in the opening of a coil above the obstruction, or that the obstructed portion of intestine is already gangrenous, and in either of these cases the result must be fatal. On the other hand, it may be urged that in these extreme cases, further interference would be almost certainly fatal, even though the obstruction were relieved, and, moreover, that the most distended coils of intestine usually rise to the surface and are situated close to the umbilicus ; and, finally, that a few lives have certainly been saved by this means. Having spoken of the operation generalh". I shall next refer to a few practical points connected with the chief causes of obstruction indivi- dually. I. Strangulation by Bands and through Apertures.* A. Bands. I. Adventitious Feritoiueal Bii.nds. — Perhaps there has been a history of peritonitis, starting possibly from the cfecum, the uterus and appendages, or a mesenteric gland. These bands are usually attached by one end to the mesentery. 2. Oonental Bands. — Here some part of the lower end of the omentum has become adherent to the brim of the pelvis, a hernial sac, the uterine appendages, or the caecum, 3. MeckeVs Dirertiaditm.'f — This is usually met with in young subjects. Tubular or cord-like, it will be found attached at one end to the ileum, within three feet of the caecum, at the other near the umbilicus, or to the mesentery or intestine. Under this arch small intestine is very liable to slip. In other cases one end is free, and ensnares or knots up a loop of intestine. 4. Some Noi'mal Structure ahnormally attached, e.g., the Fallopian Tiibe or the Appemliv.X * Sir F. Treves (^Intesf. Obxtruct., p. 13; Diet. ofSurff., vol. ii. p. 802) groups these together from the similarity of their obstruction and their close resemblance to stran- gulated hernia. f A most interesting and fully reported case successfulh' treated by laparotomy was published in the Lancet, March 9, 1889, by my old friend E. J. Pye-Smith, of Shetfield. Two others successfully treated in the same way by Mr. Glutton (^Clin. Soc. Trans., vol. xvii. p. 186) and Mr. McGill (^Brit Med. Joiirn., Jan. 14, 1888) 'wiU well repay reference. t One classification of bands useful to the operator is into those easily found and those which are inaccessible. l8o OPERATIONS OX THE ABDOMEN. In most cases bands, when found, are not difficult to deal with. If they do not give Avay to the finger as attempts are made to hook them up, they should be divided between two ligatures of silk. Occasionally transfixion is required. When one band has been discovered, the possibility of a second, attached to the pelvic brim, must always be remembered. In Gibson's list of cases there are i86 of obstruction b}^ bands, and in no less than thirty-three of these there was a record of more than one band being present, and it is probable that the proportion is even higher than this. Two other points connected with bands must be remembered : one, that if they are vascular both ends should be secured ; the other, that on the division of the band the piece of intestine which has been released may be found to be gangrenous or even perforated, and allowing its con- tents to escape into the peritoneeal sac. The intestine must then be brought outside and drained, and the peritoneal sac cleansed if possible (p. 215). Every band should be resected as closel}* to its attached points as is safe, to prevent any recurrence of the trouble. In the case of a diver- ticular band which is tubular, the contiguous peritonseal contents being- all shut off" with, sponges or tampons, the diverticulum and the intestine into which it opens are emptied bj" pressure. Then the diverticulum, being lightly clamped, is divided, an inch and a half or two inches from the intestine, the mucous coat is disinfected with pure carbolic acid and tied with silk or sutured with a few silk sutures, while a second row, which takes up and inverts the muscular and serous coats, gives further security. B. Apertures and Slits. — These may be congenital or traumatic. The two following cases are good instances, and show in sharp contrast the difficulties which may be met with : In Mr. Howard Marsh's case (^Brit. Med. Jonr/i. .June 2, 1888) a loop, probably in the middle of the jejunum, had slipped through a hole in the mesentery. The edge of this opening was so yielding that Mr. Marsh could readily stretch it with his finger-nail sufficiently to allow the loop to be drawn out. The patient made a good recovery, though in much danger for a while from the paralysed condition of the intestine. In Sir F. Treves's case (^Oper. Snrg., vol. ii. p. 3S9) the intestine was strangulated in the foramen of Winslow. Here the surgeon not only could not reduce the gut by operation during life, but at the necropsy he could not bring about reduction until the hepatic artery, portal vein, and bile duct were severed. In the case of either bands or apertures it is the lower part of the ileum which is usually strangulated. II. Intussusception. — From its frequency, especially in early life, its fatality in infants, and the fact that its treatment is less unsatisfactory because its diagnosis* is easier than other forms of obstruction, this deserves cai-feful notice. Of the varieties — the enteric, the colic, the ileo-colic, and the ileo-ceecal — the frequency of the last is well known. It is to this variety, especially in children, that the following remarks mainly apply. The treatment depends upon the duration of symptoms. In quite * Two points must always be remembered in the diagnosis of intussusception : (i) that in cases which are not acute there may be very few symptoms for some time ; (2) the rectum must always be examined, and any intussusception which may be met with not mistaken for a prolapsus. ACUTE INTESTINAL OBSTRUCTION. l8l early cases, reduction will generally be possible with comparatively little ibrce, and may be brought about satisfactorily by injection or intlation. Ver}' soon, however, the engorgement of the intussnsceptum and the included mesenter}^, or the adhesion of the entering and returning layers as the result of peritonitis, renders reduction much more difficult or impossible. In such cases distension of the colon will either fail alto- gether, or will produce only partial reduction with subsequent speedy relapse. The following figures from Gibson's list {loc. supra cit.) will serve to emphasise this important point: 94 per cent, of the cases treated within the first twenty-four hours were reducible on abdominal section, whereas only 61 per cent, of those treated on the third day were reducible. The proportion reducible by distension would necessarily have been less than the above in each case. The following results of distension will also serve to emphasise the importance of attempting reduction by distension of the bowel in early cases only, and, moreover, show how fruitless the practice of repeating distension is likel}^ to be after it has once been tried and has failed. Mr. Eve collected twenty-four cases from the records of the London Hospital in which distension was tried. Of these six died without further treatment, and the remaining eighteen required operation. Mr. Barker (Clin: Soc. Trans., vol. xxxi.) tried distension in eight cases, in all of which it failed ; and in a collection of cases by Wiggins, distension failed in 75 per cent, of seventy-two cases in which it was tried. ^iforeover, the following objections to distension must not be lost sight of : — (i) The danger of sudden collapse or rupture of the bowel ; (2) the loss of valuable time, rendering the result of a laparotomy less likely to be successful ; (3) it will be of no use in enteric intussusceptions (which form 22 per cent, of all cases), and probably of no use in ileo-colic intus- susceptions (which form 12 per cent.), so that in 34 per cent., or in one case in every three, it is practically certain to fail. If the case is seen, therefore, within twenty-four hours of the onset of symptoms, distension of the bowel may be tried. Either water or air may be used for this purpose ; of these the latter is to be preferred, as being less dangerous. A little A.C.E. mixture being given, the lower limbs being somewhat raised, the nozzle of a Lund"s inflator, or a full-sized catheter, or a rectal tube, attached by tubing to a bellows and well coated with vaseline, is carefully passed into the bowel. The nates being securely pressed round the tube, air is steadily pumped into the colon, while the surgeon keeps one hand on the abdomen, not only to prevent over-distension, but also to watch for any receding of the tumour towards the ceecal region. With regard to the force used, Dr. Goodhart {Dis. of Cltihl., p. 125), remarks : " Replacement of the bowel can usually only be effected by considerable distension of the »vhole colon, and distension of the colon sometimes requires a good deal of rather forcible pumping to complete it." This is especially the case with regard to the last few quantities of air sent in. Dr. Taj^or's advice here will minimise the risk of rupture of the bowel : " The risk can be reduced to a minimum by injecting, carefully and slowly, successive small quantities, and by gently kneading the abdomen so as to facilitate the passage of air upwards, and thus prevent the sudden over-distension of short lengths of the colon." I82 OPERATIONS ON THE ABDOMEN. If inflation fails, and in all cases seen later than twenty-four hours after the onset of symptoms, abdominal section should be at once pro- ceeded with. Operation. — The child being under the influence of the A.C.E. mixture, the parts being cleansed, and any urine drawn off, an incision is made, usually in the middle line,* sufficient to admit of the easy introduction of two or three fingers. Before opening the peritonasal sac all bleeding should be entirely arrested. The intussuscepted mass is now found, and, if possible, hooked out into the wound. But more often this is impossible, and the reduction must be effected in situ. Prof. Senn advises {loc. infra cit., p. 128) that: "The oedema and Fig. 44. Diagram of au intussusception in vertical section. M, Mesentery, a, Artery, v, Vein, d.v, Dilated vein, i.m, Inflamed mesentery. OR, Orifice of bowel at apex of iutussusceptum with thickened mucous membrane around. A, Line drawn througli usual seat of adhesions. B, Line for resection of intussusceptum. x, x, To mark the vertical incision through which resection is per- formed. (Greig Smith.) inflammatory swelling should be removed before any attempts at reduc- tion are made. This can be readily accomplished by steady and unin- terrupted manual compression of the invaginated portion." My own experience here is disappointing. The following points must now be carefully attended to. If the intussusception cannot be brought outside, two fingers of each hand should be introduced, and an attempt made (i) to draw out the intus- susception Avhile the point of entrance is held steadily. As a rule, this * As speed is very important in these cases in children, the surgeon should give him- self enough room by beginning above the umbilicus. The intussusception usually lies deeply and is difficult to get at. ACUTE INTESTINAL OBSTRUCTION. 183 is only partially successful. (2) The lower end of the invaginated part being found, the ensheathing layer should be pulled down, while the ensheathed part is pushed up. When the end of the intussusception has reached the rectum, help may be given by an assistant with a bougie ; but it will usuall}' be found that pushing or backing-out the contained bowel by gently squeezing movements between the finger and thumb, these being gradually shifted along the gut, will prove successful, when, by no force that is justifiable, could any part be drawn out. Whichever method is found to answer best must be persevered with until every atom of the mass is reduced, this being often known by the appearance of the vermiform aj)pendix. If, when the reduction is complete, any tears are noticed in the peri- tonjeal coat, these must be sewn up with a fine continuous silk suture, and a little iodoform rubbed in. Every care should be taken throughout the operation to prevent chilling, both of the child's body and limbs, and especially of any intes- tine which may have to be withdrawn. As in all abdominal sections, this operation should be concluded as speedih' as may be. When the intussusception cannot be reduced, all attempts at traction and kneading only causing tears in the peritonasal coat, the fol- lowing courses are open according to the condition of the patient, &c. : — (l) If the intussusception is gangrenous but small in amount, it should be resected. For the union of the divided ends Murphy's button has the great advantage of saving time, and is thus well adapted to acute and subacute cases in children, which form the majorit}^ of the cases. What- ever method is used some difficulty must be expected in effecting exact union in the common variety, the ileo-caecal, owing to the difference of the lumen in the two parts of the bowel ; where this difficulty is very marked, the best plan will be to close both ends by a double row of sutures, continuous and Lembert's, and then to make a lateral anas- tomosis {q.v.) hj means of Murphy's button, Robson's bobbin, &c. (2) If the invagination is irreducible but not gangrenous, it may be left, and the continuity of the canal restored hj short-circuiting the small and large intestine above and below the invagination by Murphy's button or some other means. (3) Where the patient's condition is good, as in chronic cases, an ii*reducible intussusception is best treated by an ope- I'ation based b}^ Mr. Jessett (Surg. Dis. of Stomach and Intesfines, p. 140) on what is known as spontaneous cure. It was three times performed successfully on dogs. An invagination having been made artificially, and found a week later firmly adherent, it was thus removed. A longi- tudinal opening was made into the intestine over the root of the intus- susception on the side farthest from the mesentery, about an inch and a half long, of sufficient length to allow the invaginated part to be drawn out with vulsellum forceps. The root of the invaginated part having been pulled out through the above opening, was cut through close to its origin, any vessel \A'hich required it being tied. Then the divided coats where the intussusception had been cut away were united with a lew points of suture, the lumen of the bowel being left open. The stump was then returned into the intestine, and the incision in this closed by quilt sutures. Greig Smith (Abclom. Sicnj., p. 6/6) recommended this method of treatment, but modified the operation in cases of extensive 1 84 OPERATIONS ON THE ABDOMEN. invagination, in that, as will be seen by reference to Figs. 45 and 46, he removed onl}^ the apex of the intussnsceptnni, this being the most swollen part, and therefore the chief obstacle to reduction. The rest was then gently reduced. Although reduction will be rendered possible in some cases by removal of the apex of the intussusceptum, in others the adhesion of the layers at the neck of the intussusception, to one another, will make reduction impossible. In such cases, a more complete resection of the intussusceptum will be necessary. Other and less desirable methods which may be thrust on the surgeon, owing to the circumstances under which he operates, are : (4) Resection and formation of an artificial anus.* (5) Formation of an artificial anus Fig. 45. Fig. 46. Diagram showing removal of apex of intussusceptum through an incision in the intussuscipiens. I, Entering bowel. 2, Neck of intussuscipiens. 3, Incision in intussuscipiens. 4, Cut edges united by sutures. 5, Apex of intussusceptum excised. (Greig Smith.) Operation of resec- tion of intussuscep- tum completed. (Greig Smith.) without resection. Finally, in those rare cases of invagination of the colon into the rectum the intussusception may be drawn down and removed by the operations of Mikulicz, or Mr. Barker iia this countrv. The latter surgeon's cases will be found in the Med.-Ckir. Trans., 1887, vol. Ixx. p. 335, and Brit. Med. Journ., vol. ii. 1892, p. 1226. In both cases a malignant growth was at the root of the invagination, and in each operation steps were facilitated by the ease with which the growth, after dilatation of the anus, could be pulled outside. Two rows of sutures were made to encircle the bowel, and to unite the two layers of the intussusception firmly together well above the new^ growth. As the * Prof. Senn quotes a case of Wassiljew's (^Ccntr.f. C'hlr., 188S, No. 12), in which an operation was performed to close the artificial anus six months later. It was ultimately successful. ACUTE INTESTINAL OBSTRUCTION. 185 sutures were passed, care was taken that no small intestines protruded. Both cases recovered, and the first was alive four or five years after the operation. III. Volvulus. — The intestine here is usually either twisted on its mesenteric axis, or bent at an anefle. The first is the acuter condition, owing to the strangulation of vessels. It is usually met with in the sigmoid flexure, when this has a long meso-colon, especially in adults who have been subject to constipation (Treves). The distension may be enormous, the sigmoid appearing to occupy the whole abdomen. Ulceration leading to fatal peritonitis may set in, either in the sigmoid, the colon, or the ciecum. A free incision will be required here, so as to enable the surgeon to get at the root of the volvulus. The volvulus may present at once as a hugely distended coil ; it may be felt as a localised collection of intes- tine ; if twisted, the twist may feel like a band, and a band may actually complicate the case as when a vermiform appendix is coiled round the root of the twist of the volvulus (Brit. Med. Journ., vol. ii. 1892. p. 170). If attempts at reduction fail, the volvulus should be drained by tapping or incising the summit of the loop, this being brought outside the peri- tongeal cavity. Fresh attempts at reduction are then made, and if they succeed, and if there is no tendency for the volvulus to reform, the opening is closed, and the intestine thoroughly cleansed and returned. If reduction is impossible, an artificial anus must be made immediately above the volvulus, this having been first completely emptied and closed. In a ver}' few cases where the volvulus is persistent or recurrent, and, at the same time, of small extent, it may be resected if the patient's con- dition admits of it. But volvuli of small extent can usually be reduced. The following points are noteworthy in the diagnosis and treatment of volvulus. It is not uncommon for this form of obstruction to follow an injury,* some loop of bowel distended with fasces, and with a long mesentery probably becoming suddenlj^ displaced and unable to recover itself. Again, this form of obstruction has been noticed, whether as a mere coincidence or not, in many cases in the insane. Finally, at the time of treatment. Sir F. Treves's warning (Oper. Surg., vol. ii. p. 390) must always be remembered: "'The reduction of a volviilus does not usually remove the anatomical condition that led to it." The truth of this is shown by their tendency to recur. Thus the late Mr. Greig Smith (^Abdom. Surf/., p. 450) described a case of volvulus of the small intestine which recurred a week after it had been untwisted by abdominal section. Enterotomy was then performed, and the patient for some time wore a catheter in the opening to allow of the passage of flatus into a bottle which he carried in his pocket. After some time the distended bowel had so contracted that the use of the catheter could be dispensed with. Dr. Finney reports (Johns Hopliins Ho.^p. Bull., March 1893) a case of volvulus which involved the whole colon between the ileo-csecal valve and the sigmoid ; it was rectified by operation, and recurred nearly three years later. A second recovery followed. * See cases mentioned by Mr. Turner, Dr. F. Hawkins, and Mr. Stavely (Lancet, vol. ii. 1892, p. 995) ; a case successfully operated on by Mr. Silcock (Clin. Soc. Trans., vol. xxviii. p. 180). References arc made in the latter paper to eight successful cases operated on abroad. 1 86 OPERATIONS ON THE ABDOMEN. Prof. Senn has advocated shortening the meso-colon to meet this tendency to recurrence. Fixation of the colon by two or three points of suture might be tried as less risky, if access is not prevented by disten- sion of the small intestines. In any case, great care will be needed by such patients in their diet and to ensure efficient action of their bowels. IV. Gallstones, Intestinal Calculi, &c. — Gallstones, the most common of these, present cases very favourable for operation if taken in time, owing to the simplicity of the cause of obstruction, and the facility with which it may be usually dealt with. Operation has been here too often deferred, owing to the fact that these patients, usually advanced in life, and stout, are not well suited to operation from a general point of view, and because it has been strongly insisted upon by some that if pain and spasm can only be removed, the local cause of the obstruction will pass on. This I believe to be a mistake. Sir F. Treves (Intest. Obstruct., p. 335) states that of twenty cases in which gallstones "pro- duced definite and severe symptoms of obstruction," six patients reco- vered by the spontaneous passage of the stone, and fourteen died unrelieved. It is to be hoped that the successful cases which have been ])ublished, one as long ago as 1887 (Lancet, Dec. 3), by Mr. T. Smith, Mr. Glutton (Clin. Soc. Trails., vol. xxi. 1888, p. 99), and more lately by Mr. A. Lane (ibid. ii. 1894, p. 382), and Mr. Eve (Cliii. Soc. Trans., vol. XXV. 1895, P- 91))* i^^^y ^^^^1' good fruit. In some cases, in addition to the age, stoutness, and habits of the patient, the history of previous inflammation in the neighbourhood of the gall-bladder may help the diagnosis ; in four cases, certainly, the calculus has been felt — the abdomen being undistended — before operation. But in the majority it is probable that here, as elsewhere, operation alone will demonstrate the cause of the obstruction. The following courses may be adopted : ( i ) To try and pass on the stone through the ileo-cascal valve into the large intestine. Mr. Glutton (Clin. iSoc. Trans., vol. xxi. p. 99) succeeded in doing this, the stone being situated eight inches above the valve. But usually the stone is too firmly fixed. Mr. Glutton's case is a very instructive one. The patient, a woman aged 70, was operated upon within twenty-four hours of the beginning of the attack. Fifteen months before she had passed a large facetted biliary calculus, and after her recovery from this had had a swelling in the region of the gall-bladder. This disappeared with the onset of the obstruction. A median incision four inches long having been made, the stone was readily felt, and though it tightly iitted the lumen of the intestine it could be forced along. As owing to the early date at which the operation was performed, there was no marked difference between the intestine above and below the obstruction, the site of the ileo-csecal valve was determined by making out the caecum and the appendix. There was not much difficulty in urging the calculus in the right direction, but as soon as the valve was reached some considerable force was required to make it pass through. This most successful case strongly supports Mr. Glutton's advo- cacy of an early operation, before the stone has become so immovable as to require opening of the intestine. Dr. Maclagan Qihid., p. 97) draws attention to an important point. If other stones * In this paper some thirty cases which have been treated by abdominal section are given and the result considered. ACUTE INTESTINAL OBSTRUCTION. 187 exist in the gaU-bladdcr or ducts, another may descend before the wound is healed, and, forcing its way through the recent incision, cause fatal peritonitis. (2) If the stone does not feel very hard a cautious attempt may be made to critsh it between flat-bladed forceps, guarded with drainage tube. Such a course can only be adopted when the intestine imme- diately adjacent to the stone is healthy. (3) The same precaution must be taken if Mr. Tait's suggestion of breaking up the stone with a needle is resorted to. If used, the needle must puncture obliquely, an inch and a half from the stone. (4) If the stone cannot be pushed onwards, and if it is too hard to be broken up, it must be removed. The loop being drawn well outside the peritonasal cavity, an incision must be made in the intestine opposite to the mesenteric border, the calculus removed, care being taken that its long axis corresponds with that of the wound and that the edges of this are not bruised. The wound is then closed most carefully with Lembert's or Halsted's sutures, silk being used. Whichever of the last three methods is resorted to, the stone must, if possible, first be pushed into an absolutely healthy part of the intes- tine, if that surrounding it is inflamed or thinned. (5) If the condition of the intestine is suspicious, or if, on opening it for the removal of the stone, the mucous coat is ulcerated, one of the three following courses must be followed, according to the .condition of the patient and the resources of the operator, viz. : (a) Resection. (/S) Formation of an artificial anus. (7) Where the operator is doubtful if his sutures will hold, but desires to give this method a chance, he will suture the wound of extraction and then bring this outside, packed around with iodoform gauze for twenty-four or forty-eight hours, or leave it just within the abdominal wound, anchored here by a catgut stitch, and shut off from the rest of the peritona^al sac by tampons of iodoform gauze (wrung out of I in 20 carbolic-acid lotion), the ends of which are brought out through the parietal incision. V. Thrombosis of the Mesenteric Vessels or of Abdominal Aorta. — Mention must be made of the above conditions, as it is clear, from the cases published, that, though rare, they may simulate acute intestinal obstruction very closely. The explanation appears to be that a loop of intestine, deprived of its blood-supply by an embolus, will, functionally, be as completely paralysed as if it had been strangled. Instructive cases of this kind M'ill be found published by Mr. M'Carthy (Lancet, vol. i. 1890, p. 646) and Dr. Munro, of Middlesbrough (ibid., vol. i. 1894, p. 147). Dr Munro quotes from Gerhardt and Kussmaul the following diagnostic points of these cases : (i) A source of origin for the embolus ; (2) profuse hiemorrhage from the bowels ; (3) severe colic-like pains in the abdomen ; (4) rapid reduction of tempera- ture ; (5) demonstration of an embolus in some of the other arteries ; (6) palpation of infarcts in the mesenteries. In Dr. Munro's case, one of these, situated in the meso- sigmoid, could be felt, before operation, in the left iliac fossa. To these points might be added advanced age and no evidence of malignant disease. The mischief is usually too extensive to admit of surgical interference. If it be limited to the small intestine, several branches are usually plugged. The recorded cases have almost invariably ended fatally. In one case, however, the portions of bowel and mesentery involved were removed with success. Before closing the account of the surgical treatment of acute intestinal 1 88 OPERATIONS ON THE ABDOMEN. obstruction, I must allude to Prof. Senn's* advice to try insufflation with hydrogen, in order to find the seat of obstruction. Prof. Senn, finding that distension of the entire gastro-intestinal canal (for. owing to distension of tlie csecum. tlie ileo-caecal valve is paralysed) in animals was never followed by any ill effects, has advised this (i) in reduction of intussusception, (2) in locating the obstruction during a laparotomy, (3) in detecting the site of gunshot or other perforations of the intestine. The gas is collected in a four-gallon rubber balloon, and the inflation made by compressing the balloon. A manometer or mercury gauge connects, by rubber tubing, the rectal tube on one side and the balloon on tlie other. This method, though extremely ingenious, is likely to have but a limited application. In the reduction of intussusceptions the use of ordinary air is much more handy, and has been abundantly successful. In the detection of perforations, especially those by gunshot, the test has certainly answered, but the following risks are connected with its use. It will demonstrate perforations, but nothing else, and may lead the operator, if he trusts to it, to overlook many other lesions which may be as dangerous as perfora- tions themselves. Many conditions — e.ff., impacted fseces, prolapse of mucous mem- brane, and recent adhesions — may interfere with its efficacy (Morton). Though aseptic when introduced, the gas can hardly be so after passing through many feet of intestine. It may break down most vital adhesions. It may increase, by the distension it causes, the danger of the anaesthetic, and is, of course, only available in cases where there is little, if any. distension. APPENDICITIS.! Before discussing the question of surgical interference here, it will be well to make plain what we mean \\'hen speaking later of the varieties of this disease. These are : i. Catarrhal and Early Interstitial Apjjendicitis. — Here the inflamma- tion is limited to the mucous membrane and the other coats of the appendix, but goes no farther (if the attacks be slight) than at the most a little plastic peritonitis and a few slight adhesions. ii. Appendicitis with a Localised Ahscess. iii. Acide Perforatinrj and Ganrjreiious Appendicitis. — Of these two, the first may at any time lead to a general peritonitis ; the second, if left, always does so. iv. L'elapsing or Recurrent Appendicitis. Question of Operative Interference in Acute Appendicitis. When to Operate and When to Wait. Two Camps of Opinion. One of us has already said, in a lecture elsewhere (W. H. A. Jacobson, Polyclinic, Dec. 1900), much of what follows concerning the present state of opinion on this subject. " (a) Ad.vocates of Waiting and Watcldny. '• Those who follow on these lines rely on the fact that the majority of * Zoc. svpra cit., p. 53; and Journ. Amer. Med. Assoc, June 1888: "Rectal Insuffla- tion of Hydrogen Gas an Infallible Test in the Diagnosis of Visceral Injury of the Gastro-intestiual Canal in Penetrating AVouuds of the Abdomen." f I use this term, ctymologically unsatisfactory, because it is convenient and based on correct pathology. APPENDICITIS. 189 cases of appendicitis recover under medical treatment. In other words, they represent that the dangei'oiis forms in which slong-hing or gangrene or perforation of the appendix with suppurative peritonitis, pylephle- bitis, &c., follow, ai-e but few. Dr. Hawkins, quite one of the highest authorities on the subject, puts the death-rate of appendicitis at 14 per cent., and hopes it may be reduced to 12 per cent. " With all respect to Dr. Hawkins, I, mj'self, look upon the above estimate of 14 per cent, as too low, when hospital cases are considered. It is interesting to note that Dr. MacDougall. in his address at Carlisle in 1896, quoting from returns made from the Edinburgh Royal Infir- mary for the three years 1893, 1894, and 1895, found that the death- rate of acute appendicitis was 25 per cent., and that the returns of two London Hospitals — St. Bartholomew's. 1893 to 1895, and St. Thomas's, 1892 to 1894 — gave a death-rate of nearly 20 per cent., and it is doubtful if these returns included all the cases admitted of puralent peritonitis. . . . " The advocates of waiting and watching further maintain that in the indiscriminating removal of appendices which they say has been goinp- on in America, we have had an abuse of surgery similar to that whicli characterised, some years ago, the operation of oophorectoni}". " (b) The Advocates of Operation ai Once, or at the End of Thirtij-six or Forti/-eir/ht Hours. " Let us consider how this school, to which, I confess, I have felt myself di-awn increasingly during the last few years, would answer the objections to early operation which I have just mentioned. And I will take the last first, viz., the criticism that this opei-ation of early removal of the appendix has been abused, and the comparison between it and the similar abuse with which most of us are familiar as to oophorectomy. "' There is an old saying that ' Abusiis non tollit usum.' A pendulum of opinion which sways strongly first in one direction, then in another, needs watching. And in my opinion there is a danger that in being influenced by the needless operations which have no doubt been done in America and elsewhere, we shall lose sight of the very sound and splendid work done by the best surgeons of that country. I shall allude to this more in detail shortly. I will only add that in this countrv hasty and needless operating will certainly not be the rule of treatment. l3ut there is a risk that in priding ourselves on this, we err on the other side. I am certain that the results of the best American surgeons are far superior to anything in this country, and are but little known amongst us. " With regard to the comj^arison between removal of the appendix and the ovary, I scarcely think this holds good. A diseased ovary mav cripple, but it very rarely kills ; it is not a vestigial structure ; though unsound, it is not necessarily functionless. An appendix has not, like the ovary, peculiar importance not only to its owner, but also perhaps to others, an importance quite sui fjeneris. The advocates of early operation would answer to the conservative school : ' You sanction, nay. perhaps you urge operation as soon as evidence of gangrene, perforation, suppu- rative peritonitis, or local abscess is certain. But by the time the evidence is sufficient for you to call in surgerv it is often too late ; you I90 OPERATIONS ON THE ABDOMEN. admit that it is usually impossible to diagnose such conditions as gangrene and perforation till the disaster is announced by evidence which is unmistakable, but which announces a condition in which surgical interference is too often useless.' "The advocates of early operation claim that by operating early, and thus making sure that infection has not extended beyond the appendix, the surgical death-rate would be much below the medical one, "which we have seen to be put by one of the best authorities at 14 per cent. Thus Dr. Morriss holds that the death-rate should not exceed 4 or 5 per cent, when cases of gangrene, perforation, and suppurative peritonitis are operated on, and goes so far as to say that a surgical death-rate of 2 per cent, in cases operated on early ' would be illegitimate.' " Let us examine this claim that the medical death-rate will be much lo^vered by early surgical interference. It will be seen to stand or fall very largely upon the meaning of the word ' early.' The question at once arises, ' How many cases are really seen within the first twenty-four or thirty-six hours ? ' Certainly, I think but few in hospital practice. Here the patient very often goes on working for days after he has had warnings of pain, and even sometimes with a lump in his right iliac fossa. We must face the fact that it will be difficult to determine whether, with this word ' early ' before us, we really are dealing with the first twenty-four or thirty-six hours. A patient, from carelessness or inac- curacy, or a desire to make the best of his case, from a dread of operation, may misrepresent his symptoms as just beginning. In reality this man had had, for a day or two, pain or other evidence that a catarrhal con- dition has been established, and thus the appendix epithelium has had time to become shed, and an infection-atrium has had the opportunity^ of forming before a medical man is asked to see the patient. Then, when the latter is called in, the pulse, temperature, pain, tenderness, and so forth betoken not the commencement of an attack as the patient repre- sents, but a stage in which an actual abrasion is present, perhaps even that the peritonaeum is becoming infected. " Having mentioned this caution, we will suppose, for the sake of argument, that all cases are seen within a really early stage, viz., twenty-four hours. Is it certain that early operation at this stage will be largely successful ? Let us examine the ground on which we stand. If we accept Dr. Hawkins's mortality of appendicitis treated medically as one of 14 per cent, from gangrene, perforation of the appendix, and suppurative peritonitis, in order to ensure a surgical mortality of 4 or 2 per cent. — though Dr. Morriss is inclined to look upon even the latter as ' illegitimate ' — it is clear that we must operate successfulli/ on ninety-six or ninety-eight cases of acute appendicitis in the early stage. This is a statement which there is no gainsaying, and it is one which at once makes a mind capable of weighing evidence veiy thoughtful. When one considers the conditions under which this early operation may have to be done, in a febrile patient with an infected, septic organ to be removed, with intestines very likely distended, and many other conditions present the very reverse of those which make an operation during the quiescent stage so successful, it is difficult to say how far the medical mortality of 14 per cent., or, perhaps more correctly, of 20 per cent., will be reduced, even if the surgery be always that of skilled hands. That it will be reduced by habitual earlier operation, and in the lifetime of some of us, APPENDICITIS. 191 I am certain ; but I doubt if it will be broug-ht below 8 per cent., when all the conditions and the different personal equations of the operators are weighed. " But, here, it will be only just to examine some of the results gained by the best of those American surgeons who advocate early operation in every case. These results are not sufficiently known in this countr}'. " I will take only two of the more recent ones, viz., those of Dr. Mynter, of Xiagara, and Dr. Morriss, of Xew York. Dr, Mynter (Appendicitis, p. 172), whose book emphatically bears the stamp of a candid and judicious worker, writing in 1 897, had had thirteen cases, all of which had more or less total gangrene but yet without perforation. They all recovered by prompt operation and extirpation of the appendix. Two cases were operated on during the first day. five on the second day, two on the third day, three on the fourth day, and one on the seventh day. 'These cases,' he goes on to say, ' are most interesting, as giving conclusive evidence of the importance of operating before perforation has occurred. No one can doubt that perforation with profuse perito- nitis would shortly have occurred, and that they all would have died under any other than surgical treatment.' " Dr. IMynter operated on another group of twenty cases, all of which had gangrene with perforation of the appendix, and commencing or diffuse peritonitis. Five of these recovered, while fifteen died — thirteen of diffuse peritonitis, one of gangrene of the caecum, and one of suppu- rating pvlephlebitis after the peritonitis had disappeared. The five who recovered were operated on, in two cases on the first day, in two cases on the second day. and in one case on the third day. Of the fifteen who died, one was operated on during the second day, two on the third day, five on the fourth day, two on the fifth day, four on the sixth day, and one on the seventh day. "Dr. Mynter adds: 'Comment seems unnecessary; all died if operated on later than the third day.' " Dr. Morriss's cases (Lectures on AppendAcitis, Xew York, 1895) ^"^^ somewhat less carefully tabulated, but are most instructive. " Of ninety-one cases of acute appendicitis operated on early, injifti/- nine in which only the immediate vicinity of the ajypendix ivas infected, although many of these cases involved, extensive operative icorTi, there was no death in this series of fifty-nine cases. " In six cases of intense general septic peritonitis, with the whole abdominal cavity bathed in pus, only one patient died. " In three cases with intense general septic peritonitis, not marked by the presence of pus, only one died. " In twenty-three cases of the walled-off abscess form of appendicitis, the most varied complications were present. Five only of these died, but one of these deaths was from acute suppurative nephritis, a second fi'om ' intestinal obstruction dvie to adhesions which could not be separated at the time of operation on account of the patient's condition,' and a third, already weak from several months' septicaemia due to an abscess over- looked before Dr. Morriss saw the case, died of a continuance of the septicaemia. " This death-rate of seven in ninety-one cases testifies in no uncertain terms to the admirable care and skill which must have been exercised to attain such a result. 192 OPERATIONS ON THE ABDOMEN. " Dr. Morriss is quite justified, after such success, in writing: ' I feel that the death-rate in lOO such cases as the list contains should not be more than 4 or 5 per cent., notwithstanding the fact that many of the cases were in a condition which seemed to prohibit interference.' " It seems to me that even if this surgical death-rate of 4 or 5 per cent, were doubled, viz., 8 or 10 per cent., it would give a better result than the medical one of 14 or 20 per cent., and our duty would be clear. " But the following cautions must be borne in mind : " First, that we have here the results of especial experience of those Mdio have had opportunities of acquiring especial skill. Dr. Mynter strikes a very important note when he emphasises the point that wherever the home surroundino-s are unfavourable, the well-reo-ulated operating-room of a home or hospital is a sine qua non. " Secondl}^ it is never to be forgotten that these operations are alwaj^s serious, often very difficult, and that they require good experi- ence, efficient assistance, and efficient antiseptic precautions. " Thirdly, in estimating the surgical death-rate, which I do not myself expect to be less than 6 or 8 per cent., when all the conditions under which this operation will be performed are taken into account, we must remember that in certain cases of appendicitis beginning very acutely the operation, however early, will not save life. I refer to cases where a general peritonitis sets in early, possibly within the first few hours of the case coming under notice. The explanation of these cases probably is that in some it is not really a first attack. The history given is unreliable, the appendix is already a damaged one, and either gangrene or a perforation of its unhealthy structures sets in quickly, with the resiilt of a rapid general peritonitis. In others, the explanation is that the bacillary activity is, from the first, acute, the resisting power of the patient's tissues verj^ poor, or that some minute point in the anatomy of the appendix, as the gaps between the fibres of the muscular roots [vide siqrra). facilitates rapid transit of the septic process. No one can tell how often the lives of our patients hang on such minute points. " There is another of the points of dispute between the two camps to which I would ask 3-our attention. The advocates of early operation maintain that many of the cures which are secured by medical treatment — we will call them 80 or 85 per cent.— are not permanent and complete cures when followed up ; bixt that permanent mischief is left behind, sometimes slight, sometimes severe and dangerous ; and that patients would be saved from the great annoj^ance and suffering of recurrent attacks and much waste of time if the appendix were removed in the first attack. The following is an interesting instance of how incomplete may be the cure of a case treated on medical lines, and of the thread on which such a patient's life ma}^ be hanging: " A gentleman, aged 23. was sent to me in July, 1896. by Dr. Goodhart with the fol- lowing history : — In 1895 ^^^ had had a severe attack of appendicitis, in which the tem- perature was for some days between 102° or 103°. Under medical treatment he made an apparently perfect recovery. In June 1896, while bowling for an eleven of the Zingari at Manchester, as he shot up to the crease he suddenlj- felt an acute pain and